This covers the Clinical aspect and Exam aspect of Malnutrition.

1. Malnutrition
By: Dr Veer vikram Singh
Paeds Department LGH

2. • Pathological state resulting from Relative or absolute
deficiency of one or more essential nutrients.
• Common between 3 Months and 3 years but can occur
earlier or later.
• May have Permanant effect on Physical Growth
,Development and Mental health.
• Severe acute Malnutrition Severe wasting and/or
Bilateral edema.

3. Assessment
• Wasting:
• <6 months= Visible wasting
• >6 months =APM measurement
• Severe wasting is extreme thinness diagnosed by weight
for length below -3 SD of Who child standards.

4. Edema Assessment:
• Grasp both feet ---Place thumb on top of each---Press
gently and Firmly For 10 seconds .,A Pit under each
thumb indicates bilateral edema.
• Grades of edema:
Grades Definition
Absent Absent
Grade + Mild:both feet / Ankles
Grade++ Moderate: Both Feet + lower legs
+hands and lower arms.
Grade+++ Severe:Generalised bilateral pitting
edema ,Both feet ,legs arms ,Face

5. Etiology :
Primary Malnutrition Secondary Malnutrition(not due to deficiency in
the diet)
Failure of Lactation: Mother becomes Pregnant
,suffering from illness .
Infections: Repeated Git ,Respiratory ,Urinary tract
Infections.
Ignorance of weaning: Mother Ignorance of
weaning i.e when to start and what to start.
Congenital diseases: Heart diseases(Anorexia due
to medication side effects ,fatigue on Feeding
,increase requirments ) ,Urinay tract anamolies
,Obstruction to CSF flow)
Poverty: Unable to buy high caloric diet i.e Meat
,egg and Milk
Malabsorption: Giardiasis ,Lactose intolerance
,Celiac disease ,TB intestine ,Cystic fibrosis.
Culutral Patterns:Sweet , Coffee ,tea .
Male dominated society =culture of giving fruits to
elder male 1st,leftover to female and child.
Metabolic Disorders: DM, DI, Galactosemia ,
Storage diseases , Neurodegenerative disorders.
Lack of Immunization and Primary Care: results
in Repeated common infection leads to snapping of
energy to Malnutrition.
Psycosocial deprivation:
Lack of Family Planning: Mother becomes weak
following Repeated pregnancies results in Low
Birth Weigh who become malnourished later on.

6. WHO Classification:
WHO (wasting)
(Low weight for height)
< -2 to >-3 SD
<-3 SD
Moderate malnutrition
Sever malnutrition
WHO (stunting)
(height for Age ,linear Growth)
< -2 to >-3 SD
<-3 SD
Moderate malnutrition
Severe malnutrition
WHO (wasting)
(for age group 6-59 months )
11.5 ---12.5 cm MUAC
<11.5 cm
Moderate Malnutrition
Sever malnutrition.

7. Evaluation of Malnourished child:
• History
• Examination

8. Physical Examination:
• Weight and length(height)
• Assess Skin for Purpura ,infection .
• Asses Eyes for Corneal lesions (Vitamin A deficiency).
• Ear ,Mouth ,throat examination for evidence of Infection.
• Assess Edema ,Assess Pallorness
• Abdominal exam =Abdominal distension , bowel sounds ,
abdominal splash, Palpate Liver
• Temperature :Hypothermia or Fever
• Check signs of Circulatory Collapse(Cold hands and feet
,weak radial pulse ,diminished consciousness)
• signs of pneumonia and Heart failure

9. Brittle and sparse
hair in malnourished
child.
Bitot spot ,Vitamin A deficiency
Desquamation,Ulceration
Wrist widening (Rickets)

10. Investigations
• CBC
• Stool DR
• Urine DR
• Chest X ray (pneumonia ,Heart failure(Vascular
engorgment )) ,Wrist Xray for Rickets assessment.
• RBS Monitoring

11. MARASMUS AND KWASHIORKOR
MARASMUS KWASHIORKOR
20 times more common than Kwashiorkor. Relatively uncommon.
Mostly below 2 years of age but can occur earlier or
later.
1-5 years of age but can occur earlier or later.
Due to dietry deficiency ,overdiluted milk
intake,weaning not started ,Infections ,Mother not
feeding because of fear of aggravating Diarhhea ..
Supply of required calories maybe little less but
Proteins are grossly deficient.
Growth Retadation( <60% expected weight)
,Tendon reflexes diminshed , plantar absent in
extreme cases ,no skin hair changes,monkey
face .No subcutaneous fat. Good appetite.
Generalised edema ,Growth failure(wasting masked
by edema) ,has some subcutaneous fat
,Psychomotor changes(Apathy ,irritablity) ,Hairs
changes(fine ,straight ,sparse,discolored)
,Anemia,Loose stools , Skin changes ,Liver elarged.
Puffy Moon face. Flanky pant Dermatitis.

12. Management in Severe Malnutrition:
Successful Managment Requires both Medical and Social
problems be recognized and corrected.
Initial treatments (2-3 days):
Treat and Prevent Hypoglycemia,Hypothermia ,Dehydration
,Septic shock if present(O2,IV glucose,IV fluids) ,Treat
infections ,start Feeding the child. treat anyother problem
Vitamin deficiency ,Anemia and Heart Failure.

13. Fluid therapy:
Ringers lactate with 5% Dextrose or N/S with 5%
Dextrose. 15ml/kg for 1 hr than monitor .
If Severely dehydrated Then Repeat IV over 1 hr
+Resomal orally or Ng tube.
If the child fails to improve or Radial pulse is absent
then assume septic shock and treat accordingly.

14. RESOMAL SOLUTION:
• It is modification of Oral Rehydration Solution(ORS)
recommended by WHO.
• contents
Contents Quantity
Water 2 Litres
WHO-ORS 1 Litre Packet
Sugar 50g
Mineral Mix Solution 40ml or one leveled scoop
CMV(Combined Mineeral Mix)

15. Resomal:
• If the child has dehydration but no sign of shock ,Give
Resomal Every 30 minutes for 2 hours than Every hour
for upto 10 hours.
• If the child had recieved IV fluids for Shock then we
should omit 2 hours Resomal than start upto 10 hours.
• Replace ongoing loss with 30 ml Resomal in edematous
child and 50-100 ml in non edematous child.
5-10 ml/kg body weight

16. Life threatining Problems:
Conditions Management
Hypoglycemia prevent by feeding every 2-3 hourly
Conscious child: 50ml 10% Glucose.
Losing Consciousness: 5ml/kg sterile 10% glucose
IV +50ml of 10% glucose NG tube.
Infections Prophhylactic Antibiotics in every malnourished
child.
with no sign of infection: Give Oral Amoxcillin or
Cotrimoxazole for 5 days.
Hypothermia Kangaroo technique
Clothe the child well
Treat for hypoglycemia and infections.
Severe Anemia(hb=<4g/dl) Blood transfusion
Corneal Clouding and ulceration Vitamin A and atropine eye drops

17. Dietry Managment
• Caloric Requirment=120-140 cal/kg/day
• Vitamin A =50,000(<6months) ,100,000(>6months)
,200,000(>12months)
• Vitamin D =4000 IU daily
• Vitamin K =5 mg IM or IV once daily

18. Feeding Farmulas:
F-75 F-100
75 calories /100ml
0.9g protein
Starter always should be with F-75 because it has
low protein as it is Fatal in Severly malnourished.
100Calories /100ml
2.9 g protein
F-75 is Replaced by F-100 after tolerance for 3-7
days .