Dr. Pallav Singhal discusses childhood malnutrition in India. Key points: - Malnutrition affects over 8 million Indian children under 5 and contributes to many deaths from diarrhea and pneumonia. - Severe acute malnutrition (SAM) is assessed using weight-for-height, edema, and mid-upper arm circumference criteria. - SAM treatment has two phases - stabilization and rehabilitation. Initial steps include rehydration, treating infections and deficiencies, and feeding ready-to-use therapeutic foods in graduated amounts. - Complications like shock, hypoglycemia, and hypothermia require emergency treatment with IV fluids and warming before oral feeding can begin.

1. Dr Pallav Singhal
MBBS, MD (Paediatrics)

2. Introduction
• Childhood undernutrition a major global health problem.
• Affects 8.1 million under-five children in India [1].
• Nearly 0.6 million deaths and 24.6 million DALYs (disability adjusted life years) are
attributed to this condition.
• Diarrhea and pneumonia accounts for half the under-five deaths in India, and
malnutrition is believed to contribute to 61% of diarrheal deaths and 53%
pneumonia deaths (2).
1. International Institute for Population Sciences. National Family Health Survey 3, 2005-2006. Mumbai India:
International Institute of Population Science; 200
2. Black RE,Allen LH, Bhutta ZA, de Onis M, Ezzati M, Mathers C, et al. Maternal and Child undernutrition: global
and regional exposures and health consequences. Lancet. 2008; 371: 243-60.

4. Malnutrition encompasses both ends of the nutrition spectrum, from
undernutrition to overweight.
1. SEVERE ACUTE MALNUTRITION without complications
Children 6–59 months of age,
• weight-for-height less than –3 Z-score of the median of the WHO growth
standards, OR
• or clinical signs of bilateral oedema (nutritional origin), OR
• Presence of visible severe wasting; OR
• a mid-upper arm circumference less than 115 mm
2. SEVERE ACUTE MALNUTRITION with complications
3. Moderate acute malnutrition-weight for height between
-2SD to -3SD ; without edema, or MUAC is 11-12.5 cm

6. SAM vs PEM
• Name protein-energy malnutrition is avoided, as it oversimplifies the complex
multideficiency etiology.

7. Causes SAM…?

9. THEORY
DIETECTIC HYPOTHESIS
(CLASSICAL)
Kwashiorkar: Prot deficiency
Marasmus: Energy Defi
ADAPTATION HYPOTHESIS
(GOPALAN’S)
Kwashiorkar: Adaptation Failure
Marasmus: Extreme case of
adaptation
Free Radical Hypothesis
(Golden’s)
Over production of free radicals and
breakdown of protective
mechanisms
Jelliffe’s Hypothesis Interactions and sequelae of dietary
imbalances, infections and
infestations, emotional trauma and
toxins

10. Reductive adaptation
Leads to
• liver makes glucose less—Hypoglycemia
• Heat production less—hypothermia
• kidneys less excretion of excess fluid and sodium.
• Heart- smaller and weaker with reduced output
• Sodium builds up inside cells--excess body sodium, fluid retention, and
edema.
• Potassium leaks out of cells (excreted in urine)--fluid retention, edema,
and anorexia.

11. •Gut-less gastric acid and enzymes, motility reduced--Digestion
and absorption are impaired.
•Cell replication and repair are reduced
•Red cell mass is reduced, releasing iron..

13. INITIAL ASSESSMENT
HISTORY
• The usual diet (before the current illness)
• Evidence of any chronic illness:
• presence of diarrhea (duration, watery /bloody)
• vomiting, loss of appetite, cough
• Contact with tuberculosis

14. DIETARY HISTORY
24 Hour Dietary recall
• Recall food and drink intake last 24 hour.
• Pre-morbid intake and current intake
• Freq of cereals/ pulses/ milk and products/ fruits and veg/ meat
products.
• Calc of calorie from breast: DO NOT calculate if usual feeding
going on( on demand feeds)

15. Examination
•Signs of dehydration
•Shock (cold hands, slow capillary refill, weak and rapid
pulse)
•Severe palmar pallor
•Eye signs of vitaminA deficiency
•signs of infections
•Skin infection or pneumonia, signs of HIV infection, fever.
•Hypothermia (rectal temperature <95.9°F)

16. ANTHROPOMETRY
• Height-for-age (or length-for-age for children <2 yr)-measure of linear growth, deficit
represents cumulative impact of adverse events
• weight-for-height(wasting)--acute malnutrition.
• Mid-upper arm circumference- Commonly used for screening, found to be relatively
stable between the ages 1 and 5 yr.

18. Face Moon face
Eye Dry eyes, pale conjunctiva,
Bitot spots (vitamin A),
periorbital edema
lachrymal and
salivary glands
atrophy
Lack of tears and dry mouth.
Mouth Angular stomatitis, cheilitis,
glossitis, spongy bleeding gums
(vitamin C),

20. Teeth Enamel mottling, delayed eruption
Hair Dull, sparse, brittle hair, hypopigmentation, flag sign
(alternating bands of light and normal color), alopecia
Skin Loose and wrinkled (marasmus), shiny and edematous
(kwashiorkor), dry, patchy hyper- and
hypopigmentation (crazy paving or flaky paint
dermatoses),
Nails Koilonychia, thin and soft nail plates, fissures.

21. Flaky paint Dermatosis
Flag sign
Koilonychia

22. Muscle Wasting, Chvostek orTrousseau sign
(hypocalcemia)
Abdomen Distended: hepatomegaly with fatty liver
Neurologic Global developmental delay, loss of knee and
ankle reflexes, impaired memory
Hematologic Pallor, petechiae, bleeding diathesis
.
Behavior Lethargic, apathetic, irritable on handling

23. TRIAGE

24. Indications for inpatient care
(i) Presence of a medical complication;
(ii) Reduced appetite
(iii) Presence of bilateral pitting edema

25. • Differentiate a complicated from an uncomplicated case (if require in-patient care)
• If appetite- good, still rate of weight gain at home is poor -may indicate a social problem
at household level or extensive sharing of the medical nutrition therapy.
APPETITETEST

26. RUTF
• RUTF- mixture of milk powder, vegetable oil, sugar, peanut butter, and powdered
vitamins and minerals,
• Powdered ingredients embedded in lipid rich paste..-energy dense
• Resists microbial contamination ..(very low water activity).
• Stored at room temp and tropical conditions for 3-4 months
• is energy-dense food providing 5.5Kcal/g.
• Equivalent in formulation to F 100
• Practical to use- where cooking fuel and facilities are limiting
• Continue to receive other foods and brestfeeding during medical nutrition therapy
with RUTF

27. Daily amount of RUTF to be consumed
• 3-4.9 kg: 105-130 g;
• 5-6.9 kg: 200-260 g;
• 7-9.9 kg: 260-400 g and
• 10-14.9 kg: 400-460 g.
• To given along with plenty of water in 2-3 hourly feeds.

28. A typical recipe for Ready to UseTherapeutic Food (Local Production)
% weight
Full fat milk powder 30
Sugar 28
Oil 15
Peanut butter 25
MineralVitamin Mix 1.6
Oxidation of the fatty acids, vitamin A and C, is the main factor limiting the storage life of
RUTF

29. An example of--Ready-to-use therapeutic spread produced by Nutriset

31. Principles ofTreatment

32. PHASES
1. Stabilization phase
2. rehabilitation phase(catch-up growth).
*Pushing ahead too quickly risk--“refeeding syndrome.”
*Don’t treat edema with diuretic
*Don’t give high-protein diet in early phase of treatment.

33. Emergency Management
SHOCK (Lethargic/ unconscious/ cold hands/ slow capillary refill/
weak fast pulse)
• 10D (5 mL/kg)
• IV fluid(Ringer lactate with 5% dextrose, (N /2) with 5% dextrose or Ringer lactate
alone at 15 mL/kg over 1 hr
• If signs of Improvement, repeat IV 15 mL/kg for 1 more hr.Then oral or nasogastric
rehydration.
• If does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg
slowly over at least 3 h) given.

34. Emergency treatment of severe anemia
Hb <4 g/ dl or between 4 and 6 g/ dl with respiratory distress
Give BT with whole blood 10 ml/kg over 3 hr
Lasix given at starting of BT.

35. Hypoglycemia
If conscious(asymptomatic):
• 10D(50 mL), or a feed, or 1 teaspoon sugar under the tongue-whichever is
quickest
If Unconscius(symptomatic)
• 10D (5 mL/kg) by IV
• Feed every 2 hr for at least the first day. Initially 1/4 of feed every 30 min
• Keep warm
• Start broad-spectrum antibiotics

36. Hypothermia--axillary <35°C (95°F); rectal <35.5°C (95.9°F)
• Actively rewarm
• Feed
• Skin-to-skin contact/ dress warmed clothes, cover head, wrap in warmed
blanket
• In case of severe hypothermia (rectal temperature…warm humidified oxygen
followed immediately by 5 ml/kg of 10% dextrose IV or 50 ml of 10% dextrose
by nasogastric route.
• Stop rewarming-rectal temperature 36.5°C (97.7°F)

37. Dehydration
• Do not give IV fluids unless in shock
• Give ReSoMal 5 mL/kg every 30 min for first 2 hr orally or NG tube
5-10 mL/kg in alternate hours for up to 10 hr.
• STOP--signs of overload (pulse rate increases by 25 beats/min
and respiratory rate by 5 breaths/min; increasing edema;
engorged jugular veins)
• Stop when rehydrated.

38. • Standard WHO low-osmolarity oral rehydration solution (75 mmol/L
sodium) should not-- used for oral or nasogastric rehydration in severe
acute malnutrition in dehydration or severe dehydration.
• ReSoMal or half-strength standard WHO low-osmolarity oral
rehydration solution should be given
• To prepare ReSoMal
Dissolve one sachet of standardWHO low-osmolarity oral rehydration
solution in 2 L water (instead of 1 L).
Add 40 mL of mineral mix solution (5), and 50 g of sugar
5. WHO. The treatment of diarrhoea: manual for physicians and other senior health workers. Geneva, World
Health Organization; 2005 (http://www.who.int/maternal_child_adolescent/documents/9241593180/en/).

39. Electrolytes
• Extra potassium at 3-4 mEq/kg/ day for(min 2 weeks)
• On day 1, 50% magnesium sulphate (4 mEq/ml) IM once (0.3
ml/kg; maximum of 2 ml).
0.8-1.2 mEq/kg daily
• Excess body sodium exists(even though the plasma sodium may
low)--decrease salt in diet

40. Infections
• If no complications--Oral cotrimoxazole (5 mg/kg 12 hourly of
trimethoprim) or oral amoxicillin for 5 days
• If complications- Gentamicin (7.5 mg/kg IV or IM) or amikacin
(15-20 mg/kg IV or IM) once daily for 7 days
• Ampicillin (50 mg/kg/dose IV or IM) every 6 hr for 2 days,
oral amoxicillin (25-40 mg/kg) every 8 hr for 5 days.
• If no improvement within 48 hr--IV cefotaxime (100-150
mg/kg/day 6-8 hourly) or ceftriaxone (50-75 mg/kg/day 12
hourly).

41. Correct micronutrient deficiencies
•Twice RDA--vitamins and minerals be used.
•Iron avoided, promoting free radical generation and
bacterial proliferation..Added—gaining weight and good
appetite.
•VitaminA, given to all severely malnourished..
day 0 at 50,000 IU, 100,000 IU and 200,000 IU for infants
0-5 month, 6-12 months and children > 1 yr
On day 1 and 14..IF SIGNS of xerophthalmia.

42. MicroNutrient Dose
Vitamin K single dose of 2.5 mg i/m
Thiamine B1 0.5 mg/ 1000 kcal
Riboflavin B2 0.6 mg/1000 kcal
niacin 6.6 mg/1000 kcal
Folic acid 1 mg/day (5 mg on day 1)
zinc 2 mg/kg/day
copper 0.2-0.3 mg/kg/ day
Iron 3 mg/kg/ day…(LATER)

43. Initiate Re-feeding
• Milk-based feeds- F75 in stabilization phase and F100- rehabilitation phase
• Started as soon as possible (frequent small feeds).
• If takes <80% of the target intake, nasogastric feeds initiated.
• Breastfeeding--continued ad libitum.
• Fed every 2 hours (throughout night)
• Begin with 80 kcal/kg/ day and gradually increase to 100 kcal/kg/ day

44. Catch-up growth
• Once appetite returns in 2-3 days increase volume feed
• Gradual transition from F-75 to F-100 diet (calorie density (100 kcal/100 ml) and
have at least 2.5-3.0 g protein/100 ml.)
• Increase calories to 150-200 kcal/kg/ day, and proteins to 4-6 g/kg/ day

45. Starter diets

47. Inpatient care
• Weighed each morning
• Length/height are measured on admission and discharge
• If good weight gain > 10 g/kg/ day--same treatment
• Moderate weight gain 5-10 g/kg/day—check food intake screened for systemic
infection.
• Poor weight gain <5 g/kg/ day--Inadequate feeding, untreated infection,
psychological problems and coexisting infections

48. Criteria for discharge
•Alert and active, eating at least 120-130 kcal/kg/ day
•consistent weight gain (of at least 5 g/kg/ day for 3
consecutive days) on exclusive oral feeding
•Receiving adequate micronutrients
•Completed immunization appropriate for age
•Caretaker has been sensitized to home care.

49. Failure of treatment
Primary failure
• Failure regain appetite by day 4
• Failure start losing edema by day 4
• Presence of edema on day 10
• Failure gain at least 5 g/kg/day-by-day 10
Secondary failure
• Failure gain at least 5 g/kg/day for consecutive days during the rehabilitation
phase

51. Refeeding syndrome
• Can complicate the acute nutritional rehabilitation
• May follow overly aggressive enteral or parenteral nutrition
Excessive carbohydrates
Increase in serum insulin levels
Hypokalemia, hypophosphatemia(is hallmark), hypomagnesemia.
• Phosphate ≤0.5 mmol/L--weakness, rhabdomyolysis, neutrophil
dysfunction, cardiorespiratory failure, arrhythmias, seizures, altered
level of consciousness, or sudden death.

52. Pseudotumor cerebri
•transient rise of intracranial tension
•benign and self limiting.

53. Nutritional recovery syndrome
Sequence of events due high quantity of proteins during rehabilitation,
possibly due--endocrine disturbance(ex estrogen) produced by the recovering
pituitary gland
Presents as
(i) abdominal distention,
(ii) Increasing hepatomegaly
(iii) Ascites
(iv) Hypertrichosis
(v) Parotid swelling
(vi) Gynecomastia
(vii) Eosinophilia
(viii) splenomegaly.

54. THANKYOU