The document discusses malnutrition, which includes undernutrition and overnutrition, detailing its types, global prevalence, and clinical assessment methods. It emphasizes the significance of malnutrition in children, highlighting specific nutrient deficiencies and criteria for diagnosing acute malnutrition. Management strategies for severe and complicated malnutrition in children are outlined, including feeding protocols, prevention of complications, and the importance of parental involvement in care.

1. MALNUTRITION
Adrien MUGIMBAHO

2. Definition
• Malnutrition
• Deficiencies, excesses or imbalances in intake of energy/ nutrients. The term
malnutrition covers 2 broad groups of conditions.
• Undernutrition
• stunting (low height for age),
• wasting (low weight for height),
• underweight (low weight for age) and
• micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals).
• Overnutrition

3. Epidemiology
• Rwanda:
• 38 % or 661,200 children under 5 years suffer from chronic malnutrition
(stunting or low height-for-age)
• 37 % or 643,800 suffer from anemia
• Worldwide
• 52 million children under 5 years of age are wasted, 17 million are severely
wasted and 155 million are stunted
• Around 45% of deaths among children under 5 years of age are linked to
undernutrition

4. CHRONIC MALNUTRITION
• Diminished height (stunting)
• Poor weight gain and
• Deficits in both lean body mass and adipose tissue.
• Other features include :
• reduced physical activity,
• mental apathy, and
• retarded psychomotor and mental development

5. ACUTE MALNUTRITION
• Marasmus
• Low weight-for-height and reduced MUAC
• Other physical examination findings may include:
• Head that appears large relative to the body, with staring eyes
• Emaciated and weak appearance.
• Bradycardia, hypotension, and hypothermia
• Thin, dry skin
• Shrunken arms, thighs, and buttocks with redundant skin folds caused by loss
of subcutaneous fat
• Thin, sparse hair that is easily plucked

6. Kwashiorkor (edematous malnutrition)
Symmetric peripheral pitting edema
Apathetic, listless affect
Rounded prominence of the cheeks ("moon-face")
Pursed appearance of the mouth
Thin, dry, peeling skin
hyperpigmentation and skin lesion( dermatitis)

7. Kwashiorkor con’t
Dry, dull, hypopigmented hair that falls ( silky hair)
Hepatomegaly (from fatty liver infiltrates)
Distended abdomen with dilated intestinal loops
Bradycardia, hypotension, and hypothermia
Despite generalized edema, most children have loose inner inguinal skin folds

8. SPECIFIC NUTRIENT DEFICIENCIES
Vitamin A deficiency
corneal cloudiness,
ulceration and xerosis
Bitot spots
Vitamin D deficiency
Skeletal changes with beading of the ribs
widening of the wrists
bowed legs

9. Nutritional deficiency con’t
Thiamine deficiency
 aphonia,
 peripheral neuropathy,
 nystagmus,
 ophthalmoplegia,
 cerebellar ataxia, confusion, or coma (dry beriberi),
 cardiomegaly and congestive heart failure (wet beriberi)
Zinc deficiency
 bullous dermatitis
 diarrhea

10. CLINICAL ASSESSMENT: Z-scores

11. CLINICAL ASSESSMENT: Z-scores

12. CLINICAL ASSESSMENT: Z-scores

13. CLINICAL ASSESSMENT: Z-scores

14. CLINICAL ASSESSMENT: Z-scores
• boys 0 to 2 years old
• Linear Growth
Z-score >-2: No stunting
Z-score >-3 and ≤-2: Moderate stunting
Z-score ≤-3: Severe stunting
Z-score >-2: No wasting
Z-score >-3 and ≤-2: Moderate wasting
Z-score ≤-3: Severe wasting
Weight for Length
• girls 0 to 2 years old
• Stunting
Wasting
Z-score >-2: No stunting
Z-score >-3 and ≤-2: Moderate stunting
Z-score ≤-3: Severe stunting
Z-score >-2: No wasting
Z-score >-3 and ≤-2: Moderate wasting
Z-score ≤-3: Severe wasting

15. Mid-upper arm circumference
●Age 6 to 24 months – Severe wasting <120 mm; moderate wasting
<125 mm
●Age 25 to 36 months – Severe wasting <125 mm; moderate wasting
<135 mm
●Age 37 to 60 months – Severe wasting <135 mm; moderate wasting
<140 mm

16. Diagnostic criteria
• Children 6 through 59 months
• Severe acute malnutrition:
• MUAC <115 mm, or
• Weight-for-length Z-score <-3, or
• Bilateral pitting edema
• Moderate acute malnutrition:
• MUAC 115 to 124 mm, or
• Weight-for-length Z-score -2 to -3
• Stunting (indicates chronic malnutrition):
• Moderate stunting – Height or length Z-score -2 to -3
• Severe stunting – Height or length Z-score <-3

17. Diagnostic criteria Cont’d
• Infants <6 months:
• same weight and height criteria for older infants and children
• the presence of bilateral pitting edema)
• Children 5 years and older:
• body mass index (BMI)-for-age Z-scores or MUAC-for-age Z-score
• -2 for moderate malnutrition and
• -3 for severe malnutrition

18. Management
1. uncomplicated severe acute malnutrition
Treated as outpatients, provided that the child has a good appetite and no obvious
acute infection or other medical complication
• Ready-to-use therapeutic food (RUTF),
• Regular follow-up at home or in decentralized health center
• RUTF at a dose of approximately 175 kcal (733 J)/kg/day
• Should be fed in frequent, small feedings throughout the day, as driven by the child's appetite
• Should be considered a medication for this specific medical condition (ie, SAM) and is not to
be shared with others.
• RUTF should be the only food offered to the child; breast milk and water are the only other
items the child should ingest during treatment.
• Antibiotics
• amoxicillin 40 to 45 mg/kg twice daily, or cefdinir 7 mg/kg twice daily

19. Management Cont’d
• Discharge from treatment — Children 6 to 59 months of age may be
discharged from treatment when they meet either of the following
anthropometric criteria :
• Weight-for-height Z-score ≥-2 and no edema for at least one to two weeks, or
• MUAC ≥12.5 cm and no edema for at least one to two weeks

20. Management Cont’d
2. Complicated severe acute malnutrition
• Initial stabilization
• Rehabilitation
• Follow-up

22. Steps 1 and 2
1. Prevent/treat HYPOGLYCEMIA
2. Prevent/treat HYPOTHERMIA
• KEY is frequent feeding – every two hrs night/day
• Skin to skin contact with parent, warm lamp,
warm blanket, avoid exposure

23. STEP 3
 Give ReSoMaL or comparable oral solution.
5 ml/kg every 30 min for two hours
5-10 ml/kg/h for next 4-10 hours
Do not use the IV route except in shock,
Feed through diarrhea (50-100 ml after each watery stool)
continue breast feeding
Treat/prevent dehydration

24. STEP 4
child with severe acute malnutrition has:
Excessive sodium
Low potassium
Low magnesium
So they need low sodium diet and fluid
Remember: Two weeks minimum to correct
Do NOT use a diuretic to treat edema
CORRECT ELECTROLYTE IMBALANCES

25. STEP 5
Usual signs of infection usually hidden
Give to ALL severely malnourished children
• broad-spectrum antibiotic
• measles vaccine to all children > 6 months.
• Vitamin A ( if eye symptoms present)
• Mebendazole 100 mg BID x 3 days(after 7 day)
TREAT INFECTION

26. STEP 6
All severely malnourished children have vitamin and mineral
deficiencies.
Recommended: Zinc, copper and MV daily
Vitamin A and folic acid on Day 1
Do NOT give iron until the child has a good appetite and starts
gaining weight (usually during the second week of treatment).
CORRECT MICRONUTRIENT
DEFICIENCIES

27. STEP 7 Cautious Feeding
•small, frequent feeds of low osmolality and low lactose
•May include electrolyte/mineral solution
•Day 1 – 7
•Low in protein and iron, high in energy

28. Feeding protocols
• During stabilization phase :
Start F75 100ml/kg/day divided in every 2 to 3 hours
Or 130 ml/Kg/day if no edema divided in every 2 to 3 hours
Monitor if vomiting and diarrhea
Weigh the child every day ( the child would loose weight when edema are
resolving.

29. Feeding protocol con’t
If edema are resolved and the child has appetite.
Start F100, at the last volume of F75 divided in every 3 to 4 hours
Check recurrence of edema and rapid weight gain
If the child is not tolerating F100 or edema reoccur you may go back to F75
Once the child tolerate F100, the solid food /RUTF may be introduced

30. Catch-up growth
Second week
change from starter to catch-up formula
Advance to 200 ml/kg/day div q 3 to 4 hours
Advance to local foods – peanut butter, beans,
margarine – energy dense local foods
Monitor progress after the transition by assessing the rate
of weight gain
Step 8

31. STEP 9
In severe malnutrition there is delayed mental and behavioural
development.
Provide:
• tender loving care
• a cheerful, stimulating environment
• structured play therapy 15-30 min/d
• physical activity as soon as the child is well enough
• maternal involvement when possible (e.g. comforting, feeding, bathing,
play)
• 90% expected weight for height ready for discharge
Stimulation, Play and Loving Care

32. Step 10
Preparation for
Discharge
Nutritional education
Show parent or carer how to:
• feed frequently with energy- and nutrient-dense foods
• give structured play therapy
Advise parent or carer to:
• bring child back for regular follow-up checks
• ensure booster immunizations are given
• ensure vitamin A is given every six months

33. References
• Phillips SM, Jensen C, Editor S, Motil KJ, Editor D, Hoppin AG. Micronutrient
deficiencies associated with malnutrition in children Micronutrient deficiencies
associated with malnutrition in children. 2013;1(table 1):1–15.
• Praveen S Goday M. Malnutrition in children in resource-limited countries:
Clinical assessment - UpToDate. UpToDate [Internet]. 2019;5. Available from:
https://www.uptodate.com/contents/malnutrition-in-children-in-resource-limited-
countries-clinical-assessment%0Ahttps://www.uptodate.com/contents/malnutrition-
in-children-in-resource-limited-countries-clinical-assessment/print
• WHO. Girls z-scores. 2006;15. Available from:
http://www.who.int/childgrowth/standards/LFA_girls_0_13_percentiles.pdf%5Cnpape
rs2://publication/uuid/8A8286DD-5E8A-4952-AAFF-8A0275597782
• WHO. WHO | Chart catalogue. Who. 2010.
• Ashworth A, Schofield C. Book Review: Guidelines for the Inpatient Treatment of
Severely Malnourished Children. Food Nutr Bull. 2005;26(2):245–245.
• Goday P. Malnutrition in children in resource-limited countries: Clinical
assessment - UpToDate [Internet]. UpToDate. 2019. Available from:
https://ezproxy.ufm.edu:2053/contents/malnutrition-in-children-in-resource-limited-
countries-clinical-assessment?search=malnutrition in
children&source=search_result&selectedTitle=1~150&usage_type=default&display_ra
nk=1

34. References
• USAID. Rwanda : Nutrition Profile. American [Internet]. 2014;(June):7–10.
Available from:
https://www.usaid.gov/sites/default/files/documents/1864/Rwanda-Nutrition-
Profile-Mar2018-508.pdf
• Trehan I, Manary M. Management of complicated severe acute
malnutrition in children in resource-limited countries. UpToDate.com
[Internet]. 2017;1–22. Available from: https://0-
www.uptodate.com.innopac.wits.ac.za/contents/management-of-complicated-
severe-acute-malnutrition-in-children-in-resource-limited-
countries?source=search_result&search=severe
malnutrition&selectedTitle=1~150
• Trehan I, Manary M. Management of complicated severe acute
malnutrition in children in resource-limited countries [Internet].
UpToDate.com. 2017. p. 1–22. Available from: https://0-
www.uptodate.com.innopac.wits.ac.za/contents/management-of-complicated-
severe-acute-malnutrition-in-children-in-resource-limited-
countries?source=search_result&search=severe
malnutrition&selectedTitle=1~150
• Airlines S. 済無No Title No Title. J Chem Inf Model. 2013;53(9):1689–99.