3. Introduction of Malnutrition
• World Health Organization (WHO) defines malnutrition as ‘‘the cellular
imbalance between the supply of nutrients and energy and the body’s
demand for them to ensure growth, maintenance, and specific functions.
• Malnutrition is the condition that develops when the body does not get the
right amount of the vitamins, minerals, and other nutrients
• Found in developing countries as a result of inadequate food supply
• Caused by socioeconomic, political, and occasionally environmental factors
such as natural disasters
4. Protein energy malnutrition (PEM)
• Protein Energy Malnutrition (PEM) is the deficiency of energy and protein in the diet.
• It is a nutritional disorder, which affects all the segments of population like children, women
and adult males particularly from the backward and downtrodden communities.
Definition given by WHO,
• Moderate acute malnutrition (MAM), defined as weight-for-height z-score (WHZ) between
−2 and −3 or mid-upper arm circumference (MUAC) between 115 millimeters and <125
millimeters
• Severe acute malnutrition (SAM), defined as WHZ < −3 or MUAC < 115 millimeters, or the
presence of bilateral pitting edema, or both
• Global acute malnutrition (GAM) refers to MAM and SAM together; it is used as a
measurement of nutritional status at a population level and as an indicator of the severity
of an emergency situation
5. Different Types of PEM
Clinical forms
o Kwashiorkor
Sub-clinical forms
• Underweight & Growth
failure
• Muscle Wasting ,mild or
absent
• Stunting & Oedema
• Protuberant belly
• Depigmentation of skin
&Hair color changes
• Anemia
• Poor appetite
• Enlarged Fatty Liver
• Xerosis, itchy rash
• Protein deficiency
• Common in children between 6 months
and 3 years of age
o Marasmus Sub-clinical forms
• Underweight
• Severe Muscle Wasting
(Subcutaneous fat not
preserved)
• Stunting
• Prominent Ribs
• Voracious Feeder
• No Fatty Liver
• Protein and Energy deficiency
• Common in infant under 1 year of age
6.
7. Etiology
1. Inadequate food intake-
2. Ineffective weaning
3. Infections- HIV, Gastrointestinal infections associated
with diarrhea, anorexia, vomiting, increased
metabolic needs, and decreased intestinal absorption.
Parasitic infections
4. Diseases, such as cystic fibrosis, chronic renal failure,
childhood malignancies, congenital heart disease, and
neuromuscular diseases
5. Fad diets, inappropriate management of food
allergies, and psychiatric diseases (eg, anorexia
nervosa) , burns
8. • weight loss of greater than 10% of normal body
weight
• Patients on long-term hemodialysis
• Patients with squamous cell carcinoma of the
esophagus
• Mental health conditions-depression, dementia,
schizophrenia, anorexia nervousa
• Poor hygiene, environmental and cultural factors
• Decreased absorption and abnormal metabolism
9.
10. Clinical Features
• Kwashiorkor(protein malnutrition predominant)
• Marasmus(deficiency in calorie intake)
• Marasmic kwashiorkor (marked protein deficiency and marked calorie
insufficiency signs present, sometimes referred to as the most severe
form of malnutrition)
11.
12. kwashiorkar
• Kwashiorkor is an African word, meaning a
"disease of the displaced child", which means
Weaning with inadequate food
replacement.
• Mostly in children between the ages of 1 and 3
years, when they are completely weaned (taken
off the breast).
• severe form of malnutrition associated with a
deficiency in dietary protein
• characterized by a weight for age between 60%
and 80%of reference median
• The three essential manifestations or signs of
kwashiorkor are:
1. Oedema (swelling of feet)
2. Growth failure, and
3. Mental changes
13.
14. clinical signs of kwashiorkor in detail
Oedema: accumulation of fluid in the tissues.
• Usually begins with a slight swelling in feet gradually spreading up the legs. Later,
hands and face may also have oedema.
Poor growth: Growth retardation is the earliest manifestation.
• The child will be lighter and shorter than its normal peers of same age and weigh
about 80% or less of their normal peers.
• Sometimes, in cases of gross swelling, the body weight may be relatively higher.
The child will also be wasted (thinner). The child's arms and legs will appear thin
as a result of wasting.
Mental changes: kwashiorkor child has no interest in the surrounding.
• apathy, peevishness,etc
• The child will also be irritable and prefers to stay at one place and in one position.
15. Other signs which may be present are
Hair changes: In kwashiorkor, the hair loses its healthy sheen and becomes silkier and thinner. It takes coppery red
colour (referred to as 'discoloured hairy).
• Can easily pluck small tufts of hair without causing any pain (referred to as easy pluck ability) just by passing
your hands through the hair.
Skin changes:
• dermatosis in buttocks, back of thighs & axille, dark pigmental brownish black areas of skin
Moon face: The cheeks may seem swollen with fluid or fatty tissue and often be slightly sagging.
Micronutrient deficiencies: Almost all the children manifest:
• anaemia (due to iron deficiency and Folic acid) is observed
• Eye signs of vitamin A' deficiency(xerophthalmia, keratomalacia,) riboflavin deficiency, are also common.
• Manifestations of vitamin B complex deficiency (Riboflavin deficiency) is seen.
• angular stomatitis and glossitis are also noted in many cases
GI tract- loss of appetite , vomiting , diarrhoea
liver changes – enlarged liver and fatty infiltration of liver
16. Biochemical changes-
• Serum albumin- low serum albumin level (0.7-2.2 g/100ml) normal level-
3.5-4g
• Enzymes in serum and digestive juices- low levels of choline esterase ,
alkaline phosphatase, amylase and lipase.
• Lipid metabolism:increased lipid peroxidation, with a decrease of
plasma antioxidants and decreased proportions of polyunsaturated
fatty acids in plasma and red cell phospholipids
• Carbohydrate metabolism- hypoglycemia
• Electrolyte and water balance- low potasium and normal sodium levels , Mg
deficiency , retention of water due to low serum albumin levels.
17. Marasmus
• inadequate energy intake in all forms, including protein
• which leads to over loss of adipose tissue and muscle
• Monkey faces
• common in children below the age of 2 years
• Consumption of diets deficient in both proteins and calories.
• The marasmic children are so weak that they may not have
even energy to cry, which most often is barely audible.
• The child is extremely wasted with very little subcutaneous fat
with the skin hanging loosely particularly over the buttocks.
• Oedema is absent and there are no skin and hair changes.
• However, frequent diarrhoeal episodes leading to dehydration
and micronutrient deficiencies of vitamin A, iron and B-
complex are common.
18. • increased susceptibility to infections
• absence of edema.
• growth retardation- weight for age < 60% of reference median, loss of wt
more than height
• Other changes – dry and atrophic skin , hair is
• usually sparse, dehydration , eye lesions due to VitA deficiency, anaemia
Biochemical changes-
• low serum albumin
• Low vit A serum level
clinical signs of Marasmus
19. • Extreme muscle wasting -
"skin and bones“
• Loose and hanging skin
folds
• Old man's or monkey faces
• Absolute weakness
20. Biochemical signs specific to PEM
Biochemical Changes Marasmus Kwashiorkor
Serum albumin Normal or slightly decreased low
Urinary urea per g of
the creatinine
Normal or decreased low
Urinary Hydroxyproline Index low low
Serum free amino acid ratio Normal Elevated
Anaemia May be observed Common iron and folate
deficiency may be associated
Pancreatic secretions Reduced enzymatic activity Reduced enzymatic activity
21. • Sometimes, in areas where PEM is
common, malnourished children exhibit the
features of both kwashiorkor and
marasmus. Such changes could occur
during the transition from one form of
severe PEM to another.
• These children will have extreme wasting of
different degrees (representing marasmus)
and also oedema (a sign of kwashiorkor).
• Early kwashiorkor child develop marasmus -
severe diarrhoea & prolonged
underfeeding.
• Marasmus to kwashiorkor – protein
deficient CHO rich diet
Marasmic kwashiorkor Malnutrition
24. Treatment
Diet
• Treatment of cases of kwashiorkor or marasmus involves mainly providing
appropriate nutrition support. The child should receive a diet that
provides adequate amounts of energy and protein. Both of these are
required in larger quantities than normal.
The child should be given the following concentrations:
• Energy : 170 - 200 kcal per kg of body weight
• Protein : 3 - 4 g/kg of body weight
25. Micronutrient supplementation
• Micronutrients -iron, zinc and vitamin A
• Fortification with iron alone in school children
reduced prevalence of anemia by 70%
• Iron (60 mg) and folic acid (100 mg) may be given
daily to correct anaemia.
• Zinc reduced diarrheal morbidity and also child
mortality and significant beneficial impact on child
nutrition
• Vitamin A supplementation in the neonatal period has
been used for mortality reduction.
26. Food fortification including multiple
micronutrient supplementations
(MMN)
• Considered as a complimentary strategy for improving the growth of
children less than 2 years
• Increased the weight for age Z-score (WAZ) by 0.12 compared to
iron supplementation
• Using ready-to-use nutritional “multimix” composed of rice bran,
wheat flour, cassava, safflower seeds supplements appears an
attractive preposition for combating nutritional problems in pre-
school children
27. Oral rehydration
• Since diarrhoea is very common in severe PEM, correction of dehydration is
the first step in the treatment.
• Home made (salt-sugar mixture) or commercial oral rehydration solution
(ORS) can be administered to correct dehydration.
• Intravenous fluids are required only in severe dehydration.
Control of infections and infestations
• Appropriate antibiotics should be started immediately since infections are
the immediate cause of death in many children.
• Children with intestinal infestations Like giardiasis and ascariasis should be
treated.
"prevention is better than cure". So it becomes extremely
important that we make sincere efforts to prevent and control PEM
28. Ready-to-use therapeutic food(RUTF)
• defined as a fortified peanut butter paste rich in vitamins and
energy
• treats severe wasting (low weight-for-height) in children under 5 years old
• basically a mix of powdered milk, peanut butter, and micro-
nutrients
• Each packet contains 500 calories of therapeutic food
• Typically, a child needs to eat 10-15kg of RUTF over a period of
six to eight weeks. That’s three packets of RUTF per day
• According to the American Journal of Clinical Nutrition, 98% of
children treated with RUTF were well-nourished after six
months and 96% were well-nourished after a year.
29. • Appealing taste and easy digestibility
• High nutritional value allowing malnourished children to
gain weight quickly.
30. SUPPLEMENTARY FEEDING PROGRAMMES
• Food supplementation programmes have a very important role to play to combat
malnutrition.
• The aim of these supplementary feeding programmes is to improve the nutritional
status of vulnerable groups through distribution of food supplements.
• principle: the supplementary food provided needs to be nutritionally
adequate (in terms of protein and micronutrients), and to fill the gap between
the energy a child receives from usual meals at home and his or her energy
requirements.
Following supplementary feeding programmes :
1. National Programme of Nutritional Support to Primary Education (Mid Day Meal Programme)
2. Special Nutrition Programme
3. Pradhan Mantri's Gramodaya Yojana (PMGY)
4. Composite Nutrition Programme, and
5. Applied nutrition programme
31. Applied Nutrition Programme
• The Applied Nutrition Programme was one of the first national nutrition programmes
launched in 1963 through the Community Development Department,
• Aimed at improving the nutrition of lactating and pregnant women and children.
• The programme was developed 'to educate rural people about how they can increase and
improve their food supply through their own efforts'.
The main objectives of the programme were:
1. to produce more protective foods such as eggs, fish, vegetables and fruits rich in vitamin
A and vitamin C by organising a community poultry unit, a fishery unit in rural areas,
community gardens in schools and kitchen gardens in rural households
• equipment, seeds, saplings and process training –provided by Government
2. Feeding of protective foods thus produced in community units to the most vulnerable
group i.e. children below six years, pregnant and nursing mothers was undertaken
3. training programmes and demonstrations in poultry, fisheries, horticulture and home
science
32. Mid Day Meal Programme(Pradhan Mantri Poshan
Shakti Nirman)
• The National Programme of Nutritional Support to Primary Education commonly
known as Mid Day Meals Scheme was launched in August, 1995 and renamed as
Pradhan Mantri Poshan Shakti Nirman and launched in 2021
• The mid day meal programme is one of the most important ongoing feeding
programmes
• organized by the Department of Education not only to improve nutritional status of
school children but also to attract poor children to school.
• beneficiaries of this programme are children in the pre-primary levels, children
studying the primary (Classes I-V) and upper primary (VI-VIII) stage of education
Objectives
• The programme is intended to give a boost to universalization of primary education
by increasing enrolment, retention and attendance and simultaneously impacting
upon nutritional status of students in primary classes.
34. Special Nutrition Programme
• The Special Nutrition Programme was launched by the Central Social
Welfare Board (CSWD) in 1970-71.
• The aim of the programme was to provide supplementary nutrition to
children, pregnant women and nursing mothers belonging to the
weaker sections of the society.
• The main component of the programme was food supplementation.
• The supplement consisted of 300 Kcal and 10 g protein for children and
500 Kcal and 25 g protein for Pregnant- lactating women. Feeding of the
beneficiaries was undertaken for 300 days a year.
• In addition to supplementary feeding, the scheme also included
periodic health check ups for the beneficiaries.
35. Pradhan Mantri's Gramodaya Yojana (PMGY)
• In order to achieve the objective of sustainable human development at
the village level, a new initiative in the form of Pradhan Mantri's
Gramodaya Yojana (PMGY) has been introduced in the Annual Plan
2000-01.
• Schemes related to health, nutrition, education, drinking water, housing
and rural roads are undertaken within this programme
• The PMGY has two components: Programmes for rural connectivity
with 50 percent allocation, and other programmes of primary health,
primary education, rural shelter, rural drinking water and nutrition with
the remaining 50 percent allocation.
36. Composite Nutrition Programme
• The Composite Nutrition Programme was a feeding programme launched by
the Department of Community Development, with the main objective of
providing nutrition education to the masses.
• The core of the programme was nutrition education and its particular
application through demonstration feeding.
• The programme had five components:
1. Nutrition education through mahila mandals
2. Encouragement of economic activities of mahila mandals ,
3. Strengthening 'the supervisory machinery for women's programme
4. Training of associate women workers, and
5. Demonstration feeding
37. Failure to thrive
• a condition of pediatric malnutrition who fail to gain weight and may even lose weight
• Considered as failing to thrive when their rate of growth does not meet the expected
growth rate for a child of their age
• often identified within the first 3 years of a child’s life
• It is solely defined by anthropometrics
• Children with FTT are more vulnerable to infection and behavioral problems
• More specifically, the term characterized those whose weight is below 3rd percentile on
an appropriate growth chart
43. non-disease-related causes of FTT: nutritional information deficit,
consumption of a mostly liquid diet, family stressors, maternal
depression, and food shortage
54. The nutrient requirements may be affected by the underlying medical conditions.
• First, adequate nutrition should be provided. This can be accomplished by supplying concentrated infant
formulas or using high-calorie and high-protein solid foods, in addition to a supplement.
• In cases of severe undernutrition, calories should be added back slowly to prevent refeeding syndrome.
• . For children suffering from nonorganic FTT, in addition to providing a nutrient-dense diet, lifestyle changes
may be necessary to provide an appropriate eating environment. These changes involve the parents as well as
the child. Determining a meal and snack schedule and including a personalized meal plan for the child may be
necessary. Furthermore, parents and caregivers should receive education about setting limits on meal times,
reinforcing good eating behavior, and limiting grazing and distractions.
57. • Enteral nutrition can be given through gastric feeds or postpyloric feeds
• Gastric feeds are more physiologic and mimic normal nutrition, particularly when given as a bolus feed.
• However, in children where gastric feedings are not tolerated, or those with neurologic dysfunction,
anatomical abnormalities, gastroparesis, or high risk for aspiration, postpyloric feedings should be used.
• several different enteral access points:
• Feeding tubes such as nasogastric, nasojejunal, gastrostomy, percutaneous endoscopic gastrostomy
(PEG), jejunostomy, and percutaneous endoscopic jejunostomy (PEJ)
• Nasoenteric tubes can be used in the short term, for a maximum of 8 weeks, as they can cause nasal
erosion and oral feeding aversion in children.
• If enteral nutrition is expected to be used for longer than 6 to 12 weeks, a semi-permanent tube, such as
a PEG, PEJ, gastrostomy, or jejunostomy, should be inserted instead of a nasoenteric tube
Enteral nutrition
58. Type of Formulas:
1. Polymeric:
• can be used when the entire digestive tract is normally functioning
• characterized by the presence of intact proteins
• These formulas provide 30 kcal per ounce, 12% to 15% of which are from
protein, 44% to 53% from carbohydrates, and the remaining 35% to 45% from
fat
• Vitamins and minerals are also provided to reach 100% of the RDA when 1 L is
given.
• available as standard, calorie dense, and fiber enriched.
• Fiber-enriched formulas typically contain 5 to 8 g/L of fiber. For example, a
child who presents with diarrhea may benefit from the use of a polymeric
fiber-enriched formula. Calorie-dense pediatric formulas are designed for
children younger than age 10 years and are concentrated to 1.5 kcal/mL.
59. semi-elemental
• designed to enhance nutrient absorption when the GI tract has been
compromised due to malabsorption or maldigestion.
• contain proteins that have been broken down into peptides and
amino acids.
• The macronutrient composition of these formulas is similar to that of
the polymeric formulas.
• Calorically dense semi elemental formulas can also be used when
children do not tolerate large volumes of formula
60. elemental
• indicated in several situations, such as a compromised GI tract, short-bowel
syndrome, malabsorption, and multiple protein allergies.
• The macronutrient composition of elemental formulas varies greatly.
• Carbohydrates provide approximately 46% to 63% of total calories, fat
contributes 25% to 45% of total calories, and protein adds the remaining
10% to 15% of calories.
• These formulas contain only free amino acids.
• Elemental formulas are provided in powdered form, which allows the
osmotic load to be changed based on the energy concentration of the
order.
• Elemental formulas typically have a greater osmolality than semi-elemental
or polymeric options.
61.
62. Monitoring of Enteral Tolerance
• There are several complications that may result from enteral feeds; they related
to tube function or gastrointestinal intolerance.
• Signs of intolerance include:
• large gastric residuals
• presence of GI symptoms (abdominal distention, constipation, diarrhea, nausea, vomiting),
which may lead to an inability to receive sufficient volume to obtain necessary nutrients from
enteral nutrition.
Medication related complication:
• enteral supplementation of electrolytes such as sodium, potassium, or phosphorus via
feeding tube can result in a high osmolality, contributing to signs of dumping syndrome.
• Patients on prolonged antibiotics may develop altered gut flora, resulting in diarrhea.
• Feeding tubes can migrate or be improperly placed, which can lead to aspiration and poor
tolerance
• Patients who begin nutrition support after a period of decreased intake are at risk for
refeeding syndrome. Initiating feeds at one-third of calorie goal and slowly advancing by one-
third each day with monitoring of electrolytes is necessary in this setting.
Note: dumping syndrome : a condition in which food, especially food high in sugar, moves from your stomach into your
small bowel too quickly after you eat, causing abdominal pain, cramping, and/or diarrhea.
• Patients who begin nutrition support after a period of decreased intake are at risk for refeeding syndrome. These patients are
prone to hypophosphatemia, hypokalemia, and hypomagnesemia. Physiologic alterations include tachycardia and fluid
retention.
63.
64. Parenteral nutrition
• may be indicated in pediatric patients who are unable to feed orally and do not tolerate enteral feedings
65. Parenteral Access
• Parenteral nutrition can be administered through a central or a
peripheral line.
• A central venous catheter is placed with the catheter tip into the
superior vena cava. Access through the main, central vein is often
preferred as more concentrated solutions can be provided.
• Peripheral parenteral nutrition (PPN) is delivered via a smaller vein
and is limited to 10% to 12% dextrose solutions.
66. Note: PICC - Peripherally inserted central catheter
67. Nutrient requirements in PN
• Energy requirement: For critically ill pediatric patients, the goal is set
for maintenance, not growth
• Children who need TPN may have different fluid requirements and need more energy
(up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day)
• Carbohydrate: . Provision of intravenous dextrose blunts
gluconeogenesis, thereby minimizing erosion of lean body mass. In
children aged 0 to 2 years, who are highly reliant on glucose as their
primary fuel source, intravenous dextrose should comprise a majority
of calories. Intakes of at least 50% to 60% of total energy requirement
are suggested
68. • Likewise, intake can be based on the glucose infusion rate (GIR),
which represents the amount of glucose that is oxidized
69. lipid
• Intravenous lipid injectable emulsions (ILEs) offer the advantage of being energy
dense and low in osmolality.
• Lipid turnover and fatty acid oxidation are increased during critical illness in
children, indicating that fat is a good source of energy in this setting.
• ILEs also provide essential fatty acids, even in small amounts (5% of energy
requirement from linoleic and linolenic fatty acids).
• fat in general accounts for approximately 30% to 40% of energy intake. Infants
can receive as little as 25% of their total calories from fat, or 2.5 to 3 g/kg/day.
Older children with decreased fat needs may receive a higher percentage
approximating 1.5 to 2.5 g/kg/day of fat.
• Energy intake from fat that exceeds 60% is associated with a risk of pulmonary
complications, alteration in neutrophil function, aggregation of platelets, and
mitochondrial defects.
• Most ILE are soy based and thus higher in linoleic (omega-6) fatty acid.
70. • ILEs also provide essential fatty acids, even in small amounts (5% of energy
requirement from linoleic and linolenic fatty acids).
• fat in general accounts for approximately 30% to 40% of energy intake.
Infants can receive as little as 25% of their total calories from fat, or 2.5 to
3 g/kg/day. Older children with decreased fat needs may receive a higher
percentage approximating 1.5 to 2.5 g/kg/day of fat.
• Energy intake from fat that exceeds 60% is associated with a risk of
pulmonary complications, alteration in neutrophil function, aggregation of
platelets, and mitochondrial defects.
• Most ILE are soy based and thus higher in linoleic (omega-6) fatty acid.
Because omega-6 fatty acids stimulate the production of inflammatory
mediators, soy-based lipid emulsions are somewhat undesirable.77
71. • The recommended minimum amount of protein in critically ill
children is 1.5 g/kg per day.66
• In neonates, 1.5 to 3 g/kg of protein are required. From ages 1 to 3
years, 2 to 3 g/kg of protein are necessary as a minimum, while older
children require 1 to 2.5 g/kg of protein in PN solutions.
• Amino acid solutions should not exceed 4 g/kg to prevent azotemia.
Note : Azotemia is when you have too much nitrogen and other waste products in your
blood
72. Fluid and Electrolytes
• In PN solutions, fluid and electrolytes are provided based on the clinical
condition of the patient.
73. • Vitamin and trace element solutions are added to formulas.
• In patients younger than 11 years, pediatric vitamin mixes are provided based on the weight of the child.
• Similar to normal pediatric patients, calcium and phosphorus are both nutrients of concern because they
are required for bone mineralization
• Deficiencies in zinc, selenium, and copper are common in patients receiving PN.
• Adequate levels of these minerals are necessary for development, as well as wound healing and immunity.
• Carnitine, an amino acid derivative, is required for lipid oxidation in patients receiving PN for more than 4
weeks. It can also benefit patients who have high triglycerides. Carnitine should be provided at a rate of 2
to 5 mg/kg/day.
additives
74. In order to manage FTT,
the child’s energy needs for catch up growth must be assessed . First, determine the ideal body weight for the child based
on age or height. The ideal body weight can be based on the 50th percentile on the growth charts, when stunting has
occurred. If the child being evaluated falls below the 3rd percentile, the 5th to 25th percentile can be used as the goal
weight. In nonstunted children, the ideal weight-for length can be used as well. Once the ideal body weight has been
determined, the nutritional requirements, for catch-up growth, should be set for the child
Catch-up Growth
75. In order to achieve catch-up growth, catch-up diet, i.e., F-100
(calories 100, protein 2.9 g/100 mL started 3 hourly). It is
started for weight gain, functional and immunological recovery.
If F-75 and F-100 are not available, nutritionists should
calculate the amount of starter feed (prepared with cow’s milk,
sugar, rice powder, and vegetable oil to provide approximately
75 kcal and 0.9 g protein per 100 mL) and catch-up diet (to
provide approximately 100 kcal and 2.9 g protein per 100 mL)
to be offered to admitted SAM children, based on their daily
weight measured between 10 am and 11 am.
76.
77.
78.
79. Management
• Beyond the age of 6 months, more than 90% of the iron requirements
of a breast-fed infant must be met by complementary food rich in bio-
available iron
• Dietary diversification must be encouraged.
• advisable to avoid consumption of beverages like tea and coffee with
food as tannin contained in these may interfere with iron absorption.
• Foods containing ascorbic acid may enhance iron absorption
• Cooking in cast iron vessels:
• Food fortification:Fortified wheat flour or rice
80. • Iron supplementation:Iron supplementation should be given to children
aged 6-60 months in the dose of 10-30 mg /day, three months a year
wherever prevalence of anemia is >20%
• 1-2 mg/kg/day [22] as most of India has >40% prevalence of anemia
• National Health Mission (NHM) guidelines [23] recommend bi-weekly 100
doses/year of 20 mg Fe + 100 mcg FA supplementation in 6-60 months age as syrup
• Low birth weight [LBW] babies should be supplemented with iron 2-3
mg/kg/day, beginning from 2 weeks for babies with birthweight 1500g
81. Vit A Deficiency
• Stunted children are also usually deficient in vitamin A, which
places them at increased risk of blindness and death.
• Deficiency status and risk factors:Zinc, Iron and protein-calorie
deficiencies; recurrent clinical and subclinical infections; and parasitic
infestations, adversely affect vitamin A absorption, transport and
utilization. Habitual low dietary intake of vitamin A rich animal food
or beta carotene-rich vegetables-fruits is the major factor for the poor
vitamin A status
82. Management
• Diet:vitamin A rich foods routinely (milk products like butter, ghee,
yogurt, curd, cheese, eggs, liver and yellow/ orange colored
vegetables and fruits); more so during diarrhea, measles and
respiratory infections
• Supplementation:Mega dose vitamin A supplementation is
recommended in children with severe acute malnutrition (SAM)
• Vitamin A , should be given to children with SAM on daily basis throughout the course
of treatment but not in high dosage but in a dosage of 5000 I.u daily, because F-75,F-
100 and RUTF contain vitamin A.
83. Reference:
• The clinical manifestation of the kwashiorkor syndrome is related to increased lipid peroxidation
https://pubmed.ncbi.nlm.nih.gov/9602206/
• https://egyankosh.ac.in/bitstream/123456789/31297/3/Unit-7.pdf
• https://pmposhan.education.gov.in/Files/Guidelines/2023/Guidelines%20on%20PM%20POSHAN%20SC
HEME.pdf
• https://www.cdc.gov/growthcharts/html_charts/wtageinf.htm
• https://www.en-net.org/question/2761.aspx#:~:text=are%20working%20in.-
,Should%20Vitamin%20A%20be%20given%20to%20SAM%20children%20or%20not,formulations%20co
mplying%20with%20WHO%20specifications.
• https://iapindia.org/pdf/Ch-136-Severe-Acute-Malnutrition.pdf
• Advanced medical nutrition therapy / Kelly Kane and Kathy Prelack
