Approach to a child with Malnutrition

DEFINITION & CLASSIFICATION

Malnutrition encompasses undernutrition and overnutrition. Undernutrition results from inadequate consumption, poor accretion, or excessive loss of nutrients.

WHO Classification (Based on Z-scores)

[Note: Evaluated using WHO Growth Standards for infants up to 2 years and CDC charts for 2-20 years.]

Severe Acute Malnutrition (SAM)

Diagnosed in children 6–59 months of age meeting ANY of the following criteria:

• Weight-for-height <-3 standard deviation score (<-3 SDS).
• Presence of bipedal pitting edema.
• Mid-upper arm circumference (MUAC) <11.5 cm.

CLINICAL SYNDROMES OF SEVERE UNDERNUTRITION

ETIOLOGY & DETERMINANTS

• Immediate Causes: Low birth weight, inadequate dietary intake, recurrent infections (diarrhea, pneumonia).
• Underlying/Basic Causes: Household food insecurity, poor maternal education, inadequate WASH (water, sanitation, hygiene) practices, poverty, cultural taboos.
• Mechanism: Classified as illness-related (increased metabolic demand/losses e.g., congenital heart disease, cystic fibrosis) or non-illness-related (psychosocial, food insecurity).

CLINICAL EVALUATION

History

• Dietary Intake: 24-hour recall, feeding frequency, complementary feeding initiation, formula preparation.
• Medical: Birth weight (SGA/IUGR), recurrent infections, chronic diarrhea, vomiting, developmental delay.
• Social: Family income, parental education, feeding dynamics.

Physical Examination

• Anthropometry: Measure weight, length/height, head circumference (<2 years), MUAC, triceps skinfold thickness (TSF).
• General: Assess for hypothermia (<35.5°C axillary), pallor, lethargy, edema (press dorsum of feet for 10 seconds).
• Systemic: Assess for hepatomegaly, specific vitamin deficiencies (e.g., Bitot's spots for Vitamin A, rickets for Vitamin D), perianal excoriation, signs of infection (fever often absent).
• Dehydration: Difficult to assess due to loss of subcutaneous fat; look for dry mucous membranes, thirst, weak pulses, oliguria.

TRIAGE & SETTING OF CARE

INPATIENT MANAGEMENT OF COMPLICATED SAM (10 STEPS)

Apply the WHO 10-step protocol divided into Stabilization (Days 1-7) and Rehabilitation (Weeks 2-6) phases.

Avoid fatal mistakes: Treating edema with diuretics, giving high-protein diet early, or aggressive intravenous fluids.

Phase 1: Stabilization (Days 1–7)

Restoring homeostasis; avoid weight gain.

1. Prevent/Treat Hypoglycemia:

• Measure blood glucose immediately. Threshold <54 mg/dL (3 mmol/L).
• Asymptomatic: 50 mL 10% glucose/sucrose PO or NG tube.
• Symptomatic (lethargy, seizures): 5 mL/kg 10% dextrose IV, followed by 50 mL 10% glucose NG.
• Prevention: Feed 2-hourly day and night.

2. Prevent/Treat Hypothermia:

• Defined as axillary temp <35.5°C (95°F).
• Clothe warmly, cover head, promote skin-to-skin contact (kangaroo care).
• Avoid rapid rewarming (causes disequilibrium).

3. Prevent/Treat Dehydration:

• Assume some dehydration if watery diarrhea present.
• Use reduced osmolarity ORS (ReSoMal) with added potassium.
• Volume: 5-10 mL/kg after each watery stool.
• Intravenous fluids (Ringer lactate with 5% dextrose or half-normal saline with 5% dextrose) strictly reserved for severe dehydration with shock. Target 15 mL/kg over 1 hour.

4. Correct Electrolyte Imbalances:

• Total body sodium is excessive (despite low serum Na); restrict dietary sodium to prevent heart failure.
• Administer supplemental Potassium (3-4 mEq/kg/day).
• Administer supplemental Magnesium (0.8-1.2 mEq/kg/day orally; 0.3 mL/kg 50% MgSO4 IM on Day 1).

5. Treat/Prevent Infection:

• Assume severe systemic infection universally (classical signs often absent).
• Standard empirical therapy: IV Ampicillin (50 mg/kg 6-hourly) + IV Gentamicin (5-7 mg/kg/day).
• Add 3rd generation cephalosporin (Cefotaxime) if no improvement.

6. Correct Micronutrient Deficiencies:

• Vitamin A: Single oral dose on Day 1 (50,000 IU for <6 mo; 100,000 IU for 6-12 mo; 200,000 IU for >12 mo). Repeat on Days 2 and 14 if eye signs or measles present.
• Folic acid: 5 mg on Day 1, then 1 mg/day.
• Zinc (2 mg/kg/day) and Copper (0.2-0.3 mg/kg/day).
• CRITICAL: Withhold Iron during stabilization phase (promotes free radical generation and bacterial proliferation).

7. Initiate Cautious Feeding:

• Start F-75 diet (75 kcal/100 mL, 0.9 g protein/100 mL, low lactose).
• Target intake: 100 kcal/kg/day, 1-1.5 g protein/kg/day, 130 mL/kg/day fluid (100 mL/kg/day if severe edema).
• Administer as 8-12 small frequent feeds; use NG tube if oral intake <80% of target. Continue breastfeeding.

Phase 2: Rehabilitation (Weeks 2–6)

Initiated once appetite returns and edema resolves.

8. Achieve Catch-up Growth:

• Transition to F-100 diet or Ready-to-Use Therapeutic Food (RUTF).
• Increase energy target to 150-200 kcal/kg/day and protein to 4-6 g/kg/day.
• Add Iron (3 mg/kg/day).
• Target weight gain: >10 g/kg/day (good response).

9. Provide Sensory Stimulation:

• Loving care, cheerful environment, structured play therapy (15-30 min/day).
• Facilitates recovery of brain function and motor milestones.

10. Prepare for Follow-up:

• Transfer to outpatient care when complications resolve, edema clears, and child eats well.
• Immunize (e.g., Measles vaccine) and deworm (Albendazole).
• Educate caregivers on responsive feeding, hygiene, and energy-dense home foods.

COMMUNITY-BASED MANAGEMENT (UNCOMPLICATED SAM)

• Nutrition: RUTF (thick paste of milk powder, peanuts, oil, sugar, electrolytes, micronutrients) ensuring 175 kcal/kg/day.
• Medical Therapy: 5-day course of oral Amoxicillin, Albendazole (if >1 yr), and Vitamin A (if deficient).
• Monitoring: Daily home contact initially, then twice weekly by community health workers (ASHA/ANM). Assess weight, MUAC, and edema weekly. Requires 3-5 months for full nutritional rehabilitation.