The document discusses malnutrition as a major cause of child deaths globally and in India. It outlines the signs and symptoms of severe acute malnutrition (SAM) in children and the 10 step treatment protocol to first stabilize and then rehabilitate malnourished children. This involves restoring blood glucose and body temperature, oral rehydration for diarrhea, vitamin and mineral supplements, and gradually advancing children to higher calorie therapeutic feeds. The goal is to discharge children once they have gained adequate weight and are free from infection. Prevention strategies are needed at the national, community and family level.

2. Can be UNDERNUTRITION or OVERNUTRITION
Susceptible to infections like sepsis, pneumonia and
gastroenteritis.

3. Diarrhoea
(neonatal)…
Tetanus
1%
AIDS
1%
Measles
1%
Pneumonia
(neonatal)
3%
Other
neonatal
3%
Meningitis
and Pertussis
3%
Congenital
abnormalities
5%
Malaria
5%
Injuries
6%
Sepsis
7%
Diarrhoea
(post-
neonatal)
9%
Intrapartum-
related
complications
11%
Pneumoni
a (post-
neonatal)
13%
Pre-term birth
complications
16%
Other
17%
Malnutrition is the
underlying cause of 45%
of all child deaths

4.  In children of 6 to 59 months defined as any of the
following :
 i) wt for height < -3 SD of WHO growth reference
 ii) visible severe wasting
 iii) bipedal edema
 iv) MUAC < 11.5 cm under 6 year age.

6. Immediate
determinan
t
Underlying
determinant
Basic
determinant

8.  WHO recommends exclusive inpatient management of
children with SAM.
 History : Breastfeeding, diarrhea, vomiting, appetite,
contact with tuberculosis, cough
 Examination
Anthropometry – MUAC
Clinical features

9.  SAM-children are immune-compromised, and hence show limited or
no signs of infection and inflammation.
 Assess ABC, temperature, Weight, Height
 MUAC (use WHO “MOYO” charts)
 Hypothermia (common) or fever (rare)
 Signs of dehydration-loss of elsticity of skin,weak pulse,oligouria
 Pallor ,shock –weak rapid pulse, cold hand, slow capillay refill
 Oedema (+ up to ankle, ++ up to knee, +++ generalised oedema)
 Liver size (many kwashiorkor children have this as ‘sign’ of SAM)
 Abdominal distension (small bowel bacterial overgrowth)
 Skin changes
 Look for changes in the eye for Vit. A deficiency

10. Associated with marasmus or kwashiorkor or both
Marasmus : acute starvation over borderline nutritional
status.
 Main sign is severe wasting
 Monkey face and baggy pants
 Alert child
 No edema

11. Kwashiorkor
 Main sign is pitting edema
 Fat sugar baby appearance
 Muscle wasting – hypotonic and weak child
 Skin changes: enamel spots and flaky paint
 Hair : flag sign ; loss of lustre; easily pluckable
 Anemia ,mental changes, decreased renal fn etc.

12. Ten steps in two phases :
 Stabilization phase – restoring homeostasis(2-7days)
 Rehabilitation phase – rebuilding wasted tissue

14.  < 54 mg/ dl or 3 mmol/l of glucose.
 Blood glucose measured immediately
 Symptomatic and asymptomatic
 Hypoglycemia , Hypothermia and Infection generally
occur as a triad.

15.  50 ml of 10% glucose orally or Nasogastric tube by first
feed
 Feed with starter of F-75 every 2 hr day and night
 Blood glucose monitoring every 30 min until normal

16.  5 mL/kg of 10% dextrose IV. Followed by
 50 ml 10% dextrose or sucrose by Nasogastric tube.
 First feed of F-75 2 hourly day and night after stable.
 Blood glucose monitoring every 30 min until normal.
 Start appropriate antibiotics.
 Prevention : 2 hourly feed started immediately.
Prevent Hypothermia.

17.  Rectal temp < 35.5ᵒ C or < 95.9ᵒ F
 Rewarmed by
Conduction by skin contact
Convection Heat converter
Radiation overhead heaters
 Head covered
 Feed immediately
 Temp monitored every 2 hrs.

18.  Treated over 12 hrs
 Reduced osmolarity ORS with K supplements
 Amt depends on child’s need
 5mL/ kg every 30 min for first 2 hrs and then 5-10
mL/kg every hour for next 4-10 hrs and 5-10 mL/kg
after each watery stool
 Breastfeeding continued
 After signs of hydration, ORS must stop

19.  Supplementary K : 3-4 mEq/kg/day for 2 weeks.
 50 % MgSO4(4mEq/ml) i.m. on first day, then 0.8 to
1.2 mEq/kg daily.
 Excess body sodium exists even plasma sodium may be
low so decrease salt in diet.

20.  Investigations are done :
Hb, TLC, DLC, peripheral smear.
Urine analysis and culture
blood culture, chest xray, periphweral smear for
malaria, mantoux, CSF examination.
 Majority of bloodstream infections are due to gram-
negative bacteria.
 Hypoglycemia and hypothermia are markers of severe
infection.
.

21.  Broad Spectrum Antibotics
 Parenteral ampicillin 50mg/kg/dose for at
least 2 days followed by amoxicillin
15mg/kg 8 hourly for 5 days.
 If no improvement occurs within 48hr, cefotaxine
100-150mg/kg/day 6-8 hourly.

22.  Twice recommended daily allowance of vitamin and
minerals
 Fe added only in rehabilitation phase
 Day one : Vit A < 6 months 50000 IU
 6 -12 months 1,00,000 IU
 >1 yr 2,00,000 IU
 Folic acid : 1mg/day(give 5mg on 1 day)
 Zn: 2 mg/kg/day
 Cu: 0.2 -0.3 mg/kg/day
 Iron 3 mg/kg/day

23.  Osm < 350 mOsm/L, lactose <2-3 kg/day
 5 % cal from proteins, renal solute load
 Low viscosity , adequate bioavailiability of
micronutrients.
 Easily prepared, socially acceptable.
 Cautious feeding : 80 kcal/kg/day to 100 kcal/kg/day.

24.  F-75 replaced with F-100
 Increases calories to 150-200 kcal/kg/day and proteins
to 4-6g/kg/day.
 Frequency decrease and volume increased
 Breastfeeding continued.
 Ready to use therapeutic food (RUTF) : oil based
paste ; can be stored (3-4.9kg:130gm, 5-6.9:260,
7-9.9:400, 10-14.9: 460)
 Similar nutrient profile but high energy density

25.  Cheerful environment
 Structured play therapy 15 to 30 min/day.

26.  Criteria for discharge : wt for ht is 90% of NCHS
median and no edema, 15% of weight gain
 In severely malnourished ready for discharge when
Alert, active, eating 120-130kcal/kg/day with weight
gain of 5g/kg/day for consecutive days.
Free from infection, completed immunization,
receiving micronutrients

27.  At national level: nutritional supplementation
nutritional surveillance
nutritional planning
 At community level: Health and nutritional education
Promotion of education and literacy
Growth monitoring
Integrated health package
Family planning

28.  At family level: Exclusive breast feeding
Complementary feeds
Vaccination
Adequate time between pregnancies

29.  Children <6 yrs
 Provided at Anganwadi
 Six services : Supplementary nutrition
Immunization
Nonformal preschool education
Health checkup
Referral services
Nutritional and health education

30.  Midday meal of 450 kcal and 12 g of protein for
primary stage
 700 kcal and 20 g protein for upper primary stage.

31.  Stunting
TARGET: 40% reduction in the number of children under-5 who are stunted
 Anaemia
TARGET: 50% reduction of anaemia in women of reproductive age
 Low birth weight
TARGET: 30% reduction in low birth weight
 Childhood overweight
TARGET: No increase in childhood overweight
 Breastfeeding
TARGET: Increase the rate of exclusive breastfeeding in the first 6 months up
to at least 50%
 Wasting
TARGET: Reduce and maintain childhood wasting to less than 5%