WHO defines Malnutrition as "the cellular imbalance
between the supply of nutrients and energy and the
body's demand for them to ensure growth,
maintenance, and specific functions.“
Malnutrition is the condition that develops when the
body does not get the right amount of the vitamins,
minerals, and other nutrients it needs to maintain healthy
tissues and organ function.
PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the intermediate
Represents simple starvation . The body adapts to a
chronic state of insufficient caloric intake
It is the body’s response to insufficient protein intake
but usually sufficient calories for energy
PEM is also referred to as
It is considered as the primary
nutritional problem. Also
called the 1st National
The term protein-energy
malnutrition (PEM) applies to
a group of related disorders
that include marasmus,
intermediate states of
PEM is due to “food gap”
between the intake and
Malnutrition is a special
health problem, especially
in developing countries.
95 % of all malnourished
peoples living in the sub-
tropics and tropics.
More than 70% of children
with PEM live in Asia and
26% in Africa, and 4% in
Latin America and the
Malnutrition is by far the
to child mortality:
49% of the 10.4 million
deaths occurring in
children younger than 5
years in developing
countries are associated
6 million children die of
hunger every year.
Different aetiological factors can lead to PEM in
children. They are:
Social and Economic Factors
Role of Free Radicals
Age of the Host
Amongst the Social, Economic, Biological and
Environmental Factors the common causes are:
Lack of breast feeding and giving diluted formula
Improper complementary feeding
Over crowding in family
Lack of health education
Role of Free Radicals : Two new theories have been
postulated recently to explain the pathogenesis of
kwashiorkor. These include Free Radical Damage to
liver cells giving rise to kwashiorkor.
Age Of Host :
Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
Elderly can also suffer from PEM due to alteration of
Leading cause of death (less than 5 years of age)
Protein + energy intakes below requirement for normal growth.
the need for growth is greater than can be supplied.
decreased nutrient absorption
increase nutrient losses
Linear growth ceases
Malnutrition and its signs
AETIOLOGY of PEM:
Height for Age: It is a measure of linear growth, and
deficit represents the cumulative impact of adverse
events, that ultimately results in stunting or chronic
H/A: (Ht of child/Ht of normal child of same age) ×
INDICATORS OF PEM.
Weight for Height: Low weight for height indicates
W/H: (Wt of child/Wt of normal child of same height) ×
Weight for Age:
W/A: (Wt of child/Wt of normal child of same age) ×
Mid Upper Arm Circumference: Used for screening
Body mass Index: It is a screening tool for
thinness,overweight and obesity.
BMI= Weight in Kg/square of height in meters.
Z score: It is the child’s height minus the median height
for the age and sex of the child divided by relevant
In this weight is assessed at various ages by standard
1st degree 75-90%of expected wt
2nd degree 60-75%of expected wt
3rd degree <60% of expected wt.
Childs wt=50th percentile is healthy and is taken as
Between 80-100%of 50th percentile is healthy child
Grade 1 71-80%of 50th percentile
Grade 2 61-70%of 50th percentile
Grade 3 51-60%of 50th percentile
Grade 4 <50%of 50th percentile
Weight for Age Edema present. Edema absent.
< 60 % of
A system for classifying protein‐energy malnutrition in
children based on wasting (the percentage of expected
weight for height) and the degree of stunting (the
percentage of expected height for age.
MID UPPER ARM
Community based screening programs for severe
malnutrition usually use MUAC less than 12cm to
identify severe wasting.
SKIN FOLD THICKNESS.
Special calipers (Herpenden) in the region of triceps
or back of shoulder
Normal 9-11 mm
It is for index of body wt.
GRADES LOSS OF FAT
IV BUCCAL PAD OF FAT
Z-scores of BMI for age.
GRADE BMI FOR AGE Z SCORE
Grade I Z score < -1
Grade II Z score < -2
Grade III Z score < -3
PARAMETERS MODERATE SEVERE
EDEMA ABSENT PRESENT
WEIGHT/HEIGHT Z SCORE -2 to -3 Z SCORE < -3
HEIGHT/AGE Z SCORE -2 to -3 Z SCORE < -3
It is defined as severe wasting and/or
Severe wasting is extreme thinness
diagnosed by weight for height below -3
Severe malnutrition is one of the most
common causes of morbidity and
mortality among children under the age
of 5 years worldwide.
Reductive Adaptation System
The systems of the body begin to “shut down” with
The systems slow down and do less in order to allow
survival on limited calories.
This slowing down is known as reductive adaptation.
As the child is treated, the body's systems must
gradually "learn" to function fully again.
Rapid changes (such as rapid feeding or fluids)
would overwhelm the systems, so feeding must be
slowly and cautiously increased.
Reductive adaptation affects treatment of
the child in 3 ways.
1- Presume and treat infection
Nearly all children with severe malnutrition have
However, as a result of reductive adaptation, the
usual signs of infection may not be apparent, because
the body does not use its limited energy to respond
in the usual ways, such as inflammation or fever.
Due to reductive adaptation, the severely malnourished child
makes less haemoglobin than usual.
Iron that is not used for making haemoglobin is put into
Giving iron early in treatment can also lead to “free iron” in
Free iron can cause problems in three ways:
Free iron is highly reactive and promotes the formation of
free radicals with damaging effects.
Free iron promotes bacterial growth and can make some
The body tries to protect itself from free iron by converting it
to ferritin. This conversion requires energy and amino acids
and diverts these from other critical activities
3. Provide potassium and restrict sodium
In reductive adaptation, the “pump” that usually controls
the balance of potassium and sodium runs slower. As a
result, the level of sodium in the cells rises and potassium
leaks out of the cells and is lost.
ReSoMal has less sodium and more potassium than regular
WHO recommends that children be kept in the severe
malnutrition ward or area until they reach −1 SD (90%)
In severely malnourished children, the level
considered low is less than (<) 3 mmol/litre (or <54
If the child can drink, give the 50 ml bolus of 10%
glucose orally. If the child is alert but not drinking,
give the 50 ml by NG tube.
If the child is lethargic, unconscious, or convulsing,
give 5 ml/kg body weight of sterile 10% glucose by
IV, followed by 50 ml of 10% glucose by NG tube. If
the IV dose cannot be given immediately, give the
NG dose first.
Start feeding F-75 half an hour after giving glucose ,
during the first 2 hours.
If the child’s blood glucose is not low, begin feeding
the child with F-75 right away. Feed the child every 2
hours, even during the night.
Actively re-warm the hypothermic child:
keeping the child covered
keeping the room warm,
Have the mother hold the child with his skin next to
her skin when possible (kangaroo technique), and
cover both of them.
Keep the child’s head covered.
Monitor temperature hourly.
Stop rewarming when rectal temperature is 36.5 C
The severely malnourished child is considered to
have shock if he/she:
is lethargic or unconscious and
has cold hands
slow capillary refill (longer than 3 seconds),or
weak fast pulse.
Give sterile 10% glucose 5 ml/kg by IV.
Infuse IV fluid at 15ml/kg over 1 hour.
Use 0.45% (half-normal) saline with 5% glucose).
Observe the child and check respiratory and pulse
rates every 10 minutes.
If respiratory rate and pulse rate are slower after 1
hour, the child is improving. stop the IV.
If the respiratory rate and pulse rate increase Repeat
the same amount of IV fluids for another hour.
Continue to check respiratory and pulse rates every
After 2 hours of IV fluids, switch to oral or
nasogastric rehydration with ReSoMal (special
rehydration solution for children with severe
Give 5 − 10 ml/kg ReSoMal in alternate hours with F-
75 for up to 10 hours.
Leave the IV line in place in case it is needed again.
If the child fails to improve after the Second hour of
IV fluids, then assume that the child has septic shock.
Give maintenance IV fluids (4 ml/kg/hour) while
waiting for blood.
When blood is available, stop all oral intake and IV
fluids, give a diuretic to make room for the blood,
and then transfuse whole fresh blood at 10 ml/kg
slowly over 3 hours.
Mild or moderate anaemia is very common in
severely malnourished children and should be treated
later with iron, after the child has stabilized.
Very severe anaemia
If haemoglobin is less than 40 g/l, give a blood
If there are no signs of congestive heart failure, transfuse
whole fresh blood at 10 ml/kg slowly over 3 hours.
If there are signs of heart failure, give 5 – 7 ml/kg packed
cells over 3 hours instead of whole blood. Give a diuretic;
Furosemide (1 mg/kg, given by IV)
All severely malnourished children need vitamin A
on Day 1.
Additional doses are given if:
the child has signs of eye infection, measles ,
clinical signs of vitamin A deficiency.
The additional doses are given on Day 2 and at least
2 weeks later, preferably on Day 15.
Manage watery diarrhea and/or vomiting
ReSoMal is Rehydration Solution for Malnutrition. It
is a modification of the standard Oral Rehydration
Solution (ORS) recommended by WHO.
ReSoMal contains less sodium, more sugar, and more
potassium than standard ORS
For children < 2 years, give 50 − 100 ml after each
loose stool. For children 2 years and older, give 100 −
200 ml after each loose stool.
It should be given by mouth or by nasogastric tube.
If the child develops a hard distended abdomen with
very little bowel sound, give 2 ml of a 50% solution of
magnesium sulphate IM
1 packet ORS
2 L water
50 g sucrose
40 ml mineral solution
Give all severely malnourished children antibiotics for
Give extra potassium (4mmol/kg/day).
Give extra magnesium (0.6 mmol/kg/day).
These should be given for atleast 2 weeks.
Give vitamin A.
Folic acid 1 mg.
Zinc and copper(0.3mg/kg/day).
Determine frequency & Amount of
Feed orally .
Use an NG tube if the child :
does not take 80% of the feed (i.e., leaves more than
20%) for 2 or 3 consecutive feeds.
Remove the NG tube when the child takes: 80% of
the day’s amount orally; or two consecutive feeds
fully by mouth.
On the first day, feed the child a small amount of F-75
every 2 hours (12 feeds in 24 hours, including
through the night).
If the child is hypoglycaemic, give ¼ of the 2-hourly
amount every half-hour for the first 2 hours or until
the child’s blood glucose is at least 3 mmol/l.
After the first day, increase the volume per feed
gradually so that the child's system is not
The child will gradually be able to take larger, less
frequent feeds (every 3 hours or every 4 hours).
Criteria for increasing volume/decreasing frequency
If little or no vomiting, modest diarrhea (for example,
less than 5 watery stools per day), and finishing most
feeds, change to 3-hourly feeds.
After a day on 3-hourly feeds: If no vomiting, less
diarrhea, and finishing most feeds, change to 4-
Adjusting to F-100 during transition, or
feeding freely on F-100.
Look for the following signs of readiness usually after
2 − 7 days:
Return of appetite (easily finishes 4-hourly feeds of F
Reduced oedema or minimal oedema
The child may also smile at this stage
Begin giving F-100 slowly and gradually:
Transition takes 3 days.
First 48 hours (2 days): Give F-100 every 4 hours in the same
amount as you last gave F-75. Do not increase this amount for 2
Then, on the 3rd day: Increase each feed by 10 ml as long as the
child is finishing feeds.
Continue increasing the amount until some food is left after most
feeds (usually when amount reaches about 30 ml/kg per feed).
If the child is breastfeeding, encourage the mother to breastfeed
between feeds of F-100.
Rehabilitation" phase .
After transition, the child is in the "rehabilitation"
phase and can feed freely on F-100 to an upper limit
of 220 kcal/kg/day.
(This is equal to 220 ml/kg/day.)
, give iron daily, Calculate and
administer the amount needed: Give 3 mg elemental
Fe/kg/day in 2 divided doses. Always give iron orally,
never by injection. Preferably give iron between meals
using a liquid preparation.
Monitor individual patient progress
Good weight gain: 10 g/kg/day or more
Moderate weight gain: 5 up to10 g/kg/day
Poor weight gain: Less than 5 g/kg/day
Criteria for failure to respond to
Primary failure to respond:
Failure to regain appetite Day 4
Failure to start to lose oedema Day 4
Oedema still present Day 10
Failure to gain at least 5 g/kg Day 10
of body weight per day
Secondary failure to respond:
Failure to gain at least 5 g/kg During rehabilitation
of body weight per day for 3
Review patient records for common
factors in adverse outcomes.
Deaths that occur within the first 2 days are often due
Unrecognized or mismanaged septic shock, or other
Deaths that occur after 2 days are often due to:
WHO recommends that children be kept in the severe
malnutrition ward or area until they reach −1 SD weight-
for-height. It usually requires about 2 – 6 weeks .
If a child leaves before being achieving -1 SD, he is likely
to get worse and have to return.
WHO recommends that children be kept in the severe
malnutrition ward or area until their condition is stabilized(
regained appetite, reduced edema)
In addition to feeding instructions, mothers will need to be
how to feed the child at home and give supplements.
how to continue any needed medications, vitamins , folic
acid (for 1 − 2 weeks),
and iron (for 1 month) at home
when and where to go for planned follow-up:
at 1 week, 2 weeks, 1 month, 3 months, and 6 months; then
twice yearly visits until the child is at least 3 years old.