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Dr. BABU LAL MEENA
• Inadequate consumption, poor absorption
or excessive loss of nutrients.
• Overindulgence or excessive intake of
• Refers to both undernutrition as well as
Protein energy malnutrition
Range of pathological conditions arising from
lack , in varying proportions , of protein and
Marasmus: weight for age < 60% expected
Kwashiorkor: weight for age < 80% + edema
Marasmic kwashiorkor: wt/age <60% +
Global burden- more prevalent in developing
countries. “Often starts in the womb and ends in
PEM affects every 4th child world-wide
More than 50% of deaths in 0-4 years are
associated with malnutrition
Median case fatality rate is-23.5% in severe
malnutrition reaching 50% in edematous
Childhood malnutrition underlying cause of
death in 35% of all deaths under 5.
During 1st 6 months, when most babies are
breastfed, 20-30% are already
By 18-23 months, during weaning, 30% are
severely stunted, 1/5th are underweight.
The major contributing factors are:
• Diarrhea 20%
• ARI 20%
• Perinatal causes 18%
• Measles 07%
• Malaria 05%
55% of the total have malnutrition
Indicator Interpretation Interpretation
Stunting Low height for age Chronic malnutrition
Wasting Low weight for height Acute malnutrition
Underweight Low weight for age Combined indicator to
reflect both acute on
• Only wt for age taken into account
• No comment about height
• All cases of edema in 3rd degree
ireespective of wt for age
Nutritional status Wt FOR AGE ( % of expected )
normal > 90
1st degree PEM 75-90
2nd degree PEM 60-75
3rd degree PEM < 60
Nutritional status WEIGHT FOR AGE
( % of expected )
1st degree PEM 80-90
2nd degree PEM 70-80
3rd degree PEM 60-70
4TH degree PEM < 60
WELLCOME TRUST / INTERNATIONAL CLASSIFICATION
Based on wt-for-age and presence of edema.
(% of expected )
Oedema Clinical type of PEM
60-80 + Kwashiorkor
60-80 _ Underweight
< 60 _ Marasmus
< 60 + Marasmic
Grade of malnutrition Weight for age of the
Grade I 71-80 (mild malnutrition)
Grade II 61-70 (moderate malnutrition)
Grade III 51-60 (severe malnutrition)
Grade IV <50 (very severe malnutrition)
Weight-for-height SD score
-2 to -3
Height-for-age SD score
-2 to -3
AGE INDEPENDENT INDICES
Weight for height
Mid arm circumference
Body mass index
Index ( Kanawati, Dughdale, Rao &
Skin fold thickness
Name of index Calculation Normal value Value in
Kanawati and Mc
Rao and Singh wt (kg)/Ht (cm)2
Dughdale wt (kg)/ht in cm
for a given height
Jellife’s ratio HC/CC <1 in a child
Closely spaced birth
Early stoppage of breast feeding
Too early or late weaning
Secondary due to malabsorption
• Gross wasting of muscles – skin and bones.
• Emaciation- loss of buccal pad of fat-monkey facies, loose skin of
buttocks hanging down- baggy pants appearance
• Marked stunting
• No edema
Non -essential Features
•Mineral and vitamin deficiency
• Indolent ulcers and sores
• GI symptoms – hungry
• Liver is shrunk
• Psychomotor changes – irritable
Grade 1 : Wasting starts in axilla & groin
Grade 2 : Wasting extended to thigh and
Grade 3 : Chest and abdomen
Grade 4 : Wasting of buccal pad of fat also
Weight-for-height of 70% (extreme wasting)
Presence of bilateral pitting edema of
nutritional origin, “edematous malnutrition
Mid-upper-arm circumference of less than
115 mm in children age 1-5 years old
COMPLICATIONS OF SAM
Gram negative septicemia
CAUSES OF DEATH
Mild and moderate malnutrition
Mainstay of treatment is to give adequate amounts of
protein and energy
Atleast 150kCal/kg/day, protein intake of 3g/kg/day
Best measure of efficacy of the treatment is weight gain
Locally produced RUTF
120 g = 500 Kcal
(Wheat, black gram, groundnut flour)
Limited success in uncontrolled studies
INPATIENT TREATMENT OF SEVERE
WHO TEN STEPS to recovery in
In 2 phases
•Initial stabilisation – 2 to 7 days
•Rehabilitation – several weeks
Blood glucose <54mg/dl
If cant be measured assume hypoglycemia
• 50ml of 10% glucose or sucrose solution
orally or NG f/b 1st feed
• Feed with starter F-75 q 2hrly
10% dextrose i.v 5ml/kg
Follow with 50ml of 10% glucose or sucrose
Feed with starter F-75 q 2hrly
Start appropriate antibiotics
Feed 2 hrly starting immediately
PREVENT AND TREAT HYPOTHERMIA
Rectal temp <35.5 C/95.5 F or axillary <35
Clothe the child with warm clothes
Avoid rapid rewarming
Feed the child
Give appropriate antibiotics
Assume all SAM with watery diarrhoea to have
Hypovolemia can co exist with edema.
Use reduced osmolarity ORS with potassium
supplements for rehydration and maintenance.
Initiate feeding within 2-3 hrs of starting
rehydration with F-75 formula on alt hrs with
reduced osmolarity ORS
Be alert for signs of overhydration.
CORRECT ELECTROLYTE IMBALANCE
Supplemental potassium at 3-4meq/kg/d for
atleat 2 weeks
On day1, 50% MgSO4 i.m once (0.3 ml/kg,
max upto 2ml)
thereafter give extra Mg(0.8-1.2 meq/kg daily)
Excess body sodium exists even though
plasma sodium may be low.
Prepare food without adding salt.
Multiple infections common
Usual signs of infection such as fever often
Majority of blood stream infections due to
gram negative bacteria.
Assume serious infections and treat.
Hypoglycemia and hypothermia are markers
of severe infections.
Ampicillin iv for atleast 2 days f/b oral amoxycillin
i.v. gentamicin or amikacin for 7 days.
If no imrovement within 48hrs,
Follow standard precautions like hand hygiene
Give measles vaccine if >6 months and not
immunised or if the child is more than > 9 months.
CORRECT MIRONUTRIENT DEFICIENCIES
1. Use upto twice the RDA of various vitamins
2. On day1, Vit A orally (if age>1yr 2lac IU, 6-
12 mon 1 lac IU, 0-5 mon 50,000 IU)
3. Folic acid 1mg/day ( 5mg on D1)
4. Copper 0.2-0.3 mg/kg/d
5. Iron 3mg/kg/d, once child starts gaining wt,
after the stabilisation phase.
Initiate feeding as soon as possible as frequent small
If unable to take orally- NG feeds
Total fluid recommended is 130ml/kg/d, reduce to
100ml/kg/d if there is severe, generalised edema
Continue breast feeding ad libitum
Start with F-75 starter feeds q 2 hrly
F-75 contains 75kCal/100ml with 1g protein/100ml
If persistent diarrhea, cereal based low lactose F-75 diet
as starter diet
If diarrhea continues on low lactose diets give F-75
lactose free diets
ACHIEVE CATCH UP GROWTH
• Once appetite returns in 2-3 days, encourage higher feeds
• Increase volume offered in each feed and decrease the
frequency of feeds to 6 feeds/d
• Continue breast feeding on demand
• Make a gardual transition from F-75 to F-100 diet
• F-100 contains 100kCal/100ml with 2.5-3g protein/100ml
• Increase calories to 150-200 kCal/kg/d and proteins to 4-
• Add complementary foods as soon as possible to prepare
the child for home foods at discharge
PROVIDE SENSORY STIMULATION AND
A cheerful, stimluating environment
Age appropriate structured play therapy for
atleast 15-30 mins/day
Age appropriate physical activity as soon as
the child is well enough
Tender loving care
PREPARE FOR FOLLOW UP AFTER
Said to have rcovered when wt for ht is 90% of NCHS
median and has no edema
Primary failure to respond if
• Failure to gain appetite by D4
• Failure to start losing edema by D4
• Presence of edema on D10
• Failure to gain atleast 5g/kg/d by D10
Secondary failure to respond if
• Failure to gain at least 5g/kg/d for consecutive days
during the rehabilitation phase
Complication during rehabilitation
Nutritional Recovery Syndrome
Treated with very high proteins
Abdominal distension (hepatomegaly, ascites,
splenomegaly), prominent veins, hypertrichosis,
parotid swelling, gynaecomastia, eosinophilia,
Incresed estrogen and recovering pituitary
Kwashi shake/encephalitis states (too much of
Refeeding syndrome (RFS) is a term that describes
the metabolic and clinical changes that occur on
aggressive nutritional rehabilitation of a malnourished
- Exact incidence in pediatric patients not known.
- 30% to 38% in adults on TPN with phosphorus.
- 100% in adults on TPN without phosphorus.
- 25% of adults with cancer.
• Altered membrane
potenial – Cardiac
• Sodium retention
• Fluid overload
• Fatty liver
• Altered menbrane
• Impaired Na+K+ ATPase
• Co-factor for enzymes
• Decreased ventricular
• Decreased sarcomere
• Decreased production of
(onset <72 hrs,
nadir 7 days)
(Onset <72 hrs)
< 2 weeks
- Increased weight gain, tachypnoea, features of cardiac failure,
dilutional hyponatermia – s/o fluid overload.
- Neuromuscular symptoms like weakness, paresthesias,
cramps, respiratory muscle weakness – altered membrane
potential due to electrolyte imbalance.
- Cardiac failure, rhabdomyolysis, altered mental status,
confusion, coma, hemolysis, thrombocytopenia and leukocyte
dysfunction – hypophosphatemia.
- Abdominal distention, increasing hepatomegaly, ascites,–
- Prominient thoraco-abdominal venous network
- Hypertrichosis (after 60 days)
- Parotid swelling
- Eosinophilia (after 60 days)
Cause: Not clear. Probably due to excessive intake of high quality
protein during rehabilitation, leading to increase in various trophic
hormones produced by the recovering pituitary gland.
Gomez et al, Pediatrics 1952; 10:513-526
DIAGNOSIS AND EARLY RECOGNITION IS
- There is no defined diagnostic criteria for refeeding syndrome in
- Monitoring of biochemical parameters for hypophosphatemia,
hypomagnesemia, hyperglycemia, hypoalbuminemia.
- Daily weight monitoring for the initial 7 days.
- Goal of weight gain should not be more than 1 Kg/week.
- Fluid status (intake/output) should be moniitored.
- Cardiorespiratory monitoring during the initial.
- Assess frequently for neuromuscular weakness and mental status.
- Stop all sources of calorie and protein until the electrolyte
imbalances are corrected.
- Start with 50% of the caloric intake at which the patient
- Supplement with multivitamins (including thiamine)
- Watch for recurrence of refeeding syndrome by monitoring
clinical and biochemical parameters daily.
- Limit sodium and fluid intake.
- Gradually increase the caloric requirement every 3 days.
“Start low and go slow”.
- Protein restriction is not recommended, 1.5 g/Kg/day rich in
essential aminoacids is required for anabolism to occur.
Before initiating refeeding through any route and during initial 3 –
- Hydration and fluid assessment. Early weight gain may be
secondary to weight gain.
- Daily electrolytes: Initial glucose and albumin. Daily sodium,
potassium, calcium, phosphorus, magnesium, urea and
- Cardiac status. (ECG ± ECHO)
B) ORAL FEEDING REGIMEN
1. Initial volume and calories
• In more severe cases an initial starting volume of 75% of total daily
requirements has been used
- < 7 years old - 80–100 kcal/kg/day
- 7–10 years - 75 kcal/kg/day
- 11–14 years - 60 kcal/kg/day
- 15–18 years - 50 kcal/kg/day
• If the initial food challenge is tolerated, this may be increased over 3–
5 days (Target 150 kcal/kg/day – Rehabilitation phase).
• Each requirement should be tailored to an individual’s need and the
above values may need to be adjusted by as much as 30%.
• Frequent small feeds (every 2 hrly) are recommended initially. Slowly
increase the volume per feed, max of 22 ml/kg/feed (130 ml/kg/day)
• Feeds should provide minimum of 1 kcal/ ml (F-100) to minimize
• If a milk-based feed induces diarrhoea with positive faecal
reducing substances, a hydrolysate may be used.
• An initial regimen for malnourished children suggests 0.6–1
• The feed should be rich in essential amino acids and gradually
increased as an intake of 1.2–1.5 g/kg/ day is needed for
anabolism to occur.
• Slowly increase proteins to 4 – 6 g/kg/day during the catch up
phase (Rehabilitation phase after 2 weeks).
• Twice the recommended daily allowance for vitamins and
minerals (Na, K, Ca, PO).
• Supplement with Zinc, copper, folic acid, Vit B12.
• Oral Vit A on day 1.
TAKE HOME MESSAGES
- Refeeding syndrome is due to the metabolic and hormonal
changes that occur due to aggressive nutritional
- START LOW AND GO SLOW.
- IDENTIFICATION of patients at risk and monitoring
patients during nutritional rehabilitation is the key to
- AWARENESS of the potential complications involved in
reintroducing feeds to an undernourished patient is
CRITERIA FOR DISCHARGE FROM
Weight-for-height has reached -1 SD (90%) of NCHS/WHO median
Eating an adequate amount of a nutritious diet that the mother can
prepare at home
Gaining weight at a normal or increased rate
All vitamin and mineral deficiencies have been treated
All infections and other conditions have been or are being treated,
including anaemia, diarrhoea, intestinal parasitic infections, malaria,
tuberculosis and otitis media
Full immunization programme started
Child should be seen after 1week, 2 weeks, 1
month, 3 months and 6 months. More frequently if
any problem found.
After 6 months, visits should be twice yearly until the
child is at least 3 years old.
The child should be examined, weighed and
measured, and the results recorded.
Any needed vaccine, vit A should be given.
Training of the mother should focus on areas that
need to be strengthened, especially feeding
practices, and mental and physical stimulation of the
At national level
1. Nutrition supplementation- Fortification, iodination
2. Nutritional surveillance- define the character and
magnitude of nutritional problems and strategies to
3. Nutritional planning- formulation of nutrition policy,
improve food production and supplies, ensure
At community level-
• Health and nutritional education
• Promotion of education and literacy in the
• Growth monitoring
• Integrated health package
• Vigorous promotion of family planning programs
At family level
Exclusive breast feeding
Complementary feeds at 6 months
Spacing between pregnancies