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1. Undernutrition
Dr Sunil Baniya (Intern)
Nepalese Army Institute of Health Sciences

2. Malnutrition:
 Refers to deficiencies, excesses, or imbalances in a
person’s intake of energy and/or nutrients
 Addresses 3 broad groups of conditions:
◦ Undernutrition
◦ micronutrient-related malnutrition: deficiencies (a lack of
important vitamins and minerals) or excess and
◦ overweight, obesity and diet-related non-communicable
diseases: such as heart disease, stroke, diabetes and some
cancers
2

3. Definition:
 Undernutrition is defined as an imbalance between
nutrient requirements and intake or delivery that then
results in deficits- of energy, protein, or micronutrients-
that may negatively affect growth and development.
 In general, malnutrition refers to undernutrition ( esp.
protein energy malnutrition).
 Can be illness related or non-illness related or both
3

4. Indicators of Undernutrition:
 Stunting:
o Low height for age
o Indicates chronic malnutrition
o Prolonged food deprivation or disease/ illness
 Wasting:
o Low weight for height
o Indicates acute malnutrition
o More recent food deficit or illness
 Underweight:
o Low weight for age
o Combined acute and chronic malnutrition
4

5. Classifications of PEM:
5

6. IAP classification of malnutrition:
Wellcome and Trust classification:
6
Grade of Malnutrition Weight-for-age of the standard
(%)
Normal >80
Grade I 71-80 (mild)
Grade II 61-70 (moderate)
Grade III 51-60 (severe)
Grade IV <50 (very severe)
% weight for age Edema No edema
60-80 Kwasiorker Undernutrition
<60 Marasmic kwasiorker Marasmus

7. Age independent criteria:
1. Mid-upper arm circumference
◦ Shakir’s tape method:
2. Skinfold thickness (Triceps, subscapular,
suprailiac, abdomen, thigh)
7
MUAC (cm) Colour Interpretation
>13.5 Green Normal
12.5-13.5 Yellow Borderline
<12.5 Red Wasted

8. Epidemiology:
 Worldwide but mostly occur in low- and middle-income countries
 At the same time, rates of childhood overweight and obesity are rising
in these same countries
 Male = Female
 Rural > Urban areas
 < 6 months : due to low birthweight
 4-6 months: more vulnerable due to unhygienic food introduction
Source: WHO 2018 data for children <5 years of age
8
Wasted Severly wasted Stunted Overweight/
Obese
Death
52 million 17 million 155 million 41 million 45% deaths
related to
undernutrition

9. Determinants of Child nutritional
status:
1. Basic cause
o Socioeconomic status and education level of families
o Women’s empowerment
o Cultural taboos
o Access to water
2. Underlying cause
o Food-access to sufficient quality and quantity food
o Care – feeding (breastfeeding & complementary), hygiene,
psychological care and food preparation)
o Health- curative and preventive services available
3. Immediate cause
o Low dietary intake, delayed complementary feeding
o Low birth weight
o Infection – diarrhea, pneumonia and others (cause loss of energy)
9

10. 10

11. Clinical Features:
SITES SIGNS
Face Moon face (kwashiorkor), simian facies (marasmus)
Eye Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital
edema
Mouth Angular stomatitis, cheilitis, glossitis, spongy bleeding gums
(vitamin C), parotid enlargement
Teeth Enamel mottling, delayed eruption
Hair Dull, sparse, brittle hair, hypopigmentation, flag sign
(alternating bands of light and normal color), broomstick
eyelashes, alopecia
Skin Loose and wrinkled (marasmus), shiny and edematous
(kwashiorkor), dry, follicular hyperkeratosis, patchy hyper- and
hypopigmentation (crazy paving or flaky paint dermatoses),
erosions, poor wound healing
11

12. Causes:
S.N. Primary causes (inadequate intake) Secondary casues
(despite adequate intake)
1 Poverty Chronic illness
2 Ignorance Infections
3 Food fads (specific food only) Malabsorption/ Impaired
utilization
4 Traditional habits Excessive loss
5 Prolonged breastfeeding with
inadequate supplementary food
Drugs: INH predisposes
to Vit B6 deficiency
6 Over diluted food formulas Phenytoin to folate
deficiency
7 Food restriction during illness like
diarrhea
8 Sociocultural factors (male in priority)
9 Congenital defects, IUGR, Maternal
malnutrition 12

13. Nails Koilonychia, thin and soft nail plates, fissures or ridges
Musculature Muscle wasting, particularly buttocks and thighs; Chvostek or
Trousseau signs (hypocalcemia)
Skeletal Deformities, usually as a result of calcium, vitamin D, or
vitamin C deficiencies
Abdomen Distended: hepatomegaly with fatty liver; ascites may be
present
Cardiovascula
r
Bradycardia, hypotension, reduced cardiac output, small vessel
vasculopathy
Neurologic Global developmental delay, loss of knee and ankle reflexes,
impaired memory
Hematologic Pallor, petechiae, bleeding diathesis
Behavior Lethargic, apathetic, irritable on handling
13

14. PEM: Marasmus and Kwasiorker
SIGNS Marasmus Kwasiorker
Occurrence More common Less common
Edema Absent Present
Activity Active Apathetic
Appetite Good Poor
Hepatomegaly Absent Present
Mortality Less High in early stage
Recovery Early Slow
Infections Less prone More prone
14

15. Complications (if not treated
timely):
Acute:
• Systemic or local
infections
• Severe dehydration
• Shock
• Dyselectrolytemia
• Hypoglycemia
• Hypothermia
• Congestive cardiac failure
• Bleeding disorders
• Hepatic dysfunction
• Sudden infant death
syndrome
• Convulsions
15
Chronic:
•Cachexia
• Growth Retardation
• Mental subnormality
• Visual and learning
disabilities

16. Management:
Mild and Moderate Malnutrition: on OPD basis
◦ Can be managed at home by frequent feeding orally
◦ Proper diet rich in protein and calories
◦ Calorie: 150 mg/Kg/day
 Frequent feeding upto 7 times a day
 Oil/Ghee can be used to increase the energy in therapeutic diets
◦ Protein: 3g/Kg/day
 milk, vegetables protein mixtures
◦ Adequate minerals and vitamins
◦ Best measure to assess response to therapy is weight gain
16

17. Indications for hospitalizations:
 Anorexia
 Vomiting
 Diarrhea
 Electrolyte imbalances
 Fever
 Severe infection
 Shock
17

18. WHO GUIDELINES OF MANAGEMENT
Child undergoes physiological and metabolic
changes to preserve essential processes.
1. General principles for routine care (10 steps)
2. Emergency treatment of shock and severe anemia
3. Treatment of associated conditions
4. Failure to respond to treatment
5. Discharge before recovery is complete
18

19. 19

20. THE 10 STEPS
20

21. HYPOGLYCEMIA
 Blood sugar level <54 mg/dl or 3 mmol/L
 Assume hypoglycemia when levels cannot be
determined
 Conscious child
◦ 50 ml bolus of 10% glucose by nasogastric (NG) tube
 Unconscious child, lethargic or
convulsing
◦ IV 10% glucose (5ml/kg), followed by 50ml of 10%
glucose or sucrose by NG tube
◦ Start two-hourly feeds, day and night
21

22. HYPOTHERMIA
If axillary temperature <35oC,
or rectal temperature <35.5oC (<95.9oF)
1. Warm the child
 Cover with warmed blanket &
 Place a heater or lamp nearby or
 Put the child on the mother’s bare chest (skin to skin)
and cover them – Kangaroo mother care
2. Start feeding
3. Start antibiotics
22

23. INFECTION
 Usual signs of infection such as fever are often absent
 Give broad spectrum antibiotics to all
 Hypoglycemia/hypothermia usually coexistent with infection.
Hence if either is present assume infection is present as well.
 No complications: Co-trimoxazole
 Severely ill: IV antibiotics
◦ Ampicillin  50 mg/kg/dose 6 hourly x 2 days then oral
Amoxycillin 15 mg/kg 8 hourly x 7 days
◦ Gentamicin  7.5 mg/kg/day IV OD x 7 days
 If the child fails to improve clinically within 48 hours, add
cefotaxime/ceftriaxone
23

24. ELECTROLYTE IMBALANCE
 Plasma sodium may be low though body
sodium is usually high.
◦ Sodium supplementation may increase mortality
 Potassium: @ 3-4 mEq/kg/day x 2 weeks.
 Magnesium Sulphate 50% : @ 0.3 ml/kg IM
stat max upto 2 ml (4mEq/ml) followed by
maintenance dose (0.8-1.2 mEq/kg/day)
 Edema if present is partly due to electrolyte
imbalances- DO NOT treat it with a diuretic
24

25. DEHYDRATION
 Difficult to estimate dehydration using clinical signs alone
 Assume all children with watery diarrhea to have dehydration
 Do not use the IV route for rehydration except in cases of
shock
 Continue feeding
Some unreliable dehydration signs:
◦ Mental state
◦ Mouth, tongue and tears
◦ Skin turgor
25

26.  In a severely malnourished child,
dehydration may be assumed or assessed
by:
• History of diarrhea ( with large volume of stools)
• Increased thirst
• Recent sunken eyes
• Prolonged CRT
• Weak/absent radial pulse
• Decreased or absent urine flow
 All with watery diarrhea have some
dehydration
 Treat with ORS unless shock is present
26

27. Severely malnourished children are:
◦ Deficient in Potassium
◦ Abnormally high levels of Sodium.
◦ ORS should contain less sodium and more
potassium
Recommended Rehydration Solution
for Severe Malnutrition (ReSoMal):
27
Old WHO ORS WHO (Low
osmolarity)
ORS
ReSoMal
Sodium 90 75 45
Potassium 20 20 40
Glucose 111 75 125

28. ReSoMal:
 If not available commercially
 Can also be prepared by:
◦ diluting one packet of ORS in 2 liters of water
◦ Adding 50 g of sucrose and
◦ 40 ml of mineral mixed solution
◦ Also contains Magnesium, Zinc, and Copper
28

29.  For standard cases of diarrhea WHO now
recommends the use of low sodium ORS as it
has been shown to decrease the stool output
 ReSoMal can be made by diluting one packet
of the standard WHO-recommended ORS in
1.5 litres of water
 Rest same as above
 Low sodium ORS is called the WHO ORS
29

30. MICRONUTRIENT DEFICIENCIES
 All severely malnourished children have
vitamin and mineral deficiencies
 Vitamin A: orally on day 1
 Give daily: multivitamin supplementation
30
<6 months 6-12 months > 1 year
50,000 units 1 lakh unit 2 lakh units
Folic acid 1 mg/day (give 5 mg on Day 1)
Zinc 2 mg/kg/day
Iron 3 mg/kg/day (After stabilization phase)
Copper 0.2-0.3 mg/kg/day
Vitamin K 2.5 mg IM stat

31. BEGIN FEEDING
 Small, frequent feeds
 Oral or NG feeds (never parenteral preparations)
 Milk-based formulas such as starter F-75
containing 75 kcal/100 ml and 0.9 g protein/100
ml will be satisfactory for most children
 130 ml/kg/day of fluid (100 ml/kg/day if the child
has severe edema)
 If the child is breastfed, encourage to continue
breastfeeding
31

32.  A gradual transition is recommended to avoid
the risk of HEART FAILURE.
 Monitor during the transition for signs of
heart failure
◦ Respirations increase by 5 or more
breaths/min
◦ Pulse by 25 or more beats/min for two
successive 4-hourly readings
 Reduce the volume per feed
32

33. CATCH-UP GROWTH: ENERGY DENSE FEED
 Readiness to enter the rehabilitation phase is
signaled by a RETURN OFAPPETITE, usually
about one week after admission
 Recommended milk-based F-100 contains 100
kcal & 2.9 g protein/100 ml.
 In rehabilitation phase, vigorous approach to
feeding is required to achieve very high intakes &
rapid weight gain of >10 grams/kg/day
33

34.  Replace starter F-75 with the same amount
of catch-up formula F-100 for 48 hours then
 Increase each successive feed by 10 ml until
some feed remains uneaten
 The point when some remains unconsumed
is likely to occur when intakes reach about
30 ml/kg/feed (200 ml/kg/day)
34

35. RECIPES FOR STARTER AND CATCH-UP FORMULAS
35

36. PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
 Delayed mental and behavioral development is
present
 Provide:
o Tender loving care
o Cheerful, stimulating environment
o Structured play therapy 15-30 min/day
o Physical activity as soon as the child is well enough
o Maternal involvement when possible (e.g.
Comforting, feeding, bathing, play)
36

37. PREPARE FOR FOLLOW-UP
 A child who is 90% weight-for-length (equivalent to
-1 SD) can be considered to have recovered
 Show parent or caregiver how to:
o Feed frequently with energy - and nutrient-dense foods
o Give structured play therapy
 Advise parent or caregiver to:
o Bring child back for regular follow-up checks
o Ensure booster immunizations are given
o Ensure vitamin A is given in every six months
37

38. EMERGENCY TREATMENT OF SHOCK
AND SEVERE ANEMIA
3
8
Fluid therapy in severe dehydration:
•5% dextrose in RL or ½ NS at 15 ml/kg/ hr IV or intraosseus
for 1st hour
•Monitor every 5-10 min (PR, BP, CRT)
•Assess after 1 hour
•If no improvement: Septic shock
•Improvement: Severe dehydration with shock
•Repeat RL @ 15ml/kg over 1 hour
•Again assess- if clinically better:
•ORS if tolerates orally
•10 ml/kg/hr till accepts oral

39. SEVERE ANEMIA
 Blood transfusion is required if:
◦ Hb < 4 g/dl or
◦ Presence of respiratory distress with Hb 4-6 g/dl
 Give:
◦ Whole blood 10 ml/kg slowly over 3 hours
◦ Furosemide 1 mg/kg IV at start of transfusion
 If Cardiac failure present, transfuse packed cells (5-7
ml/kg) rather than whole blood
 Monitor RR & HR every 15 minutes. If either of them
rises, transfuse more slowly
 Give oral iron x 2 months (to replenish iron stores)
39

40. TREATMENT OF ASSOCIATED CONDITIONS
Vitamin A deficiency:
Eye signs: Vit. A on days 1, 2, 14 orally
Corneal clouding/ulceration: additional eye care (atropine and
antibiotics eye drops)
Dermatosis (Zn deficiency usually associated):
Apply Zn cream/petrolium jelly/paraffin gauze
Continuing diarrhea: Poorly formed stool is not of
concern in rehabilitation phase if weight gain is
appropriate
Mucosal damage & Giardiasis: Metronidazole 7.5 mg/kg 8 hrly x
7 days
40

41. Lactose intolerance (rare):
◦ Treat only if continuing diarrhea is preventing general
improvement
◦ Starter F-75 is a low-lactose feed
◦ In exceptional cases:
 substitute milk feeds with yogurt or lactose-free infant
formula
 reintroduce milk feeds gradually in the rehabilitation
phase
Tuberculosis:
◦ Strong suspicion (contact history) but mantoux test may be –
ve
◦ Rx as per National TB guidelines
41

42. FAILURE TO RESPOND TO TREATMENT
42
Good wt gain (>10 g/kg/day): continue same
Mod. wt gain (5-10 g/kg/day): check intake &
infection
Poor wt gain (<5 g/kg/day):
o Inadequate feeding
o Untreated infection
o Specific nutrient deficiencies
o Tuberculosis & HIV/AIDS
o Psychological problems

43. PRIMARY FAILURE TO RESPOND
 Failure to regain appetite by day 4
 Failure to start losing edema by day 4
 Presence of edema on day 10
 Failure to gain at least 5g/kg/day by day 10
SECONDARY FAILURE TO RESPOND
 Failure to gain at least 5g/kg/day for 3
consecutive days during rehabilitation
43

44. DISCHARGE
 Recovered/ready when reaches 90% weight-for-length
& no edema
 Absence of infection
 Eating at least 120-130 cal/kg/day & receiving
adequate micronutrients
 Consistent weight gain (of at least 5 g/kg/day for 3
consecutive days) on exclusive oral feeding
 Completed immunization appropriate for age
 Caretakers sensitized to home care
44

45. IF TO BE DISCHARGED EARLY THEN:
 The child:
◦ > 1year
◦ Vitamin K given
◦ Good appetite &
weight gain
◦ No edema
◦ Antibiotic treatment
completed
 The mother:
◦ Available at home
◦ Motivated & trained to
look after
◦ Have resources
◦ Reside near hospital
 Local Health
Worker:
◦ Can provide support
◦ trained and motivated
45

46. Monitoring Feeding at Home Essential:
 Feed frequently at least 5 times a day
 Modify home food to suit F-100
 High energy snacks between meals
 Assistance to complete each meal
 Give electrolyte/ mineral solutions
 Breastfeeding should continue
FOLLOW UP:
 Should be done periodically at 1 week, 2
weeks, 3 months and 6 months.
46

47. References:
1. OP Ghai 8th Edition
2. Nelson Textbook of PEDIATRICS 19th
Edition
3. WHO 2018 data
47

48. THANK YOU
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