This document provides information on malnutrition, including definitions, types, epidemiology, clinical presentation, diagnosis, and management. It defines malnutrition as a pathological state resulting from relative or absolute deficiency of nutrients. The two broad types are undernutrition and overweight/obesity. Management is outlined in 8 steps: 1) treat hypoglycemia, 2) treat hypothermia, 3) treat dehydration, 4) correct electrolyte imbalance, 5) treat/prevent infection, 6) correct micronutrient deficiencies, 7) start cautious feeding, 8) achieve catch-up growth. The goal is stabilization of the child's condition followed by rehabilitation with aggressive feeding to allow for rapid weight gain.

2. Question :
1- What are the abnormal findings?
(1)
2- What is the diagnosis?
(0.5)
3- Write down the management
steps. (3.5)

3. Question:
1- What are 4 positive
findings in this picture?
(2)
2- What is the diagnosis?
(1)
3- What are the causes
which lead to this
condition? (2)

4. MALNUTRITION
By
DR. ZAHID MEHMOOD

5. MALNUTRITION
• The term malnutrition includes both ends
of nutrition spectrum from undernurtition to
overweight.

6. WHO
• Malnutrition refers to deficiencies, excesses or imbalances in a
person’s intake of energy and/or nutrients.
• The term malnutrition covers 2 broad groups of conditions
• . One is ‘undernurtition’—which includes
– stunting (low height for age),indicate chronic malnutrition
– wasting (low weight for height), indicate acute malnutrition
– underweight (low weight for age).
• other is overweight,
– obesity and diet-related noncommunicable diseases (such as heart
disease, stroke, diabetes and cancer).

7. MALNUTRITION
DEFINITION
Pathological state resulting from the relative or
absolute deficiency of one or more nutrients.
Severe Malnutrition
is defined as the presence of severe wasting
(<70 % weight –for-height or < 3SD) and/or
edema.

8. Epidemiology
• In 2017, globally there were 151 million
children under 5 year of age were stunted, 51
million wasted and 38 million overweight.
• In Pakistan
 stunting 43-45%
 wasting 10.5%
 underweight 31.6%
 overweight 4.8%

9. FACTS & FIGURES
 >70% of pediatric population is
malnourished.
 Very common in under 5 children.
 Mortality can be as much as 10 times
higher.
 Morbidity in the form of retarded
physical & mental growth.

10. TYPES AND ETIOLOGY
PRIMARY MALNUTRITION
When food is not available
1-FAILURE OF LACTATION;
Insufficient or no breast milk at all.
2-FAULTY WEANING;
 Too late or too early
 Too little or too much
 Poor quality

11. 3-POVERTY;
 Lack of Food
 Inadequate housing
 Sanitation.
 Water supply.
4-CULTURAL PATTERNS FOOD FADS
o Hot foods & cold foods
o Sweets,toffies & tea.
o Male dominated society.

12. 5-LACK OF IMMUNIZATION & PRIMARY
CARE;
 Against communicable diseases.
 Routine care for diarrhea & ARI.
 Vicious cycle.
6-LACK OF FAMILY PLANNING;
o Large families
o Malnourished & over-worked mothers

13. SECONDARY MALNUTRITION
Food is available but body cannot assimilate it.
1- INFECTIONS;
 Acute or chronic or recurrent.
 Diarrhea,
 ARI,
 Malaria,
 Measles,
 Giardiasis,
 Tuberculosis,
 Pertussis,
 UTI,etc;

14. 2- CONGENITAL DISEASES;
VSD,TOF,HYDROCEPHALUS etc;
3- MALABSORPTION;
Celiac disease, Giardiasis,
lactose intolerance
4- METABOLIC;
DM, DI, Galactosemia,
storage disorders
5- PSYCHOSOCIAL DEPRIVATION

15. CLASSIFICATION
OF
MALNUTRITION

18. WELLCOME CLASSIFICATION
Wt. for Age Edema +ve Edema — ve
80%--60% Kwashiorkor ponderal Ret
< 60% Marasmic kwas Marasmus

19. IMCI Classification of Malnutrition

20. MARASMUS
WT < 60 % WITHOUT EDEMA
Results from mainly deficiency of
calories
• It is 20 times more common.
• Over-diluted milk,
• inadequate weaning,
• Rec infections,
• measles,
• Tuberculosis &
• pertussis.

21. kwashiorkor
Results from mainly deficiency of
proteins.
1- Generalized edema.
2- Growth failure.
3- Psychomotor changes; Apathy, no
interest in surroundings.
4- Weak & wasted but has some s/c fat.
5- Hair changes; sparse,fine,straight,light
coloured
.

22. 6- Hepatomegaly.
7- Skin changes; flaky paint dermatitis,
sore ulcerated,hypo-hyperpigmented
skin.
8- Anemia,
9- loose motions,
10- Hypothermia,
11- Hypoglycemia,
12- Cardiac failure,
13- Infections &
14- vit A deficiency signs

23. Clinical Syndromes:

24. Diagnosis

25. CLINICAL APPROACH
HISTORY
• Milk feeding.
• Weaning.
• Calories.
• Vaccination.
• Milestones.
• Contact with TB,measles etc;

26. EXAMINATION
 Vital signs
 Growth parameters; wt, Lt / ht, ofc, muac.
 Detailed GPE
 Systemic Exam.

27. Physical Examination:
Arthropometic measurements:
• Head circumference
• Weight
• Height / Length
• Mid Arm Upper Circumference

28. Physical Examination:
Eyes:
• Corneal lesions, bitot spots, xeropthalamia
Ear, Mouth & Throat:
• Evidence of any infection
Skin:
• Xerosis & dermatosis
Feet:
• Oedema
Hands & Nails:
• Pallor, kolionchyia

29. Systemic Examination:
CVS:
• For apex beat & murmur
CNS:
• Look for SOMI
GIT:
• Abdominal distention &
hepatomegaly
RS:

30. Investigations:
General Investigation:
• CBC with Peripheral smear
• Serum Electrolytes
• Blood Glucose Level
• Urine complete examination
• Stool examination
• Chest X-Ray
• TST

31. Investigations:
Specific Investigation:
• Antibodies serology for coelice
disease
• Sweat chloride test for cystic fibrosis
• Echocardiography for congential
heart defects
• Enzymes Levels for inborn error of
metabolism

32. INVESTIGATIONS
1- BCP.
2- CUE.
3- X-ray chest & wrist.
4- Complete stool ex.
5- ESR, Mantoux Test, Diagnontic BCG.
6- Serum Albumin, globulin,
7- Blood glucose,Calcium,Phosphorous
8- Serum Sodium,Potassium,Urea,Creatinine.
9- PT,APT T.
10- Vitamin Levels

33. MANAGEMENT

34. GRADE 1- PCM
TREATED ON OPD BASIS.
Give one more milk feed.
Give one more solid feed.

35. GRADE -2 PCM
TREATED ON OPD BASIS.
Give two more milk feeds.
Give two more solid feeds

36. Management of 3rd degree
malnutrition
INITIAL MANAGEMENT
– Admission to hospital till the patient condition
is stable (usually for 2-7 days)
– Meant to prevent, recognize & treat the life-
threatening conditions .
– Correction of specific deficiencies
– INITIATION OF FEEDING.

37. 2 Phase Treatment:

38. Specific Management:
• Gluten free diet for coelic disease
• Enzyme replacement therapy for
inborn error of metabolism
• Corrective cardiac surgeries for
congential heart defects
• Inhalation therapy & antibiotics for
cystic fibrosis

39. Step 1. Treat/prevent hypoglycemia
Hypoglycemia BSR < 54mg/dl
Hypoglycemia and hypothermia usually occur together and are signs of
infection.
Check for hypoglycemia whenever hypothermia
TREATMENT:
If the child is conscious
50 ml bolus of 10% glucose or 10% sucrose solution orally / NGT.
Then feed starter F-75 every 30 min for 2 hours.
If the child is unconscious, lethargic or convulsing
IV sterile 10% glucose (5ml/kg), THEN
ORAL /NGT AS ABOVE
• antibiotics
• two-hourly feeds, day and night

40. MONITOR
• BSR after 2 hours.
Once treated, most children stabilise within 30 min.
If BSR still < 54mg/dl then
Repeat oral protocol as above ,until stable
• If hypothermia develops, repeat BSR
• If level of consciousness deteriorates, repeat BSR
PREVENTION:
• feed two-hourly, start straightaway or if necessary,
rehydrate first
• always give feeds throughout the night
Note: If you are unable to test the blood glucose level,
assume all severely malnourished children are
hypoglycemic and treat accordingly.

41. Step 2. Treat/prevent hypothermia
axillary temperature <35.0oC
TREATMENT:
• Treat hypoglycemia
• rewarm the child:
cover with a warmed blanket and place a heater nearby
or put the child on the mother’s bare chest (skin to skin) and
cover them
• give antibiotics
MONITOR:
• body temperature: two-hourly until it rises to >36.5oC
half-hourly if heater is used
• BSR Monitoring

42. Step 3. Treat/prevent
dehydration
Low blood volume can coexist with oedema.
Do not use the IV route for rehydration except in cases of shock
difficult to estimate dehydration status in a severely malnourished child.
TREATMENT:
So assume all children with watery diarrhoea may have dehydration
• special Rehydration Solution for Malnutrition (ReSoMal).
• 5 ml/kg every 30 min. for two hours, orally / NGT THEN
• 5-10 ml/kg/h for next 4-10 hours:
• the exact amount determined by THIRST, stool loss and vomiting.
• Replace the ReSoMal doses at 4, 6, 8 and 10 hours with F-75 if rehydration is
continuing at these times, then
• continue feeding starter F-75
During treatment, rapid respiration and pulse rates should slow down and the child
should begin to pass urine.

43. MONITOR
Observe half-hourly for two hours, then hourly for the next
6-12 hours,
pulse rate
respiratory rate
urine frequency
stool/vomit frequency
many severely malnourished children will not show these
changes even when fully rehydrated.
Continuing rapid breathing and pulse during rehydration
suggest coexisting infection or overhydration.
Signs of excess fluid (overhydration) are
increasing respiratory rate and pulse rate,
increasing oedema and puffy eyelids.
If these signs occur, stop fluids immediately and
reassess after one hour.
Return of tears,
moist mouth,
eyes and fontanelle appearing less
sunken,
improved skin turgor

44. PREVENTION
To prevent dehydration when a child has
continuing watery diarrhoea:
• keep feeding with starter F-75
• replace approximate volume of stool losses
with ReSoMal. Give 50-100 ml after each
watery stool.
• if the child is breastfed, encourage to
continue
it is common for malnourished children to pass
many small unformed stools: these should not
be confused with profuse watery stools and do
not require fluid replacement

45. Step 4. Correct electrolyte
imbalance
 All severely malnourished children have excess body
sodium even though plasma sodium may be low (giving
high sodium loads will kill).
 Deficiencies of potassium and magnesium are also present
and may take at least two weeks to correct.
 Oedema is partly due to these imbalances.
 Do NOT treat oedema with a diuretic
extra potassium 3-4 mmol/kg/d
• extra magnesium 0.4-0.6 mmol/kg/d
• when rehydrating, give low sodium rehydration fluid
(ReSoMal)
• prepare food without salt

46. Step 5. Treat/prevent infection
In severe malnutrition the usual signs of
infection, such as fever, are often absent,
and infections are often hidden.
• broad-spectrum antibiotic(s) AND
• measles vaccine if child is > 6m and not
immunized
(delay if the child is in shock)
Note: Some experts also use metronidazole (7.5 mg/kg 8-
hourly for 7 days) to prevent overgrowth of anaerobic
bacteria in the small intestine.

47. Choice of broad-spectrum
antibiotics
A) IF NO COMPLICATIONS
• Co - trimoxazole 5 ml pediatric suspension orally twice daily
for 5
days (2.5 ml if weight <6 kg). (5 ml is equivalent to 40 mg
TMP+200 mg SMX).
b) if the child is severely ill (apathetic, lethargic) or
has complications
(hypoglycemia; hypothermia; broken skin; respiratory tract or urinary
tract infection) give:
• Ampicillin 50 mg/kg IM/IV 6-hourly for 2 days, then oral amoxicillin 15
mg/kg 8-hourly for 5 days, or if amoxicillin is not available, continue
with Ampicillin but give orally 50 mg/kg 6-hourly
AND
• Gentamicin 7.5 mg/kg IM/IV once daily for 7 days

48. If the child fails to improve clinically within 48
hours, ADD:
• Chloramphenicol 25 mg/kg IM/IV 8-hourly for 5
days
Where specific infections are identified, ADD:
• specific antibiotics if appropriate
• antimalarial for malaria parasites film.
If anorexia persists after 5 days of antibiotic
treatment, complete a full 10-day course.
If anorexia still persists, reassess the child fully,
checking for sites of infection and potentially
resistant organisms, and ensure that vitamin and
mineral supplements have been correctly given.

49. Step 6. Correct micronutrient
deficiencies
All severely malnourished children have vitamin and mineral
deficiencies.
anaemia is common,
vitamin A orally on Day 1
age >12 months, give 200,000 IU
age 6-12 months, give 100,000 IU
Age 0-5 months, give 50,000 IU
• Multivitamin supplement
• Folic acid 1 mg/d (give 5 mg on Day 1)
• Zinc 2 mg/kg/d
• Copper 0.3 mg/kg/d
• Iron 3 mg/kg/d but only when gaining weight
AT
LEAST
15
DAYS

50. Step 7. Start cautious feeding
STARTED AS SOON AS POSSIBLE
• small, frequent feeds of low osmolarity and low lactose
• oral or NGT feeds (never parenteral preparations)
• 100 kcal/kg/d
• 1-1.5 g protein/kg/d
• 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe edema)
• if the child is breastfed, encourage to continue breastfeeding but give the
prescribed amounts of starter formula to make sure the child’s needs are
met.
THE SUGGESTED STARTER FORMULA
Milk-based formulas such as starter F-75 containing 75 kcal/100 ml and 0.9 g
protein/100 ml will be satisfactory for most children Give from a cup. Very
weak children may be fed by spoon, dropper or syringe.

51. A RECOMMENDED SCHEDULE IN WHICH VOLUME IS
GRADUALLY INCREASED, AND FEEDING FREQUENCY
GRADUALLY DECREASED
Days Frequency Vol/kg/feed Vol/kg/d
1-2 2-hourly 11 ml 130 ml
3-5 3-hourly 16 ml 130 ml
6-7+ 4-hourly 22 ml 130 ml
For children with a good appetite and no oedema, this schedule
can be completed in 2-3 days (e.g. 24 hours at each level).
Use the Day 1 weight to calculate how much to give, even if the
child loses or gains weight in this phase.
If vomiting & intake does not reach 80 kcal/kg/d (105 ml starter
formula/kg) despite frequent feeds and re-offering, give the
remaining feed by NG tube

52. MONITOR
• amounts offered and left over
• vomiting
• frequency of watery stool
• daily body weight
During the stabilisation phase, diarrhoea should gradually
diminish and oedematous children should lose weight. If
diarrhoea continues unchecked despite cautious
refeeding, or worsens substantially, (continuing
diarrhoea).

53. Step 8. Achieve catch-up growth
 In the rehabilitation phase a vigorous approach to feeding is
required to achieve very high intakes and rapid weight gain
of >10 g gain/kg/d.
 The recommended milk-based F-100 contains 100 kcal and
2.9 g protein/100 ml
 Readiness to enter the rehabilitation phase is signalled by a
return of appetite, usually about one week after admission.
CHANGE FROM STARTER TO CATCH-
UP FORMULA:
• replace starter F-75 with the same amount of catch-up
formula F-100 for 48 hours then,
• increase each successive feed by 10 ml until some feed
remains uneaten. The point when some remains
unconsumed is likely to occur when intakes reach about 30
ml/kg/feed (200 ml/kg/d).).

54. Monitor during the transition for signs of
• heart failure:
• respiratory rate
• pulse rate
If respirations increase by 5 or more breaths/min and pulse
by 25 or more beats/min for two successive 4-hourly
readings, reduce the volume per feed (give 4-hourly F-
100 at 16 ml/kg/feed for 24 hours, then 19 ml/kg/feed for
24 hours, then 22 ml/kg/feed for 48 hours, then increase
each feed by 10 ml as above

55. • frequent feeds (at least 4-hourly) of unlimited
amounts of a catch-up formula 150-220 kcal/kg/d
• 4-6 g protein/kg/d
• if the child is breastfed, encourage to continue
MONITOR
• weigh child each morning before feeding.
• each week calculate and record weight gain as
g/kg/d
weight gain
• poor (<5 g/kg/d), child requires full reassessment
• moderate (5-10 g/kg/d), check whether intake targets
are being met, or if infection has been overlooked
• good (>10 g/kg/d), continue to praise staff and
mothers
Calculating weight gain :

56. Step 9. Provide sensory stimulation
and emotional support
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)

57. Step 10. Prepare for follow-up after
recovery
A child who is 90% weight-for-length can be considered to have
recovered.
The child is still likely to have a low weight-for-age because of
stunting.
Good feeding practices and sensory stimulation should be
continued at home.
Advise
• bring child back for regular follow-up checks, 7-26 weeks
• ensure booster immunizations are given
• ensure vitamin A is given every six months

58. FOLLOW UP
• Follow up is of immense importance.
• Initially weekly then 2-weekly then monthly
then 2 monthly till normal wt for height.
• Measure wt, Lt, OFC, Muac.
• Ensure adequate caloric intake.
• Look for signs of nutritional deficiencies.

59. Question :
1- What are the abnormal findings?
(1)
2- What is the diagnosis?
(0.5)
3- Write down the management
steps. (3.5)

60. Key:
1-
i. Emaciated irritable child / wizened face / prominent rib cage (0.5)
ii. Loss of fat over the buttocks / body.(0.5)
2- Marasmus (0.5)
3-
Initial management (1.5)
i. Life-threatening problems are identified and treated in the hospital
ii. Specific deficiencies are corrected
iii. Metabolic abnormalities are corrected
iv. Feeding is begun
Rehabilitation (1)
i. Intensive feeding is given to recover most of the lost weight
ii. Emotional and physical stimulation are increased
iii. Training of the mother
iv. Preparations for the discharge
Follow up (0.5)
Counseling of mother & family (0.5)

61. Question:
1- What are 4 positive
findings in this picture?
(2)
2- What is the diagnosis?
(1)
3- What are the causes
which lead to this
condition? (2)

62. Key:
1- (0.5 each)
i. Puffy moon face
ii. Miserable looking and apathetic
iii. Flaky paint dermatitis
iv. Edema feet
2- Kwashiorkor (1)
3-
Primary malnutrition (1) (0.25 each for any 4 of the 5)
i. Failure of lactation
ii. Ignorance of weaning
iii. Poverty
iv. Cultural pattern and food fads
v. Lack of immunization
vi. Lack of family planning
Secondary malnutrition (1) (0.25 each for any 4 of the 5)
i. Infections
ii. Congenital diseases
iii. Malabsorption
iv. Metabolic
v. Psychosocial deprivation