This document provides information on malnutrition including burden, macronutrients, micronutrients, assessment, classification, and treatment. It discusses that malnutrition causes 3.1 million child deaths annually. It outlines protein, fat, carbohydrate, water, vitamin A, iron, and zinc sources. It describes assessing for and classifying malnutrition as moderate, severe, marasmus, kwashiorkor, or marastic-kwashiorkor. Treatment for moderate or severe acute malnutrition including stabilization, rehabilitation, and discharge criteria are covered.

1. M A L N U T R I T I O N
CPD/CME
ST FRANCIS HEALTH CARE SERVICES
NJERU, JINJA,UGANDA
LIFENET INTERNATIONAL TRANSFORMING
AFRICA HEALTH CARE
26TH /JUL/2023 @ 14:00hrs
DR. MWEBAZA VICTOR
MODULE 5: LESSON ONE

2. Burden of the disease
1. Undernutrition is estimated to cause 3.1 million child deaths every year or
45% of all child deaths
2. Severe protein-energy malnutrition (PEM) is a leading cause of death
among children younger than 5 years and causes approximately 40% of
childhood deaths in Uganda
3. Dietary recommendations vary by age based on optimal growth and
developmental needs

3. Macronutrients/Micronutrients
Macronutrients
1. Protein
2. Fat
3. Carbohydrates
Micronutrients
1. Water
2. Vitamin A
3. Iron, Zinc etc

4. Macronutrients/Micronutrients and Main Sources
Proteins
Protein foods are essential for childhood growth and development.
Where is protein found?
Animal foods such as chicken, fish, animal liver, milk, eggs, or goat.
Non-animal based foods including legumes (groundnuts, lentils), red beans,
brown rice and soya beans.

5. Fats
Fat foods allow vitamins to be transported and absorbed in the body.
Fats also provide for brain health and cell development as well as help keep our
blood healthy.
There is evidence that shows unsaturated fats are healthier than saturated fats.
However, when only saturated fats are available, they may be acceptable.
Unsaturated fats are found in fish, avocados or nuts and seeds. Saturated fats are found
in animal foods like eggs, meat, whole milk and cheese or red palm oil, butter and
margarine.
It is important to remember that a good balance of these foods is healthy for children.
Macronutrients/Micronutrients and Main
Sources

6. Macronutrients/Micronutrients and Main Sources
Carbohydrates:
Carbohydrate foods are critical for energy and provide cells with glucose.
Carbohydrates give muscles energy to move, as well as provide a fuel for the
central nervous system.
Carbohydrates should make up most of the calories we eat.
Where are carbohydrates found?
Foods like grains, rice, vegetables, fruit, beans, potatoes, and dairy all have
carbohydrates.

7. Macronutrients/Micronutrients and Main Sources
Water may be considered another macronutrient as it is a main component of good
nutrition.
Proper hydration is critical, as children’s bodies do not readily adapt to changes in
temperature.
Water is also a macronutrient because its needed in large amounts, but
unlike the other macronutrients it does not contain carbon or yeild enrgy

8. During excessive heat or physical activity, children may not get adequate
hydration because they might not feel thirsty.
Checking urine for colour may help to determine hydration. Urine should
be clear and light in colour rather than dark amber coloured. Signs of
dehydration include;Thirst, Headache, Muscle cramps, Dizziness,
Fatigue, Irritability, Nausea,Confusion/altered mental state

9. Macronutrients/Micronutrients and Main Sources
• Water recommendations will vary depending on your child’s level of physical
activity, body size and weather/surrounding temperature.
• Generally, children should drink approximately 1.5-2 L of water per day.
• A good guide to follow for correcting dehydration with IV therapy is one based on
weight called the Holliday-Segar formula:
• 0-10kg = 4mL/kg/hr
• 10-20kg = 40 mL + 2mL for each kg of body weight >10 per hr
• >20kg = 60mL + 1 mL for each kg of body weight >20 per hr

10. Macronutrients/Micronutrients and Main Sources
• Vitamin A
• A vitamin that is essential for immune health, vision, healthy skin and DNA
transcription. Vitamin A is formed in the body when foods containing beta carotene (a
retinoid) are consumed.
• Where is beta carotene found?
• Orange is the colour to look for to indicate a food may contain beta carotene. Beta
Carotene rich foods include carrots, tomatoes, orange sweet potatoes as well as dark
leafy greens.
• Children aged 6 months to 5 years can also get vitamin A from a variety of other
foods, such as liver, eggs, dairy products, fatty fish, red palm oil, ripe mangoes and
papayas, and oranges.

11. vitamin A
In areas of the world where vitamin A deficiency is common, including Uganda, the
WHO recommends vitamin A supplementation:
High dose of vitamin A is recommended every six months until the age of five years
A single high dose of vitamin A is highly absorbed, and is a fat-soluble vitamin stored in
the liver and used over an extended period of time as needed
“In infants 6-11 months of age doses of 100 000 IU and in children 12-59 months of age
200 000 IU have been considered to provide adequate protection for 4-6 months”

12. vitamin A
Supplementation for children with diarrhea with vitamin A is very
important as well.
In areas where it is known or suspected that children suffer from
vitamin A deficiency, those children with diarrhea should be
given a vitamin A supplement if they have not received one
within the past month, or if they are not already receiving vitamin
A at regular four to six month intervals”

13. ZINC
ZINC should also be given: “Zinc (tablet or syrup) can also be given for
10–14 days to reduce the severity and the duration of the diarrhea as
well as protect the child for up to two months from future diarrhea
episodes.
The dosage for children over 6 months of age is 20 milligrams per day,
for children under 6 months of age it is 10 milligrams per day

14. Iron
A mineral, iron is critical for cellular health, particularly red blood
cell health.
It also helps maintain healthy skin, hair and nails.
Children need iron-rich foods to protect their physical and mental
abilities and to prevent anemia. Iron deficiency anemia in early
childhood can lead to development delays

15. Found in beans, lentils, meats, liver, fish, and dark leafy
greens such as chard, spinach, collards or kale.
Combined with a source of Vitamin C, iron from non-meat
sources can be more easily absorbed. For example,
combining beans with tomatoes or oranges.

16. What if a child has anemia?
Children under the age of two who are diagnosed with anaemia should be targeted
and treated with daily iron supplementation until hemoglobin concentrations return
to normal.
Infants have higher iron requirements in comparison with other age groups because
they grow so rapidly.
They are born with good iron stores but beyond 6 months of age, the iron content of
the milk is not enough to meet many infants’ requirements.

17. For infants and children - oral supplementation with 3-6mg/kg/day of
elemental iron, depending on the severity of the anemia (recommended to
use ferrous sulfate)
Anemic women and girls should be targeted and treated with 120 mg of
elemental iron plus 400 μg of folic acid daily supplementation until
haemoglobin concentration is normal.

18. What else should be done about anemia?
1. Malaria and hookworm can be the main causes of anaemia.
2. Taking iron supplements to treat anaemia while having malaria can worsen
the anemia.
3. Children living in malarial areas should not take iron and folic acid
preparations, including iron-containing powders, unless the malaria has
been diagnosed and treated and they have been screened for anemia.”
4. Children living in areas where worms are highly endemic should be treated
two to three times a year with a recommended deworming (anthelmintic)
medication.

19. Assessing for Malnutrition
1. History taking which emphasize on nutritional history, growth and
development and also other elements in hx are important
2. Anthropometry, anthropometric involves noting the height/ length, MUAC,
BMI, head circumference, skin fold etc with aid of WHO Z-scores then
WFH/ WFL to assess wasting, WFA to assess for under weight, H/LFA to
assess for stunting note length is for children less than 2yrs/87.0cm and
height is for children above 2yrs/87.0cm
3. Physical examination
4. Investigations; biochemical, haematological, microbiological, radiological

20. CLASSIFICATION OF MALNUTRITION

25. S.A.M nonedematous
Most common form of malnutrition characterized by Severe wasting/weight loss caused by
inadequate intake of all nutrients, but especially energy sources (carbohydrates).
Affects the function of other organs such as the liver, kidneys, & heart and may cause low blood
sugar, low body temperature, fluid overload, and infection.
Severe constipation, Hypothermia, low blood sugar, fluid overload, infection, low pulse, low blood
pressure
Thin, dry skin, VERY hungry, Low weight and height for age
Head may look large with staring eyes; shrunken arms, thighs, & buttocks (with skin folds from loss
of fat)
Thin, weak appearance, irritable, thin, patchy hair

27. S.A.M edematous
Also known as protein energy malnutrition.
Characterized by muscle shrinking with normal or increased body fat and the
defining characteristic being Bi-lateral edema (puffy/bloated appearance from
water retention)
Severe generalized edema. Pitting edema in the lower extremities, genitalia,
and around the eyes
“Moon” face (round) - Hypothermia - Ascites/abdominal distention
Loss of appetite, irritability or apathy, yellow/orange hair colour, dermatosis

29. Marasmic-Kwashiorkor
Marasmic kwashiorkor is the third form of protein-energy malnutrition that
combines features and symptoms of both marasmus and kwashiorkor.
A person with marasmic kwashiorkor may: – be extremely thin. – show signs of
wasting in areas of the body. – have excessive fluid buildup in other parts. A
combination of both wasting & bi-lateral edema from inadequate intake of all
nutrients

30. - This type of malnutrition may be triggered by a
common infectious childhood illness
- Common signs/symptoms:
- Anorexia, Dermatitis
- Sometimes neurological abnormalities
(depression/flat affect)

33. Chronic Malnutrition
Stunting (shortness/poor cognitive development)

34. Moderate Malnutrition
1. Wasting: Weight-for-height z-score less than -2 to -3
2. Stunting (chronic malnutrition): Height or length z-score less than -2 to -3
3. MUAC-11.5cm to 12.5cm

35. Severe Malnutrition:
- Wasting: Weight-for-height z-score below -3 standard deviations
- Stunting: Height or length z-score less than -3
- Malnutrition: Severe wasting, severe stunting, OR edema
Note: The presence of bi-lateral edema of the lower limbs alone indicates severe
malnutrition, after other causes of edema have been ruled out)
- Mid-upper arm circumference of less than or equal to 11.5cm in children 6 months
- 5 years

36. Treatment of Moderate Acute Malnutrition
o Assess the child’s feeding & counsel the mother on feeding recommendations
o If there are feeding problems, provide counsel & follow up in one week
o Assess for possible TB infection
o Counsel the mother on danger signs & advise to return immediately if any of these
signs are observed.
o Follow-up in 30 days to reassess the child.
o Provide further counselling if needed.
o Refer if the child has worsened, is losing weight, or there is a feeding problem

38. Treatment of Severe Acute Malnutrition
Uncomplicated: Good appetite & are clinically well (NO medical complication,
severe bilateral edema, or clinical signs of sepsis)
Community-based therapy is recommended
1. Given a course of antibiotics (such as amoxicillin)
2. Give RUTF (Ready to Use Therapeutic Formula) if the child is ≥6 months &
treat until fully recovered
3. Children should also be offered safe drinking water & breastfeeding should
continue if they are being breastfed

39. Treatment of Severe Acute Malnutrition
4. Provide counselling to the mother on how to feed the child.
5. Should receive daily recommended intake of Vitamin A throughout the
treatment period (5000 IU daily - either as a part of therapeutic foods or vitamin
formulation)
6. Assess for possible TB infection
7. Advise the mother on when to return (danger signs)
8. Follow up should be done weekly

40. Treatment of Severe Acute Malnutrition
Complicated:
Poor appetite, medical complications, severe edema, or present with one or
more childhood illness danger signs
Admission required - Refer to hospital but health centres should be aware of
treatment process

41. Initial stabilization:
• Treatment of hypoglycemia, hypothermia (temperature control/warming), &
dehydration
• Identify and treat infection (treatment with antibiotics)
• Treat electrolyte and vitamin deficiencies
• Begin feedings (increase as appetite increases)
• For breastfed infants, continue breastfeeding
• If the clinic has stock, give F-75 formula (75 kcal/100 mL) in small amounts
frequently.
• Energy intake should equal approximately 80 kcal/kg per day, not to exceed 100
kcal/kg

42. Treatment of Severe Acute Malnutrition
Fluid replacement;
- Half-strength Darrow's solution with 5% dextrose (dilute full-strength Darrow's
solution with an equal amount of 5% D5W), OR
- Ringer's Lactate with 5% dextrose, OR If neither is available, 0.45% saline + 5%
dextrose should be used.
- Initial bolus: no more than 15 mL/kg over one hour…if signs of improvement
(decrease in respiration rates and pulse), give a second bolus of 15 mL/kg if child
still cannot take anything by mouth
- “If the child is not improving after the first bolus, he/she may be suffering from
shock rather than dehydration”

43. Rehabilitation
- 2-6 weeks long
- Train the mother to continue care at home
- Address social problems
- Focus on emotional stimulation & sensory development
- Feeding formula is changed to F-100 formula (100 kcal/100 mL) OR RUTF (Ready-To-Use
Therapeutic Food)
- F-100 should be diluted in infants less than 6 months of age
- Should be fed at least five times a day
- In children older than two, solid local foods rich in vitamins and minerals should be introduced
- WHO recommends Vitamin A 5000 IU per day throughout the treatment period either through
therapeutic foods (F-75, F-100, or RUTF) or a multivitamin supplement

44. Treatment of Severe Acute Malnutrition (complicated)
Most severely malnourished children are anemic, so…
- a folic acid supplement should be given starting the day of admission (5 mg initial
dose, followed by 1 mg daily)
- iron (3 mg/kg per day in three divided doses) should be started in the rehabilitation
phase and continued for 3 months
- Zinc provided for children with diarrhea. “Children with severe malnutrition who are
receiving F-75, F-100 or ready-to-use therapeutic food that complies with the WHO
specifications should not be given additional zinc supplements even if they have
diarrhea, as these therapeutic foods contain at least the recommended amounts of
zinc for management of diarrhea.”

45. Discharge
WHO suggests that children 6 - 59 months of age may be discharged from
treatment (either inpatient or outpatient) when they meet certain criteria:
- Weight-for-length z-score is ≥-2 and no edema for least 2 weeks, OR
- Mid-upper-arm circumference is ≥12.5 cm and no edema for at least 2 weeks
- After discharge, monitor the physical, mental, and emotional development
*Note: For children with HIV who are not already treated with ARV's, treatment
should be started as soon as possible, once metabolic complications and
sepsis have been stabilized