1) Malnutrition is defined as a cellular imbalance between nutrient supply and demand that impacts growth, maintenance, and functions. Severe malnutrition can be classified using weight-for-age, presence of edema, and weight-for-height measurements. 2) Identifying severely malnourished children involves weighing, measuring length/height, and calculating standard deviation scores. Mid-upper arm circumference less than 11.5cm also identifies severe wasting. 3) Severely malnourished children experience a physiological state called "reductive adaptation" where body systems slow down to survive on limited calories. This requires special treatment approaches compared to well-nourished children.

2. Definition
• The World Health Organization (WHO) defines
malnutrition as the cellular imbalance
between the supply of nutrients and energy
and the body’s demand
• to ensure growth, maintenance, and specific
functions.

3. Classification of Undernutrition
1-Gomez Classification : uses weight-
for-age measurements; provide
grading as to prognosis
Weight-for-Age% Status
90-100 Normal
75-90 1st degree
60-75 2nd degree
<60 3rd degree
2-Wellcome Classification : simple since based
on 2 criteria only - wt loss in terms of wt for
age% & presence or absence of edema
Wt-for-Age% Edema No Edema
80-60 Kwashiorkor Undernutrition
< 60 Marasmic-kwashiorkor Marasmus
3-Waterlow Classification : adopted by WHO; can distinguish between deficits of
weight-for-height% (wasting) & height-for-age% (stunting)
N Mild Mod Severe
Ht-for-Age% >95 90-95 80-90 <80
Wt-for-Ht% >90 80-90 70-80 <70

4. Identifying the child with
malnutrition:
• Weighing the children.
• Measure length/height
• If a child is less than 2 years old (or less than 87 cm if the age is not
available), measure recumbent length.
• If the child is aged 2 years or older (or 87 cm or more if the age is
not available) and able to stand, measure standing height.
• In general, standing height is about 0.7 cm less than
recumbent length.
• Determining a standard deviation score (SD-score) based on
the child’s weight and length:

5. standard deviation score (SD-score)

6. Mid-upper arm circumference
(MUAC)
• Community based screening programs for
severe malnutrition usually use MUAC less
than 11.5cm to identify severe wasting.

7. Introduction
• Severe malnutrition is one of the most
common causes of morbidity and mortality
among children under the age of 5 years
worldwide.
• Severely malnourished children often die
because doctors unknowingly use practices
that are suitable for most children, but highly
dangerous for severely malnourished children.

8. Reductive Adaptation System
• The child with severe malnutrition must be
treated differently because his physiology is
seriously abnormal due to:
• Reductive Adaptation System

9. Reductive Adaptation System
• The systems of the body begin to “shut down” with
severe malnutrition.
• The systems slow down and do less in order to allow
survival on limited calories.
• This slowing down is known as reductive adaptation.
• As the child is treated, the body's systems must
gradually "learn" to function fully again.
• Rapid changes (such as rapid feeding or fluids) would
overwhelm the systems, so feeding must be slowly
and cautiously increased.

10. • Reductive adaptation affects
treatment of the child in 3 ways.
• 1- Presume and treat infection
• Nearly all children with severe malnutrition
have bacterial infections.
• However, as a result of reductive adaptation,
the usual signs of infection may not be
apparent, because the body does not use its
limited energy to respond in the usual ways,
such as inflammation or fever.

11. 2.Iron
• Due to reductive adaptation, the severely malnourished
child makes less haemoglobin than usual.
• Iron that is not used for making haemoglobin is put into
storage.
• Giving iron early in treatment can also lead to “free iron” in
the body.
• Free iron can cause problems in three ways:
• • Free iron is highly reactive and promotes the formation of
free radicals with damaging effects.
• • Free iron promotes bacterial growth and can make some
infections worse.
• • The body tries to protect itself from free iron by
converting it to ferritin. This conversion requires energy and
amino acids and diverts these from other critical activities.

12. 3. Provide potassium and restrict sodium
• In reductive adaptation, the “pump” that
usually controls the balance of potassium and
sodium runs slower. As a result, the level of
sodium in the cells rises and potassium leaks
out of the cells and is lost.
• ReSoMal has less sodium and more potassium
than regular ORS.

13. • Severe wasting.
• Oedema.
• Dermataosis.
• Eye signs.

14. Severe wasting Oedema Dermatosis Eye signs
front view
-ribs easily seen
-upper arms look
loose
-thighs look loose
+ mild: both feet + mild: discoloration
or a few rough patches
of skin
Bitot’s spots –
back view
-ribs and shoulder
bones easily seen
- flesh missing from
the buttocks
+ + moderate: both
feet, plus lower legs,
hands, or lower arms
+ + moderate:
multiple patches on
arms and/or legs
Pus and inflammation
(redness) are signs of
eye infection.
+ + + severe:
generalized oedema
including both feet,
legs, hands, arms and
face
+ + + severe: flaking
skin, raw skin, fissures
(openings in the skin)
Corneal clouding
Corneal ulceration

15. Classification of malnutrition:
Classification of malnutrition:
Undernutrition is defined as insufficient food intake combined with
repeated
occurrence of infectious diseases (UNICEF, 2007).
Moderate Acute Malnutrition (MAM) is defined by WHO/UNICEF as:
Weight-for-Height Z-score <-2 but >-3
Severe Acute Malnutrition (SAM) is defined by WHO/UNICEF as:
MUAC (mid-upper arm circumference) <11.5cm
Weight-for-Height Z-score <-3
Bilateral pitting oedema

16. Essential components of care:
• WHO recommends that children be kept in
the severe malnutrition ward or area until
they reach −1 SD (90%) weight-for-height.

17. Feeding formulas: What are F-75 and F-100?
• F-75 is the "starter" formula to use during
initial management, beginning as soon as
possible and continuing for 2−7 days until the
child is stabilized.
• F 75 a diet that is low in protein and sodium
and high in carbohydrate. F-75 contains 75
kcal and 0.9 g protein per 100 ml.

18. • As soon as the child is stabilized on F-75, F-100
is used as a "catch-up" formula to rebuild
wasted tissues.
• F-100 contains more calories and protein: 100
kcal and 2.9 g protein per 100 ml.

20. There are ten essential steps:
1.Treat/prevent hypoglycaemia
2.Treat/prevent hypothermia
3.Treat/prevent dehydration
4.Correct electrolyte imbalance
5.Treat/prevent infection
6.Correct micronutrient deficiencies
7.Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional
support
10. Prepare for follow-up after recovery

21. • In severely malnourished children, the level
considered low is less than (<) 3 mmol/litre (or
<54 mg/dl).
• If the child can drink, give the 50 ml bolus
of 10% glucose orally. If the child is alert but
not drinking, give the 50 ml by NG tube.

22. Treat hypoglycaemia:
• If the child is lethargic, unconscious, or convulsing,
give 5 ml/kg body weight of sterile 10% glucose by
IV, followed by 50 ml of 10% glucose by NG tube.
If the IV dose cannot be given immediately, give the
NG dose first.
• Start feeding F-75 half an hour after giving glucose ,
during the first 2 hours.
• If the child’s blood glucose is not low, begin feeding
the child with F-75 right away. Feed the child every
2 hours, even during the night.

23. Manage hypothermia
• Actively re-warm the hypothermic child:
• keeping the child covered and
• keeping the room warm,
• Have the mother hold the child with his skin
next to her skin when possible (kangaroo
technique), and cover both of them.
• Keep the child’s head covered.

24. Manage Shock:
• The severely malnourished child is considered
to have shock if he/she:
• is lethargic or unconscious and
• has cold hands
• plus either:
• slow capillary refill (longer than 3 seconds),or
• weak or fast pulse.

25. • Give oxygen, IV glucose, and IV fluids for
shock
• Give sterile 10% glucose 5 ml/kg by IV
• then infuse IV fluid at 15ml/kg over 1 hour.
• Use 0.45% (half-normal) saline with 5%
glucose).
• Observe the child and check respiratory and
pulse rates every 10 minutes.

26. • If respiratory rate and pulse rate are slower after
1 hour, the child is improving. stop the IV.
• If the respiratory rate and pulse rate increase
Repeat the same amount of IV fluids for another
hour.
• Continue to check respiratory and pulse rates
every 10 minutes.
• After 2 hours of IV fluids, switch to oral or
nasogastric rehydration with ReSoMal (special
rehydration solution for children with severe
malnutrition).

27. • Give 5 − 10 ml/kg ReSoMal in alternate hours with F-75
for up to 10 hours.
• Leave the IV line in place in case it is needed again.
• If the child fails to improve after the Second hour of IV
fluids, then assume that the child has septic shock.
• Give maintenance IV fluids (4 ml/kg/hour) while
waiting for blood.
• When blood is available, stop all oral intake and IV
fluids, give a diuretic to make room for the blood, and
then transfuse whole fresh blood at 10 ml/kg slowly
over 3 hours.

28. Manage anemia:
• Mild or moderate anaemia is very common in severely
malnourished children and should be treated later with
iron, after the child has stabilized.
• Very severe anaemia
• If haemoglobin is less than 40 g/l, (or packed cell volume is
less than 12 %), give a blood transfusion.
• If there are no signs of congestive heart failure, transfuse
whole fresh blood at 10 ml/kg slowly over 3 hours.
• If there are signs of heart failure, give 5 – 7 ml/kg packed
cells over 3 hours instead of whole blood. Give a diuretic;
Furosemide (1 mg/kg, given by IV)

29. Corneal ulceration
• All severely malnourished children need
vitamin A on Day 1.
• Additional doses are given if:
• the child has signs of eye infection, measles ,
clinical signs of vitamin A deficiency.
• The additional doses are given on Day 2 and
at least 2 weeks later, preferably on Day 15.
Child's age Vitamin A Oral Dose
< 6 months 50 000 IU
6 − 12 months 100 000 IU
>12 months 200 000 IU

30. Manage watery diarrhoea and/or vomiting with
ReSoMal:
• ReSoMal is Rehydration Solution for Malnutrition. It
is a modification of the standard Oral Rehydration
Solution (ORS) recommended by WHO.
• ReSoMal contains less sodium, more sugar, and more
potassium than standard ORS
• For children < 2 years, give 50 − 100 ml after each loose
stool. For children 2 years and older, give 100 − 200 ml
after each loose stool.
• It should be given by mouth or by nasogastric tube.
• If the child develops a hard distended abdomen with
very little bowel sound, give 2 ml of a 50% solution of
magnesium sulphate IM.

31. Give antibiotics:
• Give all severely malnourished children
antibiotics for presumed infection.
IF: GIVE:
NO COMPLICATIONS Amoxil Oral
Cotrimoxazole Oral (25 mg sulfamethoxazole + 5 mg
trimethoprim / kg) every 12 hours for 5 days
COMPLlCATIONS
(shock, hypoglycaemia,
hypothermia, dermatosis
with raw skin/fissures,
respiratory or urinary tract
infections, or
lethargic/sickly appearance)
Gentamicin IV or IM (7.5 mg/kg), once daily for 7
days, plus:
Ampicillin IV or IM (50 mg/kg), every 6 hours for 2 days
Followed by: Amoxicillin Oral (15 mg/kg), every 8 hours for
5 days

32. •

33. Determine frequency & Amount
of feeds
• Feed orally .
• Use an NG tube if the child :
• does not take 80% of the feed (i.e., leaves
more than 20%) for 2 or 3 consecutive feeds.
• Remove the NG tube when the child takes:
80% of the day’s amount orally; or two
consecutive feeds fully by mouth.

34. Determine frequency of feeds:
• On the first day, feed the child a small amount of F-75
every 2 hours (12 feeds in 24 hours, including through
the night).
• If the child is hypoglycaemic, give ¼ of the 2-hourly
amount every half-hour for the first 2 hours or until the
child’s blood glucose is at least 3 mmol/l.
• After the first day, increase the volume per feed
gradually so that the child's system is not
overwhelmed.
• The child will gradually be able to take larger, less
frequent feeds (every 3 hours or every 4 hours).

35. Determine amount of F-75 needed per feed:

36. • Criteria for increasing volume/decreasing
frequency of feeds:
• If little or no vomiting, modest diarrhoea (for
example, less than 5 watery stools per day),
and finishing most feeds, change to 3-hourly
feeds.
• After a day on 3-hourly feeds: If no vomiting,
less diarrhoea, and finishing most feeds,
change to 4-hourly feeds.

37. Adjusting to F-100 during transition, or
feeding freely on F-100:
• Look for the following signs of readiness
usually after 2 − 7 days:
• Return of appetite (easily finishes 4-hourly
feeds of F 75)
• Reduced oedema or minimal oedema
• The child may also smile at this stage.

38. • Begin giving F-100 slowly and gradually:
• Transition takes 3 days.
• First 48 hours (2 days): Give F-100 every 4 hours in the
same amount as you last gave F-75. Do not increase this
amount for 2 days.
• Then, on the 3rd day: Increase each feed by 10 ml as
long as the child is finishing feeds.
• Continue increasing the amount until some food is left
after most feeds (usually when amount reaches about 30
ml/kg per feed).
• If the child is breastfeeding, encourage the mother to
breastfeed between feeds of F-100.

39. Rehabilitation" phase
• After transition, the child is in the
"rehabilitation" phase and can feed freely on
F-100 to an upper limit of 220 kcal/kg/day.
• (This is equal to 220 ml/kg/day.)

40. Others??
• Folic acid: Each child should be given a large dose
(5mg) on Day 1 and a smaller dose (1mg) on
subsequent days.
• Multivitamin: daily (not including iron).
• Iron:
, give iron daily,
Calculate and administer the amount needed:
Give 3 mg elemental Fe/kg/day in 2 divided
doses. Always give iron orally, never by injection.
Preferably give iron between meals using a liquid
preparation.

41. Monitor individual patient progress and care:
• Good weight gain: 10 g/kg/day or more
• Moderate weight gain: 5 up to10 g/kg/day
• Poor weight gain: Less than 5 g/kg/day

42. Criteria for failure to respond to
treatment
Criteria Time after admission
Primary failure to respond:
 Failure to regain appetite Day 4
 Failure to start to lose oedema Day 4
 Oedema still present Day 10
 Failure to gain at least 5 g/kg Day 10
of body weight per day
Secondary failure to respond:
 Failure to gain at least 5 g/kg During rehabilitation
of body weight per dayfor 3
successive days

43. • Problems with the treatment facility:
• Poor environment for malnourished
children.
• Insufficient or inadequately trained staff.
• Inaccurate weighing machines.
• Food prepared or given incorrectly.

44. Review patient records for common factors in
adverse outcomes:
• Deaths that occur within the first 2 days are
often due to:
Hypoglycaemia.
Overhydration.
Unrecognized or mismanaged septic shock, or
other serious infection.
• Deaths that occur after 2 days are often due to:
• Heart failure.

45. • WHO recommends that children be kept in the severe
malnutrition ward or area until they reach −1 SD weight-for-
height. It usually requires about 2 – 6 weeks .
• If a child leaves before being achieving -1 SD, he is likely
to get worse and have to return.
• WHO recommends that children be kept in the severe
malnutrition ward or area until their condition is stabilized(
regained appetite, reduced edema and good acceptance
of RUTF during transition phase.

46. Give general discharge
instructions:
• In addition to feeding instructions, mothers
will need to be taught:
• The mother has been thoroughly trained in
how to feed the child at home and give
supplements.
• how to continue any needed medications,
vitamins , folic acid (for 1 − 2 weeks),
• and iron (for 1 month) at home

47. • when and where to go for planned follow-up:
• at 1 week, 2 weeks, 1 month, 3 months, and
6 months;
• then twice yearly visits until the child is at
least 3 years old.

48. THANKS FOR YOUR
PATIENCE….