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)
| Parameter | Definition | Moderate Deficit | Severe Deficit |
|---|---|---|---|
| Underweight | Low weight-for-age | ←2 SD to -3 SD | ←3 SD |
| Stunting | Low height-for-age; denotes chronic malnutrition | ←2 SD to -3 SD | ←3 SD |
| Wasting | Low weight-for-height; denotes acute malnutrition | ←2 SD to -3 SD | ←3 SD |
[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
| Feature | Marasmus | Kwashiorkor |
|---|---|---|
| Pathophysiology | Energy deficit; acute starvation over borderline nutritional status. | Protein deficit; oxidative stress. |
| Appearance | Skin and bones; thin. | Fat, sugar baby appearance. |
| Edema | Absent. | Present (pitting); starts in legs/feet, spreads to hands/face. |
| Wasting | Severe muscle and fat wasting (shoulders, arms, buttocks, thighs). | Muscle wasting present but masked by edema. |
| Facies | Monkey facies (loss of buccal pad of fat). | Moon face. |
| Skin/Hair | Loose skin (baggy pants appearance). | Flaky paint dermatosis; easily pluckable hair; Flag sign (alternating hypopigmented/normal bands). |
| Mentation | Alert. | Apathy, irritability, unhappy. |
| Hepatomegaly | Absent. | Present (fatty liver). |
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
| Category | Criteria | Management Setting |
|---|---|---|
| Complicated SAM | Severe edema (+++), poor appetite (fails appetite test), medical complications (pneumonia, dehydration, sepsis), IMNCI danger signs. | Inpatient Management (Nutrition Rehabilitation Center). |
| Uncomplicated SAM | Good appetite, clinically well, no medical complications, mild/moderate edema. | Supervised Home/Community-Based Management. |
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.