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5. Malnutrition
 Malnutrition is a general term for a medical
condition caused by an improper or insufficient
diet. It must often refer to under nutrition
resulting from inadequate consumption.

6. Incidence
% of children of :
 Stunting: 36%
 Severe stunting : 12%
 Wasting : 10%
 Severely wasting: 2%
 Underweight: 27%
 Severely underweight:
5%
 Overweight: 1%
2016 (NDHS)

9. WHO classification
 Stunting: Low height- for- age indicator of chronic
malnutrition.
 Wasting: Low weight- for- height indicate or
suggest acute malnutrition.
 Underweight: Low weight- for- age. It is the
combined indicator to reflect both acute and
chronic malnutrition

10. Protein Energy Malnutrition
(PEM)
 It can be defined as a group of clinical conditions
that may result from varying degree of protein
deficiency and energy (calories) inadequacy.

11. Classification of PEM
Mild PEM: It is most common between the ages of
9 months and 2 yr. It's main a cause is deficit
dietary intake for a short period.
 Growth failure: This is manifested by slowing or
cessation of linear growth; static or decline in
weight; delayed bone maturation.

12. Mild PEM Contd…
 Infection
 Anaemia: May be mild to moderate.
 Activity: This may be diminished
 Skin and hair changes: These may occur rarely.

13. Classification Contd…
 Moderate PEM: If the food deficit persists for a
longer period, the child will develop moderate
PEM. This is also known as Runche (the local
language of moderate PEM) which mean crying
children. Common age for moderate PEM is
between 1 to 4 years.

14. Moderate PEM Contd…
 The presentation of moderate PEM are similar to
mild PEM but it is more easily recognizable forms
which includes children appear more slow and
less energetic, growth failure, wrinkling of skin
over the front of thighs, distended abdomen,
repeated infection.

15. Classification Contd…
 Severe PEM: Severe form of PEM is associated
with one of classical syndromes, namely,
marasmus, kwashiorkor, or Marasmus
kwashiorkor

19. Ten essential steps of
management
1. Treatment or prevent hypoglycemia
 If the child is conscious and glucose level is less
than 54 mg/dl then 50ml bolus of 10% dextrose
orally or by NG tube. Start feeding every 30 min for
2 hours.
 If unconscious: IV 10% glucose (5ml/kg) followed
by 50 ml of 20% glucose and feeding as above.

20. Treat /prevent hypothermia
 Clothes the child with warm clothes; ensure that
the head is also covered with a scarf or cap
 Provide heat using overhead warmer, skin contact
or heat convector .
 Feed the child immediately
 Give appropriate antibiotics

22. Treat/ prevent dehydration
 Do not use the IV route for rehydration except in
case of shock. Give special rehydration solution.
 Resomal 5 ml/kg every 30 min for 2 hours, orally or
by NG them 5-10 ml/kg/hour for next 4-10 hours.
 Amount depends on stool loss and how much
child wants to drink

23. Correct electrolyte imbalance
 Deficiency of K and Mg which may take 2 weeks or
more to correct.
1. Give supplemental potassium at 3-4 mEq/kg/ day for
at least 2 weeks.
2. On day l, give 4 mEq/ml magnesium sulphate IM.
Thereafter, give extra magnesium (0.8-1.2 mEq/kg
daily).

24. Treat/ prevent infection
 Treat with ampicillin 50 mg/kg QID IV for at least
2 days followed by oral amoxicillin 15 mg/kg TDS
for 5 days and amikacin 15-20 mg/kg IM or IV OD
for 7 days.
 If no improvement occurs within 48 hr, change to
IV cefotaxime or ceftriaxone.

25. Correct micronutrient
deficiencies
 Folic acid 1 mg/ day (give 5 mg on first day1)
 Zinc 2 mg/kg/ day
 Copper 0.2-0.3 mg/kg/day
 Iron 3 mg/ kg/ day

26. Start caution feeding
 Start feeding as soon as possible as frequent small
feeds. If unable to take orally, initiate nasogastric
feeds.
 Total fluid recommended is 130 ml/kg/ day; reduce to
100 ml/kg/ day if there is severe edema.
 Continue breastfeeding .

27. Feeding pattern
Days Frequency Volume/kg/
feed
Volume/kg/
day
1-2 2hrly 11ml 130ml
3-5 3hrly 16ml 130ml
6-7+ 4hrly 22ml 130ml

28. Achieve for catch up growth
 Once appetite returns in 2-3 days, encourage
higher intakes.
 Increase volume offered at each feed and decreases
the frequency of feeds to 6 feeds per day.
 Continue breastfeeding.

29. Achieve for catch up growth
 Increase calories to 150-200 kcal/kg/ day, and
proteins to 4-6 g/kg/ day
 Add complementary foods as soon as possible to
prepare the child for home foods at discharge

30. Provide sensory stimulation
and emotional support
 A cheerful, stimulating environment
 Age appropriate structured play therapy
 Age appropriate physical activity as soon as the
child is well enough

31. Prepare for follow up visit:
1. Primary failure to respond is indicated by:
 Failure to regain appetite by day 4
 Presence of edema on day 10
 Failure to gain at least 5 g/kg/day-by-day 10

32. Prepare for follow up visit:
2. Secondary failure to respond is indicated by:
 Failure to gain at least 5 g/kg/day for consecutive
days during the rehabilitation phase

34. Nursing Management
Assessment
 Ask the nutritional history with the patient and
their visitor.
 Monitor laboratory values that indicate well being
or deterioration.

35. Nursing Diagnosis
 Imbalanced nutrition less than body requirements
related to inadequate intake.
 Delayed growth and development related to
malnutrition.
 Activity intolerance related to generalized
weakness.

36. Nursing Intervention
 Provide good oral hygiene.
 Provide a pleasant environment or as a child want.
 Provide high protein supplements based on
patient needs and capabilities.
 If patient want own home food encourage family
members to bring food from home to the hospital.

40. Reference of malnutrition
 Paul VK, Bagga A, Ghai Essential Pediatrics, eighth Edition. CBS
Publisher and distributors Pvt Ltd, New Delhi, India: 2009. pg
95-107.
 Uprety K, Child Health Nursing, fourth Edition (2071 Bhadra),
Tara Books and Stationery, Chhetrapati, Kathmandu, pg 346- 352
 Dahal K, Community Health Nursing –II, fifth Edition, Makalu
Publication House, Dillibazar, Kathmandu, Nepal, page 172- 175
 Shrestha T, Nursing Care of Children, first Edition 2015 August,
Medhavi Publication Jamal, Kantipath, Kathmandu, Page 204-
209
 https://www.who.int/news-room/fact-
sheets/detail/malnutrition
 http://dohs.gov.np/wp-content/uploads/2020/11/DoHS-Annual-
Report-FY-075-76-.pdf