How to manage it

1. MALNUTRITION
IN CHILDREN
DR C MOYO

2. DEFINITION OF MALNUTRITION
Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance
of essential nutrients or impaired nutrient utilization.
MALNUTRITION
Over nutrition
consumption of too many
calories
Under nutrition
the diet does not provide adequate
calories and protein for growth and
maintenance or there is inability to
fully utilize the food eaten due to
illness

3. Fig: Undernourished and Obese

4. TYPES OF UNDERNUTRITION
TYPES OF
UNDER-
NUTRITION
ACUTE MALNUTRITON:
is an indicator of current nutritional status and reflects recent weight
changes
-classified as moderate or severe and clinically presents in 3 ways:
Marasmus non edematous severe acute malnutrition
Kwashiokor edematous severe acute malnutrition
Marasmic kwashiokor
CHRONIC MALNUTRITION : presents as stunting( low height for age) as a result
of retarded linear growth . prevents children from reaching their physical and
cognitive potential
MICRONUTIENT DEFICIENCY: Fe, Iodine, Vitamins, Zn, Mg, Ph, K

5. CAUSES OF
MALNUTRITION

6. IMMEDIATE CAUSES.
• Immediate causes operating at the individual level are inadequate
food intake or/and severe or repeated infections.
• Poor diet:. The poor diet might be due to not enough food, or a lack of
variety of foods in meals; low concentrations of energy and nutrients
in meals; infrequent meals; insufficient breastmilk; and early weaning.
• Disease: Diseases, especially infectious diseases, cause undernutrition
because a sick child may not eat or absorb enough nutrients, or may
lose nutrients from the body due to vomiting or diarrhoea, or have
increased nutrient needs which are not met.
• measles; diarrhoea; AIDS; respiratory infections; malaria; and
intestinal worms, malignancy

7. IMMEDIATE CAUSES :Infection malnutrition cycle
In practice, undernutrition and infection often occur at the same time because one can
lead to another, as illustrated in the cycle below.

8. UNDERLYING CAUSES
• Are responsible for manifestation of the immediate causes
Household food insecurity Inadequate care Unhealthy household environment
and lack of healthcare
-food inadequate in
quantity and quality:
>low income
>poor budgeting
>floods/drought
>little knowledge about
feeding, childcare&
hygiene
>poor health seeking
behaviour
>cultural practices e.g
poor distribution of food
>overcrowding
>low immunization coverage
>poor healthcare services
>lack access to safe water and
effective sanitation

9. BASIC CAUSES
• political, legal and cultural factors may defeat the best efforts of
households to attain good nutrition, e.g
>degree to which the rights of women and girls are protected by law
and custom
>the economic system determines how income and assets are
distributed
>Government’s commitment to prevent and fight malnutrition

10. PATHOPHYSIOLOGY ctd..
• profound physiological and metabolic changes that take place when a child
becomes malnourished.
• A malnourished child’s metabolism reduces activity, to adapt to the lack of
nutrients and energy, and slows down to survive on a limited intake of
essential nutrients in order to preserve essential body functions.
• These changes affect every cell, tissue and system. The process of change is
called reductive adaptation.
• The initial reductions do not alter the ability of the body to respond to
minor changes but they impair its capacity to cope with stressful situations
(infection, cold, an intravenous infusion or excessive oral liquids)

11. PATHOPHYSIOLOGY ctd.
Cardiovascular system
• Cardiac output and stroke volume are reduced.. . •
Blood pressure is low.
• Plasma volume is usually normal and red cell volume
is reduced
* Any significant increase in blood volume can easily
produce acute heart failure; any decrease will further
compromise tissue perfusion
Gastrointestinal system
• Production of gastric acid is reduced.
• Intestinal motility is reduced.
• The pancreas is atrophied and production of
digestive enzymes is reduced.
• The mucosa of the small intestine is atrophied;
secretion of digestive enzymes is reduced.
• Absorption of nutrients is reduced
Liver function
• Synthesis of all proteins is reduced.
• The capacity of the liver to take up, metabolize, and
excrete toxins is severely reduced.
• Gluconeogenesis is reduced, with high risk of
hypoglycaemia especially during infection.
• Bile secretion is reduced.
Genitourinary system
• Glomerular filtration rate is reduced.
• The capacity of the kidney to excrete excess
sodium, acid or a water load is greatly reduced.
• Urinary phosphate output is low.
• Urinary tract infection is common.

12. PATHOPHYSIOLOGY ctd…
Metabolism
• Basic metabolic rate is reduced by about 30%. •
Energy expenditure due to activity is very low. • Both
heat generation and heat loss are impaired; the child
becomes hypothermic in a cold environment and
hyperthermic in a hot environment.
Endocrine system • Insulin levels are reduced and the
child has glucose intolerance. • Insulin growth factor
1 (IGF-1) levels are reduced, although growth
hormone levels are increased. • Cortisol levels are
usually increased
Immune system • All aspects of immunity are
reduced. • The lymph glands, tonsils and thymus are
atrophied. • Cell-mediated immunity is severely
depressed. • Levels of immunoglobulin A (IgA) in
secretions are reduced. • Complement components
are low. • Phagocytes do not kill ingested bacteria
efficiently. • Tissue damage does not result in
inflammation or migration of white cells to the
affected area. • The acute-phase immune response is
reduced. • Typical signs of infection, such as an
increased white cell count and fever, are frequently
absent. • Hypoglycaemia and hypothermia are signs of
severe infection, usually associated with septic shoc
Skin
The skin and subcutaneous face are atrophied leading
to loose folds of the skin therefore many signs on
dehydration may be misleading e.g sunken eyes,
reduced skin turgor
-many glands, e.g sweat, tear, and salivary glands are
atrophied

13. CLASSIFICATION OF ACUTE MALNUTRITION
MEASUREMENT INDEX SEVERE ACUTE
MALNUTRITION
MODERATE ACUTE
MALNUTRITION
Weight for height/length -3SD (WHO) <-2 SD >/=- 3SD (WHO)
Mid upper arm circumference
(MUAC)
< 115 mm > /=115mm & <125mm
Bilateral pitting edema yes no
Classify as severe if presence of any of the following :
- bilateral pitting edema
–weight for length <-3SD (WHO)
– infant too weak or feeble to suckle effectively
–mother reports breast feeding failure and infant not gaining weight at home
Age
6-59
months
Age<6/12

14. TRIAGING
• Guides staff on steps to follow in identifying children of normal nutrition and those who have
MAM/SAM

15. Equipment needed for diagnosis
Weight
Scale

16. Equipment needed for diagnosis
• MUAC TAPE

17. MUAC-<11.5cm

18. HISTORY TAKING
-recent intake of food and fluids/ Able to drink or breastfeed
-usual diet before current illness/breastfeeding
- Mother’s perception of appetite
-Has recent and frequent vomiting & diarrhoea; duration+ type of diarrhoea (watery/bloody)
- Has any other reported problem , chronic cough, recent measles, HIV,
-contact with TB or adult with undiagnosed chronic cough
- Immunization history
- Family circumstances, (e.g. death of siblings, absent or illness of parents, poverty assessment,
etc.
-Size at birth (small, normal, large), prematurity

19. EXAMINATION
• observe the child for movements, alertness, cry, body tone and general demeanour. If the child
appears critically ill, look for critical signs, then move directly to the emergency triage, assessment
and treatment plus admission (ETAT+) protocol.
• Check for signs of dehydration or shock(o Lethargic or unconscious o Cold hands o Slow capillary
refill (>3 seconds) o Weak (low volume) or rapid pulse)
• Vital observations (RR, Temperature fever>37.5, hypothermia rectal temp < 35.5
• Anemia palmar palor(if hands arent cold)/ mucous membranes / conjuntiva
• Eyes for signs of vit A deficiency( dry conjuctiva, bitot’s spots, corneal ulceration, keratomalacia)
• Mouth ulcers
• Hair and Skin changes (hypo/hyperpigmentation, desquamation, ulceration over
limbs/thighs/groin/genitalia/buttocks, exudative lesions resembling burns, rash)
• Localizing signs of infection-ent, skin, pneumonia
• Signs of HIV infection/ Tap spine for early signs of Pott’s disease.

20. Features of severe malnutrition- severe
wasting

21. Features of malnutrition- bilateral pitting
pedal oedema
Press both sides for 5 sec Then let go- it leaves a pit-depression

22. ETAT protocol (EMERGENCY TRIAGE ASSESSMENT AND
TREATMENT)
• Call for help
• in order of emergency, assess and treat the ABCD
• Airway and breathing, “A” and “B”: • Does the child’s airway appear obstructed? Look and listen to determine whether
there is poor air movement during breathing. • Does the child have severe respiratory distress? (Head nodding, grunting,
central cyanosis, fast breathing, retractions, not able to feed.)manage the airway and give oxygen
• Circulation “C” • Check the radial pulse, capillary refill time, and coldness of extremities. If you cannot feel a radial pulse of
an infant (less than 1 year of age), feel the central pulse. If the room is very cold, rely on the femoral/carotid pulse to
determine whether the child is in shockIf the child is in shock due to diarrhoea with very severe dehydration start
resuscitation with iv fluids
• Disability “D” Level of consciousness: Is the child lethargic or in coma (unconscious)? Check the level of consciousness on
the “AVPU” scale (A alert, V responds to voice, P responds to pain, U unconscious). Convulsions: Is the child convulsing give
IV glucose for hypoglycaemia. Give an anticonvulsant for convulsions
• Hypothermia – hyperthermia • Does the child have a low body temperature (< 35.0 °C axillary or < 35.5 °C rectal). Low
body temperature is a sign of hypoglycaemia and sepsis. Warming the child is an emergency treatment. • Does the child
have a very high body temperature (≥ 38.5 °C axillary or ≥ 38°C rectal)? Cooling the child with tepid sponging in used
• Carry out emergency investigations (blood glucose, blood smear, haemoglobin). Send blood for typing and cross-matching
if the child is in shock, appears to be severely anaemic or is bleeding significantly.
• After stabilization proceed to assessing, diagnosing and treating the underlying problems

23. investigations
• chest X-ray,
• urine dipstick,
• blood, urine or cerebrospinal fluid (CSF) , stool mcs
• Cbc and inflammatory markers
• Hiv
• Malaria rdt and smear
• TST
• Blood sugar
• Blood group& xmatch- if indicated

24. ADMISSION CRITERIA
• All children <6/12 with SAM
• SAM with medical complications –
anorexia/no appetite
–intractable vomiting
–convulsions
–lethargy, not alert
– unconsciousness
–lower respiratory tract infections
– fever /hypothermia
–severe dehydration or shock
–severe anemia
-hypogylcemia
– any open skin lesions
–presence of severe candidiasis or other signs of immunosuppression
• Caregiver refuses OTP
• readmission

26. PRINCIPLES OF MANAGEMENT (the 10 steps)

27. Step 1- treatment of hypoglycemia
• All severely malnourished children are at risk of developing hypoglycemia
• Dfn – RBS< 3mmol
• If blood glucose cant be measured assume all children with sam have
hypoglycemia
• Hypoglycemia Can be a result of systemic infection or poor appetite
• Signs:
-hypothermia -
lethargy/drowsiness
-loss of consciousness -
convulsions
-eyelid retraction

28. Step 1- treatment of hypoglycemia
Patients who are conscious or able to
drink
Patients who are losing consciousness,
cant be aroused or convulsing
50mls of 10% glucose water, sugar
water or f75 by mouth
If only 50% glucose solution is
available dilute one part to 4 part
sterile/boiled water and give orally
5mls/kg of 10% dextrose iv
-Give 2-3 hourly oral/ngt f-75 feeds to prevent recurrence
-Monitor sugars
-Give appropriate antibiotics
-*10% glucose water( 2level teaspoons of glucose powder+50mls H20)

30. Step 3- Dehydration
• Misdiagnosis and inappropriate treatment of dehydration in the commonest cause of death of
the malnourished patients
• Whenever possible rehydration should be oral as iv infusion easily causes overhydration,
pulmonary edema and heart failure, and should only be used in shock
• Before starting rehydration, weight the child, mark liver edge on the skin with a marker, and
record HR and RR
Reliable signs of dehydration in SAM Unreliable signs of dehydration in SAM
-history of diarrhea
-thirst - hypothermia
-sunken eyes
-weak or absent radial pulse
-cold hands and feet
-reduced urine flow
-mental state
-mucous membranes
-tears
-skin turgor

31. Dehydration -RESOMAL
• Because children with SAM are deficient in potassium and have abnormally high levels of sodium in their
body, the recommended ors for malnutrition (ReSoMal) contains less sodium and more potassium than the
standard WHO low-osmolarity oral rehydration solution or standard ors
• Magnesium, selenium, zinc and copper have been added in formulation of ReSoMal to start correction of
these deficiencies.

32. Treatment of Severe dehydration in
SAM
• Treat with resomal until target weight is reached (weight deficit= weight %dehydration 1000g)
• For conscious children on admission assume that it is 3% of the admission body weight, for
unconscious children use a figure of 5% of body weight
• Give the required amount of fluids as sips by cup or spoon every few minutes, usengt in the
weak/exhausted, vomiting and pts with painful oral sores
• Give ReSoMal orally or by nasogastric over a maximum of 12 hours:
-Starting with:
- ReSoMal 10 ml/kg per hour for the first 2 hours orally. -
Re-weigh the child to determine if the child is gaining or losing weight:
- If the child is gaining weight AND clinically improving, continue.
- If the child’s weight is steady (the same), increase the ReSoMal to 15 ml/kg/h.
- If the child is losing weight, increase the ReSoMal to 20 ml/kg/hr
-If the child is gaining weight, but clinically deteriorating STOP ALL ATTEMPTS at rehydration – the child is
not dehydrated.
- If diarrhoea continues give children 20–30 ml of ReSoMal after each loose stool
% %

33. FEEEDING DURING
REHYDRATION
-breast feeding shd not be
interrupted
-begin f75 as soon as
possible usually within 2-3
hrs after starting
rehydration, alternate f75
with resomal

35. Shock
• A- Patency
• B- Breathing, commence oxygen
• C- IV 10% glucose at 5mls/kg, IVF-1/2SD in 10% dextrose at 15mls/kg
for 1 hour
• Observe the child and monitor RR, PR every 10 minutes
• If RR,PR are reducing, then patient is improving. Repeat bolus at
15mls /kg for 1 hour. Continue checking RR and PR every 10 minutes

36. • After 2 hours of IVF, switch to oral/NGT with resomal.
• Alternate resomal with F75 feed for up to 10 hours
• If RR,PR are increasing with an increase in JVP and increase in size of
hepatomegaly or appearance of hepatomegaly, then patient is
deteriorating. Stop IVF and consider septic shock
• If HB < 5ml/kg, transfuse at 10ml/kg whole blood
• If blood not available immediately, start maintainance IVF at
4ml/kg/hr, while waiting for blood

37. HYPERNATREMIC DEHYDRATION
• common in areas with a dry atmosphere, particularly if the air temperature is also high
• Diagnosis
-serum sodium>150mmol
- change in the texture and feel of the skin (doughy feeling)
-abdomen becomes progressively sunken and wrinkled “scaphoid abdomen” or “prune belly”).
-fever may develop fever.
-progressive drowsines
- convulsions which are not responsive to the normal anti-convulsants (phenobarbitone, diazepam etc.)
• Treatment
- correct slowly over 48hrs ( rapid correction can cause cerebral edema)
-If the child is conscious or semi-conscious and there is no diarrhoea insert ngt and start 2.5 ml/kg per
hour of 10% sugar water or breast milk. Do not give F75 at this stage.
- If there is accompanying diarrhoea, Give one fifth normal saline in 5% dextrose orally or by
nasogastric tube
-If the child is unconscious: Then the same volumes of fluid (5% dextrose if there is no diarrhoea and
one fifth normal saline in 5% dextrose if there is diarrhoea) can be given by IV infusion

38. Management of severe anemia
-diagnosis :
-HB<4g/dl
- hematocrit <12%
- very severe palmar/conjunctival palor
can lead to heart failure therefore need for blood transfusion

39. Step 4 &6 –correct
electrolytes/micronutrients
• All children with SAM have
-K &Mg deficiencies which may take 2 or more weeks to correct
-excess body sodium
• Give extra K, Mg (fortified feeds,&Resomal)
• Prepare food without salt
• Folic acid supplementation –5mg stat then 1mg od, also in F75/ F100/RUTF,
• Fe supplementation
- not to be given in the stabilization phase ( can worsen bacterial infections),
-on f100 give iron 3mg/kg/day, RUTF contains enough iron
• Preventive vit A stat ( <6months-50000iu, 6-12 -100000iu, >1 yr 200000iu)
• Cu/Zn in F75/100

40. Step 5- Treat/prevent infections
• In SAM the usualsigns of infection e.g fever are often absent, therefore assume all
children with sam have an infection and treat with antibiotics
• Put into place a high level of infection control, including hand-washing for health
workers, mothers, carers and children, and hygiene measures for bedding and the
environment
COMMON INFECTIONS
-candidiasis
– otitis media
–meningitis
– eye infections
- pneumonia
–HIV /TB
-malaria
– measles
–skin infections( scabies, kwashiokor dermatosis, perianal excoriation)

41. Step 5- Treat/prevent infections
• Give all patients with Severe acute malnutrition antibiotics for presumed infection
• Deworming routine (albendazole/ mebendazole)
• Malaria prevention- routine
• Vaccination
• Treatment of specific conditions
No complications Give oral antibiotics
Amoxyl 25mg /kg/ dose bd for 5/7
With complications Iv Benzyl penicillin or Ampicillin with
gentamycin
3rd generation cephalosporins e.g
ceftriaxone/ cefotaxime

42. Step 7- Initiate feeding
-in the initial phase a cautious approach is required because children with SAM cannot tolerate the
usual amounts of dietary protein, fat and sodium
- begin with frequent small feeds of F75- is low in protein, fat and sodium and high in carbohydrate
with a full and balanced complement of all minerals and vitamins
- Oral/NG feeds (never parenteral preparations)
- Continue breastfeeding
- Start with 130 mls/kg/day ( 2 hourly feeds day1-2, 3 hourly feeds day 3-5, 4 hourly feeds day 6
onwards)
- Monitor amount of feed offered &left over, vomiting, diarrhea, daily bodyweight, edema

43. Step 8- Catch-up growth
-Signs that the child has reached this phase: (return of appetite &most/all the
edema has gone, Medical complications start resolving, the child is awake and
increasingly alert)
-make gradual transition to catch-up formula (f100)
-replace f75 with equal amounts of f100 for 2/7 then increase subsequently by
10mls at each feed, continue increasing until some food is left
-continue breastfeeding
-Modified porridges and complementary foods can be used
-Move back to f75 if patient deteriorates,

44. F75 vs F100

45. Refeeding syndrome
• a potentially fatal condition, caused by rapid initiation of refeeding after a period
of undernutrition.
• It is characterised by hypophosphataemia, associated with fluid and electrolyte
shifts and metabolic and clinical complications.
• Clinical features: nausea, vomiting, lethargy, respiratory insufficiency, cardiac
failure, hypotension, delirium, coma and death
• Treatment : reduce feed intake to 50%, correction of electrolytes and supportive
therapy

46. SENSORY STIMULATION
-provide TLC
-cheerful stimulating environment
-structured play therapy
-involve caregiver

47. DISCHARGE AND FOLLOW UP
• After correction of all the complications, with good appetite, its time
to discharge and follow up in OTP