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Presentation by Professor Jalal Akber

What is nutrition?

The world health organisation (WHO) defines nutrition as A process where living organisms utilise food nutrients for the maintenance of life, maturation, and normal functioning of organs and tissues and the production of energy.

MALNUTRITION Is defined as a pathological state resulting from relative or absolute deficiency of one or more essential nutrients.

Primary: When there is deficiency of food availability. Secondary: When food is available but body cant assimilate it for one or another reason.

Primary Malnutrition: 1. Failure of lactation. 2. Ignorance of weaning. 3. Poverty. 4. Cultural patterns and food fads. 5. Lack of immunization and primary care. 6. Lack of family planning.

Secondary Malnutrition
1. Infections. 2. Congenital disease. 3. Malabsorption. 4. Metabolic disorder. 5. Psychosocial deprivation.


Kwashiorkor is characterized by oedema, oedema, apathy and low body weight. In addition, there may be dermatosis, dermatosis, hair changes, hepatomegaly, hepatomegaly, diarrhoea and mental changes.

Marasmus is characterized by very low body weight, loss of subcutaneous fat, muscle wasting and absence of oedema. oedema.

Combined forms with clinical signs of both marasmus and kwashiorkor are included here. They show gross wasting as well as oedema.

Malnutrition Underweight Marasmus Kwashiorkor Body weight
(% of standard)

Oedema _ _

6060- 80 <60 60 80

Marasmic Kwashiorkor


Malnutrition Body weight of standard) First degree 75 - 90 Second degree 60 - 75 Third degree <60


Grade 1 (Mild) 70 80% 70% Grade 11 (moderate) 60

Grade 111 (severe) <60%

Height for age <90 Weight for age expressed as % <80 80 120 >120
Chronic Malnutrition Stunted but no Malnutrition Stunted & Obese


Acute Malnutrition



Mid arm circumferance 16.5 14 14 cm 12 cm Degree of Malnutrition No malnutrition 1st & 2nd degree malnutrition 3rd degree malnutrition

<12 cm

Skin fold
Skin fold thickness is assessed by the Herpenden Caliper in the region of triceps or back of shoulders; Normal: 9 -11 mm.

Evaluation of the malnourished child: History

Breast feeding history. Usual diet before current episode of illness. Foods & fluids taken in past few days. Duration & frequency of vomiting or diarrhea. Appearance of vomit or diarrheal stools. Time when urine was last passed. Contact with people with measles or tuberculosis. Deaths of siblings. Birth weight. Milestones. Immunization.


Anemia Dry skin

Vitamin K deficiency

Zinc Deficiency




Pulse Blood pressure clubbing Nails





Frontal & parietal prominence

Hair: Alopecia. Dyspigmented. Thinning. Pluckable. Dry

Sunken (dehydration)

Ptosis (Vitamin B1)

Conjunctiva Pallor (anaemia). Xerosis (Vitamin A). Conjunctivitis (Vitamin B2, C).

Bitot spots (Vitamin A).

Scleral icterus (CLD).

Cornea: Xerosis (Vitamin A). Cloudy (Vitamin A). Keratomalacia (Vitamin A). Opacification (Vitamin A, Zinc). Vascularisation (Vitamin B2).

Retina: Optic neuritis (Vitamin B12). Optic atrophy (Vitamin B1).

Eye movements: Ophthamoplegia (Vitamin E).

Photophobia (Vitamin A, Vit:B2, Zinc).

Facial nerve:

Percuss for Chvostek s sign (calcium).

Angular cheilosis and stomatitis. (iron, vitamin B2, niacin).

TEETH Caries (fluoride). Loose (vitamin C). Enamel defects (vitamin D).

TONGUE Glossitis, reddening and ulceration (vitamin B group). Moisture (hydration). Cyanosis (CHD).

BUCCAL MUCOSA Reddened & ulcerated (vitamin B group). Petechiae (vitamin C). GUMS Swollen,bleeding (vitamin C).

Goitre (iodine).


Full gait examination, looking for: Cerebellar ataxia (vitamin E, zinc). Peripheral neuropathy (vitamins B1, B6, B12). Romberg s sign (vitamin E, B12). Examine back for scoliosis, kyphosis and lordosis (vitamin D).

Palpate: Muscle bulk (PCM). Ankle oedema (PCM, CLD). Long bone tenderness (vitamin C). Calf tenderness (vitamin B1, selenium). Power: decreased (PCM, vitamin C, sodium, potassium, phosphate). Tone: decreased (PCM).

Reflexes: Decreased (vitamins B1, B6, B12, E). Increased (vitamin B12). Slow return (iodine).

Sensation: Peripheral neuropathy (vitamins B1, B6, B12, E). Posterior column dysfunction (vitamins B12, E).


CBC, ESR RBS. Urine D/R and Culture Stool D/R and Culture Chest X-ray. XMT. Serum proteins. Electrolytes. Urea/Creatinin Urea/Creatinin LFT MP

Hypothermia. Hypoglycemia. Electrolyte Imbalance Cardiac failure. Infections. Vitamin A deficiency. Severe anemia.


Presence of severe wasting ( <70% weight for height or 3SD) and/or edema.

General Principles for Management

There are 10 essential steps. 1) Treat hypoglycemia. 2) Treat hypothermia 3) Treat dehydration 4) Correct electrolyte imbalance 5) Treat infection 6) Correct micronutrient deficiencies 7) Start cautious feeding 8) Achieve catch-up growth 9) Provide sensory stimulation and emotional support 10)Prepare for follow-up after recovery

These steps are accomplished in two phases.

1. Stabilization Phase (within 7 days) 2. Rehabilitation Phase (2-6 weeks)

Hypoglycemia is present when blood glucose is <54mg/dl (<3mmol/l ) Treatment:
If child is conscious, give: 50ml bolus of 10% glucose (1 round tsf of sugar in 3.5 tbsp of water) orally or by N/G tube. Then feed starter F-75 every 30 minutes for 2 hours. (give 1 quarter of the 2 hourly feed each time) Keep warm Antibiotics

If child is unconscious or convulsing, give: IV 10% Glucose (5ml/kg) or, if unavailable, 50ml 10% Glucose by N/G tube. Starter F-75 every thirty minutes for 2 hours (give 1 quarter of the 2 hourly feed each time) Keep warm Antibiotics Monitoring: Repeat RBS 2 hour. Rectal temperature; if this falls to <30.5 *C, repeat RBS Level of consciousness

If axillary temperature is <35.0*C, or Rectal <35.5*C Treatment:
Re-warm the child either, clothe the child (including head), cover with a warm blanket and place a heater or lamp nearby. Or Put child on mother s bare chest, skin to skin, and cover them. Give antibiotic Feed straight away (or start rehydration if needed)

Rectal temperature 2 hourly, until it

rises to >36.5*C Feel for warmth Check for hypoglycemia whenever hypothermia is found.

Do not use the IV route for rehydration, except in shock, Infusing slowly to avoid flooding the circulation and overloading the heart. Standard WHO ORS contains too much Sodium and too little potassium for severely malnourished children. Instead give special Rehydration Solution for Malnutrition (ReSoMal).

ReSoMal 5ml/kg every 30 minutes for 2 hours, orally for by N/G tube. Then; 5-10 ml/kg per hour for next 4-10 hours. Replace the ReSoMal doses at 6 hours and 10 hours with an equal amount of F-75. If rehydration is continuing at these times. Begin feeding with starter F-75 During treatment, rapid respiration and pulse rate should slow and child will begin to pass urine.



half hourly for 2 hours. Then hourly for next 4-10 hours regarding.

1)Pulse rate 2)Respiratory rate 3)Urine frequency 4)Stool/Vomit frequency Continuing rapid respiratory and pulse rates during rehydration suggest coexisting infection or overhydration

Signs of over hydration are:

Increased respiratory rate (>5 breaths per minute or more) Increased pulse rate (>25 beats per minute or more) If these signs occur, stop fluid immediately and re-assess after one hour.


All severely malnourished children have excess body Sodium and low Potassium and Magnesium. Edema is partially due to these imbalances. (DO NOT treat edema with diuretic) give Extra potassium 3-4 milimoles per kg per day, Extra magnesium 0.4-0.6 milimoles per kg per day, Give ReSoMal Prepare food without salt.

Assume all malnourished children have an infection and give routinely on admission: Broad spectrum antibiotics AND Measles vaccine if child is >6 months and not immunized. In addition, some experts recommend Metronidazole (7.5mg/kg 8 hourly for 7 days) to hasten repair of the intestinal mucosa and reduce the risk of oxidative damage and systemic infection arising from the overgrowth of anaerobic bacteria in gut.

Choice of broad spectrum anti-biotic a) If the child is with no complications give Co-trimoxazole 5ml orally twice daily for 5 days (2.5ml if weight <4kg). b) If the child is severely ill or has complications give, Ampicillin 50mg/kg IM/IV 6 hourly for 2 days, then oral amoxycillin 15mg/kg 8 hourly for 5 days, and gentacin 7.5mg/kg IM/IV once daily for 7 days.

If the child fails to improve clinically within 48 hours, ADD: Chloramphenicol 25mg/kg IM/IV 8 hourly for 5 days. Where specific infection are identified, ADD: Specific antibiotics if appropriate Antimalarial treatment if the child has a positive blood film for malaria parasite.


All severely malnourished children have vitamin and mineral deficiencies. Anemia is common, do NOT give iron initially but wait until the child has a good appetite and starts gaining weight. As giving iron can make infection worse. Give: Vitamin A, orally on day 1 ( >1 year 200000 IU , 6-12 months 100000 IU, 0-5 months 50000 IU) Give daily for at least 2 weeks: 1) Multivitamin Supplement 2) Folic acid 1mg/day 3) Zinc 2mg/kg per day 4) Copper 0.3mg/kg per day 5) Iron 3mg/kg per day but only when gaining weight.



Feeding should be started as soon as possible and should be designed to provide just sufficient energy and protein to maintain basic physiological processes. The essential features of feeding in the stabilization phase are: Small/frequent feeds of low osmolarity and low lactose. Oral or N/G feed (never par enteral preparations) 100kCal/kg per day 1-1.5gm Proteins/kg per day 130ml/kg per day of fluid (100ml/kg per day if the child has severe edema) If the child is breastfed, continue to breastfeed but make sure the prescribed amount of starter formula is given.

F-75: 130 ml/kg/day 2 hourly

F-75: 100 ml/kg/day 2 hourly

A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreases is as follows. Days Frequency 1 -- 2 2-hourly 3 --5 3-hourly 6 --7 + 4-hourly Monitor and note: Amount offered and leftover Vomiting Stool frequency and consistency Daily weight gain Vol/Kg/fee d 11ml 16ml 22ml Vol/Kg/Day 130ml 130ml 130ml


Weight gain of >10g gain/kg per day. The recommended milk based F-100 contains 100KCal and 2.9g Proteins/100ml To change from starter to catch-up formula: Replace starter F-75 with small amount of Catch-up formula F-100 for 48 hours then Increase each successive feed by 10ml until some feed remains uneaten.

After the Transition, give Frequent feed (at least 4 hourly) of unlimited amount of catch-up formula 150-220KCal/kg per day 4-6gm Protein/kg per day If Child is breastfed, encourage to continue, also give F-100 as indicated

Monitor progress by assessing the rate of weight gain. If weight gain is

Poor (<5gm/kg per day) child requires full reassessment Moderate (5-10gm/kg per day) check if intake targets are being met or if infection has been overlooked. Good (>10gm/kg per day) continue to praise staff and mother


1. Vitamin A deficiency If the child has any eye signs of deficiency, give orally:Vitamin A on days 1, 2 and 14 (if aged >1 year give 200,000iu; if aged 6-12 months give 100,000iu, if aged 0-5 months give 50,000iu). If first dose has been given in referring centre, treat on days 1 and 14 only.

If there is corneal clouding or ulceration, give

additional eye care to prevent extrusion of

the lens:instil chloramphenicol or tetracycline eye drops (1%): 1 drop 4 times daily for 7-10 days in the affected eye. instil atropine eye drops (1%), 1 drop three times daily for 3-5 days cover with saline-soaked eye pads and bandage

2. Dermatosis Signs:hypo- or hyper-pigmentation desquamation ulceration (spreading over limbs, thighs, genitalia, groin, and behind the ears) exudative lesions (resembling severe burns) often with secondary infection, including Candida Zinc deficiency is usual in affected children and the skin quickly improves with zinc supplementation

IN ADDITION:Dab affected areas with gauze soaked in 0.01% potassium permanganate solution Apply barrier cream (zinc and castor oil ointment, or petroleum jelly or tulle gras) to raw areas Omit nappies so that the perineum can dry

3. Parasitic worms
give Mebendazole 100mg orally, twice daily for 3 days

Mucosal damage and Giardiasis are common causes of continuing diarrhea.

Where possible examine the stools by microscopy. Give:Metronidazole (7.5mg/kg 8-hourly for 7 days) if not already given

Lactose Intolerance.
Only rarely is diarrhea due to lactose intolerance. Treat only if continuing diarrhea is preventing general improvement. Starter F-75 is a low-lactose feed.

In exceptional cases:substitute milk feeds with yoghurt or a lactose-free infant formula reintroduce milk feeds gradually in the rehabilitation phase

If TB is strongly suspected (contacts, poor growth despite good intake, chronic cough, chest infection not responding to antibiotics):Perform Monteux test (NB false negatives are frequent) Chest x-ray If positive test or strong suspicion of TB, treat according to national TB guidelines.


A fall in hemoglobin concentration during treatment is normal as intracellular sodium moves out into the plasma causing an expansion of the plasma volume. Avoid giving transfusions after the first 24h. A blood transfusion is required on day 1 if: Hb is less than 4g/dl or if there is respiratory distress and Hb between 4 and 6g/dl Give:whole blood 10ml/kg bodyweight slowly over 3 hours furosemide 1mg/kg IV at the start of the transfusion If the severely anemic child has signs of cardiac failure, transfuse packed cells (5-7ml/kg) rather than whole blood.

Recipe for ReSoMal oral rehydration solution (using the new ORS formulation)
Ingredient Amount

Water (boiled & cooled) WHO-ORS Sugar Electrolyte/mineral solution ReSoMal contains approximately 45mmol/l Na 40mmol/l K 3mmol/l Mg.

1.7 liters 1 liter-packet 40g 33ml

Recipe for Electrolyte mineral solution

Weigh the following ingredients and make up to 2500ml. Add 20ml of electrolyte/mineral solution to 1000ml of milk feed. Potassium Chloride: Tripotassium Citrate: Magnesium Chloride: Zinc Acetate: Copper Sulphate: Water: make up to:

224gm 81gm 76gm 8.2gm 1.4gm 2500ml


The HDD-I can be given to all malnourished children. The diet is of semi solid consistency which can also be fed through an NG tube.
Weight 40 gm 30 gm 20 gm 90 gm 90 ml 900 ml 1530 17.25 Calories Protein Rice flour Dal Milk Powder Sugar Oil Water 143 105 100 432 750 3.00 6.75 7.50

The HDD-I diet provides approximately 45 calories/ oz or 1.5 calories/ ml. (HDD-I has been developed by the Nutrition Support Programme- a Government Assisted programme.).

F-75 feed volumes by feeding frequency, and body weight and for nasogastric feeding
Childs Weight Kg 2-hourly (ml/feed) 3-hourly (ml/feed) 4-hourly (ml/feed) Switch to NG Feeding if intakes (ml) fall below:-

2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0

20 25 25 30 30 35 35 35 40 40 45

30 35 40 45 45 50 55 55 60 60 65

45 50 55 55 60 65 70 75 80 85 90

210 230 250 270 290 320 340 360 380 400 420

4.2 4.4 4.6 4.8 5.0 5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0

45 50 50 55 55 55 60 60 65 65 70 70 75 75 75 80 80 85 85 90

70 70 75 80 80 85 90 90 95 100 100 105 110 110 115 120 120 125 130 130

90 95 100 105 110 115 120 125 130 130 135 140 145 150 155 160 160 165 170 175

440 460 490 510 530 550 570 590 610 640 660 680 700 720 740 760 780 810 830 850

8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0

90 90 95 95 100 100 105 105 110 110

135 140 140 145 145 150 155 155 160 160

180 185 190 195 200 200 205 210 215 220

870 890 910 930 950 980 1000 1030 1040 1060

F-75 feed volumes for children with severe edema

edematous weight Kg
3.0 3.2 3.4 3.6 3.8 4.0 4.2 4.4 4.6 4.8 5.0




(ml/feed) (ml/feed) (ml/feed)

25 25 30 30 30 35 35 35 40 40 40 40 40 45 45 50 50 55 55 60 60 65 50 55 60 60 65 65 70 75 75 80 85

5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0 8.2 8.4

45 45 45 50 50 50 55 55 55 60 60 60 65 65 65 70 70

65 70 70 75 75 80 80 85 85 90 90 95 95 100 100 105 105

85 90 95 95 100 105 105 110 115 115 120 125 125 130 135 135 140

8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 11.2 11.4 11.6 11.8 12.0

70 75 75 75 80 80 80 85 85 85 90 90 90 95 95 95 100 100

110 110 115 115 120 120 125 125 130 130 135 135 140 140 145 145 150 150

145 145 150 155 155 160 165 165 170 175 175 180 185 185 190 195 195 200

Recovery takes place in two stages: Initial recovery occurs in 2-3 weeks when 2edema disappears and other signs improve. Consolidation phase: In next 2-3 months 2child regains normal weight & is considered clinically recovered.

Criteria for discharge from hospital

Weight gain is adequate. Eating an adequate amount of nutritious diet that the mother can prepare at home. All vitamin & mineral deficiencies have been treatd. All infections have been treated. Full immunization programme started.

Able and willing to look after the child. Knows how to prepare appropriate food & to feed the child. Knows how to make appropriate toys & to play with the child. Knows how to give home treatment for diarrhoea, fever & ARI .

Able to ensure follow up of the child & support for the mother.

After discharge the child & the child family are followed to prevent relapse & assume the continued physical, mental & emotional development of the child. Planned follow up of the child at regular intervals after discharge is essential. As the risk of relapse is greatest soon after discharge, the child should be seen after 1 week, 2 weeks, 1 month, 3 months & 6 months. If a problem is found visits should be more frequent until it is resolved. After 6 months, visits should be twice yearly until the child is atleast 3 years.