Malnutrition in children remains a significant public health problem. Severe acute malnutrition (SAM) can be life-threatening and is defined by severe wasting or nutritional edema. Recognizing signs of SAM like loose skin and visible bones is important for diagnosis and treatment. Management of SAM involves carefully monitoring medical complications, providing a structured feeding plan, and follow up after discharge to prevent future malnutrition. The pathophysiology of SAM is characterized by "reductive adaptation" where body systems slow down to conserve energy in a state of limited calories and nutrients. Gradual refeeding is needed to help systems regain normal function.

1. MALNUTRITION IN
CHILDREN

2. OBJECTIVES
• INTRODUCTION_Epidiomiology.
_Component of nutrition.
_Causes of malnutrition
PRINCIPLES OF CARE_Recognizing signs of Malnutrition.
_Weighing and measuring the child.
_Recomended criteria of Admission.
PATHOPHYSIOLOGY OF SEVERE MALNUTRITION.
MANANGEMENT OF MALNUTRITION;
_MGT of medical complications.
_Overview of the essential component of care.
_Feeding plan.
_Discharge and monitoring plan.

3. PRE-EVALUATION TEST
• Describe the malnutrition situation in kenya [5mks].
• Is malnutrition a public health concern? How [5mks].
• Outline the causes of malnutrition.[5mks]
• Recognize signs of moderate or SAM.[5MKS].
• Are you able to conduct anthropometric measurements.[5mks]
• Explain “Reductive adaptation [5mks]
• Outline essential components of care .[5mks]
• Are you aware there is difined feeding plan and monitoring for patient
with SAM? Explain 15mks.

4. EPIDIEMIOLOGY/MALNUTRITION SITUATION
• Recent data shows that an unaceptibly large numbers of children
under 5 are still afected by malnutrition.
• Acording to 2014 data; 26% are stunted,4% waisted,11%
underweight,8% LBWT and 9% women undernaourished.
.Globally 14.6% of all newborns have low BWT,1 in 5 children
stunted[149.2m],45.4m [6.7%] wasted,38.9m[5.7%] over
weight,451.8m adults are undernaourished and 2.2B are overweight.

5. KCRH Nutrition situation
INDICATOR JULY AUG SEP TOTAL
SAM[MOH 733] 50 41 96 193
MAM[MOH733][ 59 44 133 236
SUW&UW[MOH711
0-<6 Months
60 57 47 164
SUW
&UW[MOH711]6-
23Months
49 24 55 128
SUW &UW[MOH
711]24-59Months
02 01 00 3
Stunting/severe
stunting[moh 711]0-
<6m
59 30 39 128
Stunting/severe
stunting[MOH711]6
-23m.
39 19 33 91

6. MALNUTRITION AS A PUBLIC HEALTH
CONCERN
• WHO classify malnutrion worldwide as greatest threat to public
health, with SAM afecting nearly 20 million in childen under 5 causing
upto 1 million dates yearly.
• Most susceptible age for MAL, is 6-18Months but may also occur in
infants less than 6 months due to early introduction of solid to
children,
• Its commonly underecgnized and undertreated in hospital patients
thus SCREENING SHOULD BE UNDERTAKEN TO ALL CHILDRENS.

7. CAUSES OF MALNUTRITION
• MAL is state when the body does not have enough of the required
nutrients[under nutrition],or excess of required nutrients[over nutrition].
• Nutrional status includes 3 indices;
• 1.stunting ---height for age
• 2.wasting__weight for height
• 3.Underweight_weight for age
• Of more concern today, SAM is difined by 2 distinct entities:Severe
wasting[marsmus] and nutrional oedema [kwashiokor].
• Has 2 components;
• Macro nutrients –carbs,proteins,fats and oils.
• Micro nutrients-vitamins and minerals.
• Causes of malnutrion involves the following;

8. Causes of malnutrition
• Immediate causes; inadequate food intake and diseases
• Underlying causes; limited access or availlability of food,adequate
health care, lack of knowledge and unemployment.
• Basic causes; lack of access of market due to poor infrastructure

9. PRINCIPAL OF CARE
Recognizing signs of Malnutrition
• Severe muscle waiting:-
• A child with severe wasting has lost fat and muscle and appear very thin.[marasmus]
• To look for severe wasting ,remove the child’s clothes.
• Look at the front view of the child;
-Is the outline of the child’s ribs easily seen?
_Does the skin of the upper arms look loose?
_Does the skin of the thigs look loose?
At the back view of the child,look for;
_Are the ribs and shoulder bones easily seen?
_Excessive skin hanging from the buttocks [baggy pants] and protrussion of hip bones?

10. Oedema
• Oedema is the swelling due to excess fluid in the tissues.
• Oedema is usually seen in the feet and lower legs and arms.
• In severe cases it may also be seen in the upper limb and face.
• Oedema is graded as follows;
• Absent or [o]= No billateral pitting oedema.
• Grade += mild both feet/ankle.
• Grade ++ =Moderate both feet,plus lower legs,hands or L arms.
• Grade +++ =severe generalised bilateral pitting oedema,including
both feet,legs arm and face.

11. Characteristics of Marasmus and kwashiokor
Severe weight loss and waisting Bilateral pitting oedema
Front view ;ribs easily seen,skin of upper arms
loose,skin of thighs loose
Loss of appetite
Back view;Ribs and shulder bones easily seen,muscle
missing from buttocks,resulting in loose skin or ‘baggy
pants’.
Apathetic and lethagic,irritable when handled
Normal hair. Change in hair colou[yellow,redish,orange] which
become sparse,dry and brittle.
Frequent infections with minimal external signs[not
oftn showing fever]
Dermatosis
Usually active and may appear to be aleart
May have a good appetite.

12. Dermatosis
• Is skin condition.
• The extent of dermatosis dermatosis can be described in the
following way;
• + mild :discoloration or a few rough patches of the skin.
• ++ moderate mutiple patches on arms and or/legs
• +++ severe flaking skin,raw skin,fissures[openings of the skin

13. Eye signs
• Children with severe malnutrition may have signs of eye infection and
or vitamin deficiency.
• Bitot’s spots.superficial formy white spots on the conjuctiva.
• Pus and inflamation-redness
• Corneal clouding is seen as an opaque appearance of the cornea.
• Corneal ulceration-break in the surface of the cornea.

14. WEIGHING AND MEASURING THE CHILD
• Measuring weight.
• Measuring leghth/height.
• Mid upper arm circumference.

15. Recommended criteria for admission
• According to WHO ,A child with SAM and has the following medical complications;
• 1. Unable to breastfeed,drink or feed.
• 2.Vomiting everything.
• 3.Convulsions.
• 4.Very weak ,lethargic or unconsious.
• 5.Hypothermia:axillary temp<35c or rectal <35.5c.
• 6.Fever >37.5
• 7.Pneumonia or severe pneumonia.
• 8.Shock
• 9.Dehydration[watery diarrhoea with sunken eye balls]
• 10.Dysentery.
• 11.Hypoglycemia.
• 12.Severe Anaemia

16. ct
• 13.Jaundice.
• 14.Bleeding tendencies.
• 15.Dermatosis +++
• 16. Corneal clouding or ulceration.
• 17.Measles[now or with eye/mouth complications.

17. PATHOPHYSIOLOGY OF SEVERE
MALNUTRITION
• A child with SAM must be treated diferently becouse his physiology is
seriously abnormal due to Reductive adaptation.
• Reductive adapatation. Reffers to when the systerm of the body
begin to “shut down”. The system slow down and do less in order to
allow survival on limited calories. This slowing down is known as
Reductive adapatation.
• As the child is treated ,the body’s systems must gradually ‘lern’ to
function fully again.
• Rapid changes [such as rapid feeding or fluids] would overwhelm the
systems,so feeding must be slowly and cautiously increased.

18. Reductive adaptation care of the child in
number of ways; [A] CVS
• Cardiac output and stoke volume reduced.
• Infusion of saline may cause an increase in venous pressure.
• Any increase in blood volume can easily produce acute HF.
• Any decrease will further compromise tissue perfussion.
• Blood pressure is low.
• Renal perfussion and circulation time are reduced.
• Plasma volume is usually normal and red cell volume is reduced.
-basic metabolic rate is reduced by about 30%,Energy expenditure due to
activity is very low,both heat generation and heat loss are impaired[hypo in
cold and hyper in hot enviroment.]

19. GIT
• Production of gastric acid is reduced.
• Intestinal mortility is reduced.
• Pancrease is atrophied and production of digestive enzymes is
reduced.
• Small intestine mucosa is atrophied,secretion of digestive enzymes is
reduced.
• Absorption of nutrients is reduced.
• Increase absorption of bacteria that normaly form part of the gut
flora which then cause infection.

20. Liver fnx
• Synthesis all protein is reduced.
• Abnormal metabolites of amino acid are produced.
• Capacity of liver to take up,metabolize and excreate toxins is severely
reduced.
• Energy productionfrom substrates such as galactose and fructose is
much slower than normal.
• Gluconeogenesis is reduced,which increases the risk of
hypoglycemia[often the only sign before death is drowsiness.
• Bile secreation is reduced

21. GUT
• Glomerular filtration is reduced.
• Capacity of kidney to excreate excess acid or water load is greatly
reduced.
• Urinary phosphate output is low.
• Sodium escreation is reduced.
• Urinary tract infection is common.

22. IMMUNE SYT
• All aspect of immunity are diminished.
• Lymph glands,tonsils and the thymus are atrophied cell –mediated[t-cell] immunity is
severely depressed.
• IgA levels in secretions are reduced.
• Complement components are low.
• Phagocytes do not kill ingested bacteria effeciently.
• Tissue damage does not result in inflamation or migration of white cells to the affected
area.
• Acute phase immune response is diminished.
• Typical signs of infection, such as an increased white cell count and fever, are frequently
absent.
• Hypogylcemia and hypothermia are both signs of S.infection and usually associated with
septic shock’

23. ENDOCRINE
• Insulin levels reduced and the child has glucose intolerance.
• Inslin growth factor1[IGF-1] level are reduced.
• Growth hormone levels are increased.
• Cortisol levels are usually increased.

24. NOTE BETTER/NB
• INFECTION_ Nearly all children with SM have bacterial infections.however
due to RA ,The usual sign of infection may not be apparent and thus all pt
with SM must be covered on BSA.
• IRON IN SM CHILDREN._due to RA ,SAM makes a less haemoglobin than
usual.iron that is not used for making hb is put into storage tus xtra iron
stored in the body even though the child may appear anaemic. Giving iron
early in treatment will not cure anaemia but causes the following;
• Free iron is very reactive and promotes the formation of free radical which
may engage in uncontrolled chemical reaction with damaging effects. Free
iron promotes bacteria growth and conversion to feratin requires a lot of
energy.
• NA+/K+ PUMP- Sodium level rises and pottasium leak outside cells and lost