1. Malnutrition
Dr.Anita Lamichhane
MD resident (Pediatrics)
Shaikh Zayed hospital ,
Lahore

2. • > 3.5 million/year , mothers & children die due to
the underlying cause of under nutrition
• > 55 million (10%) of children are wasted
• < 19 million are severely wasted.

3. South ASiA And Sub-SAhArAn AfricA hAve
the higheSt ShAreS of Young children who
Are underweight.
Prevalence of Underweight Children Under Age 5, by Country
Source: Carl Haub, 2007 World Population Data Sheet.

4. vitAmin A And iron deficiencieS Are AlSo
PrevAlent Among children < 5 YeArS .
Percent of Children Under Age 5 with Vitamin A and Iron Deficiencies, Selected Regions

6. dAtA from PAkiStAn
• 36 % of children -- underweight before the current
floods.
• Researchers claim that up to 44 % of children of rural
area stunted.
• A survey by the World Health Organization -the
number of underweight pre-school children (0-5
years of age) is 40 %

7. mAlnutrition
• Derived from malus (bad) and nutrire (to nourish)
• Includes both
 Under nutrition (deficiency of one or more
essential nutrients)
 Over nutrition (an excess of a nutrient or
nutrients)

8. • Macronutrients (carbohydrates, lipids, proteins &
water) - needed for energy, cell multiplication &
repair
• Micronutrients are trace elements, vitamins &
nutrients - essential for metabolic processes

9. AdAPtAtion to StArvAtion
energY Source
• Depletion of glycogen stores
gluconeogenesis ( glucose / insulin)
(Glycerol, amino acids, lactate/ pyruvate)
• Fatty acid oxidation and ketone bodies
Utilization
• Reduced protein catabolism & gluconeogenesis

10. AdAPtAtion to StArvAtion
fluid & electrolYte
• Inhibition of sodium pump
intracellular Na
total body water
• urinary loss of K, calcium, phosphate,
magnesium & zinc
• total body K+ : hypotonia, apathy, impaired
cardiac function

11. refeeding SYndrome
• Metabolic disturbances occur at this point
• Starvation- loss of lean muscle mass, water and
minerals
phosphorus
• Carbohydrate refeeding, insulin release
• glucose uptake
• Hyphosphatemia- red cell ATP
• K,Mg, glucose,thiamine

12. clASSificAtion

13. who clASSificAtion
• Defined as the presence of edema of both feet
or severe wasting {70% weight for
height/length or (<-3SD)} or clinical signs of
severe malnutrition

14. gomez clASSificAtion
• If the wt is > 90 % of the expected weight –no
malnutrition
• 1st degree- wt is 75-90% of the expected weight
• 2nd degree- wt is 60-75% of the expected weight
• 3rd degree- wt is < 60 % of the expected weight

15. modified gomez clASSificAtion
• If the wt is > 80 % of the expected wt –no
malnutrition
• 1st degree- wt is 70-80% of the expected wt
• 2nd degree- weight is 60-70% of the expected wt
• 3rd degree- wt is < 60 % of the expected wt

16. wAter low clASSificAtion
Height Weight for age expressed as percentage
for age
<80 80-120 >120
<90% Chronic Stunted but Stunted and
malnutrition no obese
malnutrition
> 90% Acute Normal Obese
malnutrition

17. welcome clASSificAtion
Edema present Edema absent
Weight for Kwashiorkor Ponderal
age 80-60 % Retardation
of standard
Weight for Marasmic Marasmus
age < 60 % kwashiorkor
of standard

18. hArvArd clASSificAtion
• If the wt falls 50th percentile- healthy child
• Grade I- if wt is 71-80% of 50th percentile
• Grade II- if wt is 61-70% of 50th percentile
• Grade III- if wt is 51-60% of 50th percentile
• Grade IV- if wt is 50% of 50th percentile

19. generAl clASSificAtion
Mid arm circumference – measured with a
measuring tape
• At 12 months- 16.5 cm
• Between 12-48 months= 12.5-16.5 cm
• Cut off point- 75 % of the expected mid arm
circumference
• If less than the cut off point (<14 cm)= malnourished

20. Skin fold thickness
• Herpeden caliper
• Triceps/back of shoulder
• Normal= 9-11 mm
• If < 9 mm- malnourished

21. Quac strip
• Special tape having colors on it
Up to green Normal
colour
Yellow colour Borderline
malnutrition(14-12 cm)
Red colour Malnourished (< 12 cm)

22. • Body mass index (BMI) weight in kg
height in m²
<16 Malnourished
>25 Obese
16-25 Normal

24. etiologY
Primary malnutrition Secondary malnutrition
Failure of lactation Parasitic infestations, Measles, whooping
cough, Primary tuberculosis, Urinary tract
infection
Ignorance of weaning Congenital heart disease, Urinary tract
anomalies
Poverty Giardiasis,Lactose intolerance, Celiac
disease, Tuberculosis of the intestine
Cystic fibrosis
Cultural patterns and food Inborn errors of metabolism,galactosemia
fads
Lack of immunization and
primary care
Lack of family planning

26. kwashiorkor marasmus
Derived from Ghanian dialect derived from the Greek
meaning first second- after birth marasmos, which means
of the second baby, the first wasting
baby is deprived from the Due to dietary deficiency
breast feeding, which is the only /severely restricted food intake
source of protein
Underweight Extremely underweight below <
60%
Edema is always present Edema is always absent
Thin lean muscles, fat is present Muscle wasting with loss of
subcutaneous fat
Hair changes are present-fine, No hair changes
straight,sparse,discolored

27. kwashiorkor marasmus
Poor appetite and anorexic Good appetitie
Flaky paint dermatitis, ulcers, Normal skin
hypo/hyperpigmentation
Miserable looking and apathetic Appearance of monkey face or
little old man face,alert facies
Liver enlarged (fatty infiltration) No hepatomegaly

28. Initial assessment of the severely
malnourished child

29. hiStorY
• Recent intake of fluids & foods
• Usual diet (before the current illness)
• Breast feeding
• When was weaning started
• Duration & frequency of diarrhea & vomiting
• Type of diarrhea (bloody/watery)
• Loss of appetite

30. • Time when urine was last passed
• Family circumstances-literacy level, socioeconomic
status, housing, family members, vaccination
• Chronic cough
• Contact with tuberculosis
• Recent contact with measles
• Milestones reached

31. exAminAtion
• Proper exposure of the child
• General look /appearance:
Stunted,wasted,edematous, alert, apathetic,
emaciated
• Anthropoetic measurements: weight, height, head
circumference, mid arm circumference- plot in the
centile chart

32. • Signs of dehydration & shock – cold hands, absent
tears, slow capillary refill, weak & rapid pulse
• Hypo/hyper thermia
• Head- depressed and open fontanelle,fine sparse
hair, hypo/ hyper pigmented, easily pluckable
• Hands –severe palmar pallor, clubbing, pulse,
widening of wrist

33. • Eyes- signs of vitamin A deficiency
• Ear – discharge from the ear, (serosanguneous or
purulent)
• Neck-Goitre, lymph nodes
• Mouth- angular stomatits,Oral hygiene, gum
(bleeding/hyperplasia),dentition, tongue( flat , loss of
papilla, red and beefy), ulcer, oral thrush

34. • Skin – colour, whether dry and lusterless, any
exudative changes (resembling severe burn) often
exist with secondary infecttion (including
Candida),petechiae and bruises
• Chest- shape, prominent costochondral junction,
Chest
ricket rosary, crowding of ribs, Harrison's sulcus
• CVS- signs of heart failure
CVS

35. • Edema , jaundice
• Skin changes of Kwashiorkor
• Abdomen - distended, protuberant, tone of the
muscles, bowel sounds, tender hepatomegaly

37. inveStigAtionS
• Full blood counts, peripheral smear for MP
• Blood glucose level
• Septic screening
• Stool for cysts, ova, and C/S, fat globules
(Malabsorption)

38. • Urine microscopy and C/S
• Electrolytes, Ca, Ph & ALP, Serum albumin & total
proteins
• CXR & Mantoux test
• Exclude HIV

39. comPlicAtionS
• Hypoglycemia
• Hypothermia
• Hypokalemia
• Hyponatremia
• Heart failure
• Dehydration & shock
• Infections (bacterial, viral & thrush)

40. mAnAgement
• INITIAL TREATMENT (emergency treatment)
• REHABILITATION
• FOLLOW UP

41. • Stabilization Rehabilitation
• 1 week 2-6 weeks
• Hypoglycemia
• Hypothermia
• Dehydration
• Electrolytes
• Infections
• micronutrients No iron Add iron
• Initiate feeding
• Catch up growth
• Sensory stimulation
• Follow up

42. Initial treatment ( First phase)
(usually 2-7 days)

43. fluidS And electrolYte
bAlAnce
• Iv infusion - indicated in a severely malnourished
child with circulatory collapse (otherwise N/G
feeding)
• ½ strength Darrow’s solution with 5% dextrose
• Half normal saline(0.45%) with 5% dextrose
• Give i/v fluid 15 ml/kg over 1 hour

44. • Measure the vital signs( pulse rate, respiratory rate)
at the start & every 5-10 minutes
• If signs of improvement, then repeat i/v 15 ml /kg
over 1 hour, then switch to oral /NG rehydration
with ReSoMal 10 ml/kg/hour up to 10 hour
• Initiate refeeding with starter F-75 ( 75 calories/100
ml)
• If the child fails to improve, assume the child has
septic shock

45. • Give maintenance i/v fluid (4ml/kg/hr) while waiting
for blood
• Transfuse fresh whole blood 10 ml/kg slowly over 3
hours (packed cells used if in failure)
• Start antibiotics
• If the child comes out of shock, then start 70 ml/kg
of RL(if not available, NS) over 5 hours in infants (<12
months) and over 2/12 hours in children (aged 12
months to 5 years)

46. • Reassess the child every 1-2 hours
• As soon as the child can drink, give ORS solution
• Reassess after 6 hours(in infants) and 3 hours(in
children)
• Classify dehydration and then choose the
appropriate plan (A,B,or C) to continue treatment

47. • If available, add selenium & iodine
• Solution stored in sterilized bottles in fridge
• Discards if it turns cloudy
• Add 20 ml of the concentrated electrolyte/mineral
solution to each 1000 ml of milk feed

48. how to mAke reSomAl???
• ORS 1 packet
• Water 2 litres
• Sugar 40 gram
• Mineral mix 33 ml ( Zn given as syrup zincate, Mg
given as I/V, K= 100 gm of KCl in 1 litre of water
(take 40 ml of KCl)

49. correction of hYPoglYcemiA
PREVENTION:
By feeding every 2 -3 hours/day
TREATMENT:
o Conscious child- 50ml of 10% glucose/sucrose PO
o Unconscious child- 5ml/kg of 10% glucose I/V
followed by 50ml of 10% glucose/sucrose by N/G
Tube

50. hYPothermiA
Marasmic infants and children are more at risk of
hypothermia
if underarm temperature < 350C (950F)
The child is rewarmed by:
 Kangaroo Method
 Warm Blanket & Lamp method

51. control of infection
o MILD INFECTIONS: Cotrimoxazole BD x 5 days
o SEVERE INFECTIONS WITH COMPLICATIONS:
 Ampicillin:50mg/kg I/M, I/V 6hr x 2days
 Amoxicillin:15mg/kg oral 8hr x 5 days
 Gentamicin:7.5mg/kg I/M,I/V O.D x 7days

52. • Measles vaccination if the child is 6 months old &
not immunized or if the child is > 9 months old & has
been vaccinated before
• Mebendazole 100 mg PO OD x 5 days

53. orS Solution for SeverelY
mAlnouriShed children
• Malnourished children- deficient in K+ & abnormally
high Na+
• ORS soln should contain high K and low Na than the
standard WHO- recommended solution
• Mg, Zn & Cu should also be given
•

54. Composition of ReSoMal
Component Concentration (mmol/l)
Glucose 125
Na 45
K 40
Cl 70
Citrate 7
Mg 3
Zn 0.3
Cu 0.045
Osmolarity 300 mosmol

55. • ReSoMal available commercially
• Can also be made by diluting one packet of the
standard WHO-recommended ORS in 2 litres of
water; 50 g of sucrose (25g/l) and 40 ml (20 ml/l) of
mineral mix
• Mineral mix supplies
 K+ - affects cardiac function & gastric emptying
 Mg2+ - essential for K+ to enter the cells and be retained
 does not contain iron
• Mineral mix is stored at room temp and added to
ReSoMal or liquid feed at a conc. Of 20 ml/l

56. Mineral mix solution
Substance grams
KCl 89.5
Tripotassium citrate 32.4
MgCl2.6H2O 30.5
Zinc acetate.2 H2O 3.3
CuSO4.5 H2O 0.56
Sodium selenate 0.01
Potassium iodide 0.005
Water make upto 2500 ml

57. Vitamins Amount per litre of liquid diet
Water soluble
B1 0.7 mg
B2 2 mg
Nicotinic acid 10 mg
B6 0.7 mg
B12 1µg
B5 3 mg
C 100 mg
Biotin 0.1 mg
Folic acid 0.35 mg
Fat soluble
Vit A 1.5 mg
Vit D 30 µg
Vit E 22 mg
Vit K 40 mg

58. Types of formula feed
• F-75 (75 Kcal/ 3215kJ/100 ml)-used during the initial
phase
• F-100 (100 Kcal/420kJ/100 ml)-used during the
rehabilitation phase

59. F-75 (starter) F-100 (catch-up)
Dried skimmed milk (g) 25 80
Sugar (g) 70 50
Cereal flour (g) 35 -
Vegetable oil (g) 27 60
Electrolyte/mineral 20 60
solution (ml)
Vitamin mix (mg) 140 140
Water, make up to (ml) 1000 1000

60. Constituent Amount per 100 ml
F-75 F-100
Energy (kCal) 75 100
Protein (g) 0.9 2.9
Lactose(g) 1.3 4.2
Potassium (mmol/l) 3.6 5.9
Sodium (mmol/l) 0.6 1.9
Magnesium (mmol/l) 0.43 0.73
Zinc (mmol/l) 2 2.3
Copper (mmol/l) 0.25 0.25
%age of energy from
• protein 5% 12%
• fat 32% 33%
Osmolarity 333 419
(mOsmol)

61. how to PrePAre??
• F-75/F-100
• Add the dried skimmed milk,, sugar, cereal flour and
oil to some water and mix
• Boil for 5-7 mins
• Allow to cool
• Add the mineral mix and vitamin mix and mix it
again
• Make up the volume to 1000ml with water
• If dried skimmed milk not available, then 300 ml of
fresh cow’s milk can also be used

62. • F-75 diet should be given to all children during the
initial phase of treatment
• At least 80 kcal/kg should be given but not > 100
kcal/kg
• If < 80 kcal/kg given- the tissues continue to break
down & the condition will deteorate
• If >100 kcal/kg be given- serious metabolic
imbalance will develop

63. Feeding after the appetite
improves
• The initial phase of Tx ends when the child becomes
hungry
• Now transfer to F-100 diet with an equal amount of
F-100 for 2 days before increasing volume offered at
each meal

64. Recording the food intake
• Type of feed given
• Amounts offered and taken must be recorded
accurately after each feed and deducted from the
total intake
• Once a day the energy intake for the last 24 hours
should be determined & compared with the child’s
weight

65. dietArY mAnAgement
o 2-3 weeks
o Calorie : 120 -140 cal/kg/day
o Protein :3- 5 gm/kg/day
o Elemental iron: 3-6 mg/kg/day (ferrous sulphate)
o Vitamin A: 300,000I.U then 1500I.U/day

66. o Vitamin D: 4000 I.U/day
o Vitamin k: 5mg I/M, I/V once only
o Folic acid: 5 mg on day 1, then 1 mg/day
o Copper: 0.3 mg/kg/day

67. Basic principle of dietary
management
• Improve the nutritional level of the child as quickly as
possible by providing a diet with sufficient energy
producing foods & high quality proteins

68. initiAl refeeding
o Frequent small feeds of low osmolarity & low
lactose
o Oral/NG feeds (never parenteral preparation)
o 100 cal/kg/day
o Continue breast feeding if the child is breast fed

69. • Increase each successive feed by 10 ml until some
feed remains uneaten
• Assess progress: weigh the child every morning
before being fed, plot the weight
• Calculate weight gain every 3rd day
• If the weight gain is poor (<5 g/kg/day), check
whether the intake targets are being met
• good wt gain = (>10g/kg/day)

70. SenSorY StimulAtion
Provide
• Tender loving care
• A cheerful stimulating environment
• A structural play therapy for 15-30 mins / day
• Physical activity as soon as the child is well enough
• Maternal involvement as much as possible

71. criteriA for trAnSfer to
nutritionAl rehAbilitAtion
• Eating well
• Improvement of mental state
• Sits, crawls stands or walks
• Normal temperature
• No vomiting/diarhea/edema
• Gaining wt > 5 gm/kg body wt/day x 3 consecutive
days

72. nutrtionAl rehAbilitAtion
o Infants <24 months fed
exclusively on liquid/ semi solid
food
o Older children given solid food

73. Feeding < 2 years
• F-100 diet be given every 4 hours, night & day
• Increase the amount of diet at each feed by 10 ml
• When feed is not finished, the same amount should
be offered at the next feed
• process is continued until some feed is left after
most feed
• Any feed not taken should be discarded, should
never be reused

74. • If the intake is <130 Kcal, the child is failing to
respond
• F-100 should be continued until the child achieves
-1SD (90%) of the media WHO reference values for
weight for height

75. Feeding children >2 years
• Introduce solid food, local foods should be fortified
to increase their content of energy, mineral and
vitamins
• Oil added to increase the energy content
• The mineral & vitamin mixes used in F-100 should be
added after cooking
• Other ingredients-dried skimmed milk may also be
added to increase the protein content
• Supplementation of food with folic acid and iron

76. • Daily weight and plotted on a graph
• Mark the point that is equivalent too -1SD (90%) of
the median/WHO reference values for wt. for ht. on
the graph which is the target weight for children
• Usual weight gain is 10-15/kg/day

77. how to cAlculAte the cAlorieS
• Required calories = currently required for age + 25% calories
for catch up growth
o for e.g. calculation of calories for one year old child with
weight 6.5 kg
o expected wt at one year = 10 kg
o So the required calorie should be = 1000 ( 100 cal/kg/day)+
250 (25% of 1000 calories)
o Start with 625 cal/day or whatever the child is taking and if it

78. • Then increase by 10% per day
24
2/3
solid 1/2
18
months 1/2 1/2
12
1/3
2/3
6
liquid
0
Calories required

79. Source of cAlorie SuPPlY
• Carbohydrate : 50-55%
• Fat: 30-35%
• Protein: 10-15%

80. • Daily increment
• < 6 months= 50 calories/day
• 6-9 months= 75 calories/day
• > 1 year=100 calories/day

81. micronutrient deficiencieS
• Iron & folic acid for anemia
• Iron dose : 3mg/kg/day in 2 divided doses
• Folic acid :5mg on day one then 1mg/day
• Zinc : 2-3 mg/kg/day
• Copper : 0.3 mg/kg/day
• Ferrous sulphate (3-6 mg/kg/day)

82. treAtment of the ASSociAted
conditionS
Eye problem
• Vit A supplement
• Chloramphenicol/tetracycline drops- 4 drops daily x
7-10 days
• Atropine drops 1 drop tds x 3-5 day
• Cover with saline soaked eye pad
• Bandage the eyes

83. • Severe anemia: blood transfusion
• Skin lesions in kwashiorkor: zinc supplementation,
barrier cream ( Zn and castor oil ointment), nystatin
cream to skin sores,oral nystatin(1000 IU QID)
• Bathe or soak the affected area for 10 mins/day in
0.01% KMnO4 solution

84. • Giardiasis: metronidazole
• Lactose intolerance: substitute with yogurt or lactose
free formula, reintroduce milk feeds in the
rehabilitation phase
• Treatment of tuberculosis

85. Congestive cardiac failure
• usually a complication of overhydrationn,very severe
anemia, blood or plasma transfusion or giving a diet
with high Na content
• When due to fluid overload:
 stop all oral intake and IV fluids
 Diuretic IV ( furosemide 1 mg/kg)
 Do not give digitalis unless the diagnosis of heart
failure is unequivocal & the plasma K level is
normal

86. Drugs for the treatment of malaria in
severely malnourished child
Drug Dosage
Plasmodium malaria,P.ovale &
susceptible forms of P. malaria
Chloroquine Total dose: 25 mg of base/kg orally given
over 3 days
Day 1& 2= 10 mg og base/kg in a single dose
Day 3: 5 mg of base/kg in a single dose
Plasmodium falciparum malaria
Chloroquine Same as above
Quinine 8 mg of base /kg orally TDS x 7 days
Primethamine+sulphadoxine 5-10 Kg: 12.5 mg+250 mg orally in a single
dose
11-20 kg:25 mg+500 mg orally in a single
dose

87. nutrtionAl rehAbilition
Child should be weight daily
o Usual weight gain is 10 to 15Gm/kg/day
o Treatment failure: when the child doesn't gain wt at
least 5Gm/kg/day for 3 consecutive days
o target wt for discharge achieved after 2 to 4 wks

88. recoverY
• Takes place in 2 phases
INITIAL RECOVERY PHASE
 It takes 2 -3 wks: edema & other signs improve
CONSOLIDATION PHASE
 In next 2 to 3 months child regains normal weight
and is clinically recovered

89. criteriA for diSchArge from
hoSPitAl
1. CHILD
• Weight gain is adequate
• Eating an adequate amount of diet
• Vitamins & mineral deficiencies treated
• All infections & other conditions treated
• Full immunization programme started

90. 2. MOTHER
• Able & willing to look after the child
• Knows how to prepare & feed balance diet
• Knows how to play with child
• Knows how to give home treatment for diarrhea,
fever and ARI. Warn for danger signs

91. FOLLOW UP
• Follow up at regular intervals after discharge
• Child should be seen after
 every 2 days for 1 wk
 once weekly for 2nd wk
 at 15 days interval for 1 - 3 months
 monthly for 3- 6 months
• More frequent visits if there is problem
• After 6 months, visits twice a year until the child is at
least 3 years old

92. PrognoStic fActorS in Pem
• Grade of PEM & the type
• Grade III-IV marasmus & severe of Kwashiorkor are
associated with increased mortality
• Girls diagnosed as marasmus have been found to
have a higher death rate than boys
• Age: case fatality rate decrease with increase in age

93. • low weight for age is a sensitive indicator of
mortality
• Presence of serious complications like septicemia,
pneumonia & severe diarrheal diseases with
dehydration
• severe hypokalaemia & hyponatremia- poor
prognosis
• hypoproteinemia & hypoalbuminemia- poor
prognosis

94. Prevention
• Education of mother
• Counseling regarding family planning and spacing
between children
• Promotion of breast feeding
• Education of the parents regarding immunization of
the children

95. THANK YOU