PROTEIN ENERGY MALNUTRITION

BY DR R.NARAYANAN
UNDER THE GUIDANCE OF
DR R.K GUPTA
MALNUTRITION
◻ Malnutrition is a condition that results from eating
a diet in which one or more nutrients are either not
enough or are too much such that the diet causes
health problems. It may involve calories, protein,
carbohydrates, vitamins or minerals.
◻ It includes both obesity, undernutrtion, vitamins and
mineral deficiencies.
PROTEIN ENERGY MALNUTRITION
◻ PEM is the leading cause of death of children under 5
years old worldwide.

◻ PEM is a range of pathological conditions arising from

coincident lack, in varying proportions of protein and
calories, occurring most frequently in infants and young
children and commonly associated with infections.
◻ SAM affects an estimated 9.3 million under-five
children in India.
◻ Over a 10yr period since 2005-06, the
proportion of under-five children suffering from
SAM, as measured by weight for height Z score <
-3SD, based on WHO standards has increased
from an already high proportion of 6.4 to 7.5%.
◻ As per the NFHS-4, 35.7% of children below five
years are underweight, 38.4% are stunted and
21.4% are wasted.
INDICATORS OF PEM
◻ The children with PEM are classified based on
various indicators to describe the duration and
severity of undernutrition. These indicators are
1. Weight for age(W/A),
2. Height for age (H/A) and
3. Weight for height (W/H)
INDICATOR ACUTE MALNUTRION CHRONIC
MALNUTRITION
W/A(underweight) low low

H/A( stunting) Normal Low

W/H( wasting) Low Normal

 Indicators of malnutrition
Indicator Interpretation

Stunting Low height for age Indicator of chronic malnutrition,

the result of prolonged food
deprivation and / or disease.

Wasting Low weight for Suggests acute malnutrition ,

height the result of more recent food
deficit or illness

Under Low weight for age Combined indicator to reflect

weight both acute and chronic
malnutrition
 CLASSIFICATION OF MALNUTRITION
WHO CLASSIFICATION – In 2006, WHO published the new classification based on
following parameters to replace the previously recommended NCHS/WHO growth
reference charts.
PARAMETERS MODERATE SEVERE
UNDERNUTRION UNDERNUTRITION
Symmetrical edema Absent May be Present
(oedematous
malnutrition)
Weight for height SD score between -2 SD score <-3 (70% of
(measure of wasting) and-3 expected)
(70-79%of expected) Severe wasting
Wasting
Height for age ( SD score between -2 SD score <-3
measure of stunting) and-3 (<85% of expected)
(85%-95% of expected) Severe stunting
Stunting
SEVERE ACUTE MALNUTRITION

Recommended criteria for identification of

SAM (6months-5yrs of age)
◻ Weight for height < -3SD and/or

◻ Visible severe wasting and/or

◻ Mid arm circumference < 11.5cm and/or

◻ Oedema of both feet of nutritional origin

Mid-Upper Arm Circumference (MUAC)
for Assessment and Admission

13.5 <12.5

Wasted
12.5 TO 13.5
Normal

◻ It increases rapidly in 1st year of life (11-16 cm)

and remain stable (16-17 cm) in 1 to 5 year.
◻ value below 11.5 cm indicates severe malnutrition.
11 11
Recommended criteria for identifying
SAM in infants < 6months of age
◻ Any infant more than 49cm** in length who has
following features are treated as SAM
◻ Weight for height < 3SD and/or
◻ Visible severe wasting and/or
◻ Oedema of both feet of nutritional origin.

**- For infants whose length < 49 cms, visible severe

wasting can be used as a criteria to identify SAM
VISIBLE SEVERE WASTING
◻ Presence of muscle wasting in the gluteal region
◻ Loss of subcutaneous fat
◻ Prominence of bony structures especially over the
thorax
ETIOLOGY
Childhood malnutrition is caused by combination of
factors like
◻ Lack of exclusive breastfeeding,

◻ Late/inadequate provision of complementary feeds,

◻ Feeding diluted feeds containing less amount of

nutrients.
◻ Recurrent diarrhoea and respiratory tract infections,

◻ Illiteracy, ignorance, Food fads

◻ Poverty, overpopulation,

◻ Gender inequality, bias for male child

◻ Poorly accessible medical care in remote areas etc.

 improper and / or inadequate inadequate absorption
food intake of food

poor dietary
illiteracy MALNUTRITION habits

Diseases /
Deficient supply of food
recurrent infection

metabolic
emotional abnormalities
factors
16
17

Keith West
Clinical syndromes of undernutrition
FEATURES MARASMUS KWASHIORKAR
Etiology Dec intake of proteins, calories Dec protein intake
and other nutrients
Age Common <1 yr(0-3 yrs) 1-4 yrs
Incidence More common Less common
Appetite Increased Anorexia
Appearance Old man appearance Moon facies
Sensorium Alert, playful, active Apathy, dull, irritable
Weight <60% 60-80%
Edema absent present
Skin changes Absent present
Muscle wasting more Less(edema masks
wasting)
Organomegaly Not seen Hepatomegaly(fatty
liver)
 PATHOGENESIS
❑ GOPALAN’S THEORY OF ADAPTATION
❖ Some children develop marasmus while others
develop kwashiorkor even though there is no
quantiative and qualitative difference in their diets.
❖ This is explained by Gopalan’s theory which says
that marasmus develops due to good adaptation to
poor diet while kwashiorkor is the result of
adaptation failure.
❖ In marasmus, decreased calorie intake leads to
increased cortisol levels. Increased cortisol level
leads to tissue catabolism, which causes muscle
wasting.
❖ In this process, glucose and aminoacids are released into
the circulation. The glucose is utilized by the brain and the
amino acids are used for the synthesis of albumin and
beta lipoprotein.
❖ Thus, the albumin levels is maintained in the blood and
hence no edema occurs in marasmus. Thus beta
lipoprotein helps in mobilizing the fat from the liver; hence
the fat is not accumulated in the liver
❖ In kwashiorkor, there is decrease in insulin level which
prevents proteins synthesis. Hence, albumin and
lipoprotein synthesis do not take place. Hence, edema
and fatty liver develop.
❑ GOLDEN THEORY OF FREE RADICALS
In PEM, free radical play a role in the pathogenesis
of edema. According to the Golden’s theory,
antioxidant depletion may cause kwashiorkor and
it may, therefore, be prevented with antioxidant
supplementation.
❑ JELLIFFE’S HYPOTHESIS
A mixture of interactions and sequelae of dietary
imbalances, infections and infestations, emotional
trauma and toxins.
HORMONE MARASMUS KWASHIORKAR REMARKS

GROWTH NORMAL/HIGH VERY HIGH LOW IGF AND

HORMONE SOMATOMEDIN
S
GLUCOCORTIC VERY HIGH HIGH STRESS,
OIDS INFECTIONS
INSULIN AND NORMAL LOW BETA CELL
IGF DYSFUCTION
SOMATOMEDIN LOW VERY LOW ALTERED
S AMINOACID
POOL
GLUCAGON NORMAL/ NORMAL/ ALPHA/BETA
VARIABLE VARIABLE CELL RATIO
THYROXIN NORMAL/ NORMAL/ LOW T4 TO T3
VARIABLE VARIABLE CONVERSION,
IODINE
CLINICAL FEATURES
◻ HAIR – Lack of lustre
Thinness and sparseness
Straightness of hair
Flag sign
Easy pluckability
◻ FACE – Moon face (kwashiorkor)
Simian face (marasmus)
◻ EYES – Bitots spots
Conjuctival xerosis
Corneal xerosis
Keratomalacia
Angular palpebritis
◻ Teeth – Mottled enamel
◻ Gums – Spongy, bleeding gums
◻ Glands - Thyroid and Parotid enlargement
◻ LIPS AND TONGUE – Angular stomatitis
Cheilosis
Atrophic papillae
Scarlet and raw tongue
Angular scars
◻ Nails - Kolionychia
◻ Subcutaneous - Loss of subcutaneous fat
tissue
◻ SKIN – Xerosis
Follicular hyperkeratosis
Petechiae
Pellagrous dermatosis
Flaky-paint deramtosis
◻ Musculoskeletal - Muscle wasting
systems Craniotabes
Frontal and Parietal bossing

Epiphyseal enlargement
Knock knees or Bow legs
Hemorrhages
Beading of ribs
Wide open anterior frontanelle
Deformities of thorax
◻ GIT - Hepatomegaly
◻ CVS - Microcardia/Cardiomegaly
Tachycardia
◻ CNS - Psychomotor change
Mental confusion
Sensory loss
Motor weakness
Calf tenderness
Loss of ankle and knee jerks
Loss of position sense
APPROACH TO A CHILD WITH PEM
HISTORY – Increased emphasis should be given to
◻ DIETARY HISTORY – Complete dietary history

should include regarding duration and frequency

of breastfeeding, history of bottle feeding, time of
initiation of complementary feeding, feeding
practices, food given during the weaning and illness,
calorie requirement and calorie intake.
◻ IMMUNIZATION HISTORY

◻ SOCIOECONOMIC HISTORY
EXAMINATION
◻ Anthropometry

◻ Vitals (for Hypothermia, dehydration, shock)

◻ Look for hair, skin, mucous membrane changes

◻ Hepatomegaly

◻ Assess for infections

◻ Assess for signs of Vitamin deficiency

 INVESTIGATIONS
❑ CBC with PBF
◻ Liver function tests
◻ Renal function tests
◻ Blood sugar
◻ Serum electrolytes
◻ Total protein and albumin
◻ Urine routine and culture
◻ Chest x-ray
◻ Tuberculosis workup
◻ HIV
MANAGEMENT OF MALNUTRITION
◻ Management of malnutrition depends on its severity
MILD and MODERATE MALNUTRITION
◻ In these cases, usually the children are hungry, tolerate
feeds orally and can be feed orally.
◻ These children can be managed at home by frequent
feeding.
◻ Proper diet rich in calories and protein should be advised.

◻ At least 150kcal/kg/day and 3g/kg/day protein should

be given.
◻ Adequate minerals and vitamins should also be provided

◻ The best measure to assess response to therapy is weight

gain
APPETITE TEST
◻ It is used to test appetite in community based
management program where therapeutic food is being
used.
◻ Poor appetite is reliable indicator for severity of illness
and thus need for hospitalization.
◻ Good appetite, no edema, no complication - then
community/home based management.
◻ Appetite test feed
Most commonly used is RUTF
◻ In our country:

for children 7–12 months: Use catch-up diet instead

of RUTF. Offer 30-35ml/kg of Catch-up diet. If the
child takes more than 25ml/kg, the child is
considered to have a good appetite.
◻ For children >12 months: Use feed prepared from
locally available food items. The following food items
may be offered.
❖ Roasted ground nuts 1000gm
❖ Milk powder 1200 gm
❖ Sugar 1120 gm
❖ Coconut oil 600ml
How to prepare?
◻ Take roasted ground nuts and grind them in mixer.
◻ Grind sugar separately or with roasted ground nut
◻ Mix ground nut, sugar, milk powder and coconut oil
◻ Store them in airtight containner
◻ Prepare only for one week to ensure the quality of
feed
◻ Store in refrigerator
How to do appetite test?

◻ Do the test in a separate quiet area

◻ Explain the mother/caregiver how the test will be done
◻ The mother/caregiver should wash her hands
◻ The mother sits comfortably with the child on her lap and
offers the food
◻ The child should not have taken any food for the last 2 hours
◻ The test usually takes a short time but may take up one hour.
◻ The child must not be forced to take the food offered
◻ When the child has finished, the amount taken is judged or
measured.
Criteria for passing appetite test :

BODY WEIGHT (IN KG) MINIMAL AMOUNT OF

RUTF TO BE
CONSUMED (IN GMS)
<4 15
4 to 6.9 25
7 to 9.9 35
10 to 14.9 50
 Ready to Use Therapeutic Food (RUTF)

◻ RUTF are energy-dense, micronutrient enhanced pastes

used in therapeutic feeding.
◻ Typical primary ingredients of RUTF include peanuts, oil,
sugar, milk powder and vitamin and supplements.
◻ FOOD VALUE PER 100G

ENERGY 543 kcal

PROTEIN 15 g
FATS 35 g
CARBOHYDRATES 43 g
◻ Advantages of RUTF
❖ Firstly, it provides all the nutrients required for recovery.
❖ Secondly, it has a good shelf life and does not spoil
after opening
❖ Since RUTF is not water based, the risk of bacterial
growth is very limited, and consequently it is safe to use
without refrigeration at household level
❖ It is liked by children, safe and easy to use without
medical supervision
❖ It can be used in combination with breastfeeding and
other practices for infant and young child feeding.
RUTF in INDIA
◻ Despite the above mentioned advantages, use of RUTF for
management of malnutrition is not an accepted policy of
Government of India.
◻ Reasons
❖ Concerns have raised that the use of RUTF may replace the
nutritional traditional practices and family foods.
❖ The Government has no enough evidence for the long term benefit
of RUTF’s
❖ Once RUTF was stopped, children often slipped back into
malnutrition.
❖ There is high cost involved in purchasing RUTF’s packets which are
not feasible for a longer run.
❖ There are chances of corruption by the intervention commercial
exploitation beyond the treatment of severe acute malnutrition
❑ Despite the various disadvantages stated by the Indian
Government, its application with community management
of acute malnutrition, supported by WHO, UNICEF has
resulted in successful treatment of children with malnutrtion
❑ Currently, 61 countries have some form of treatment for
severe acute malnutrition with a community component
available
❑ Hence, there has been few studies and researches for
finding out alternative to RUTF by using locally made
available resources without compromising the nutritional
value of RUTF.
ALTERNATIVES TO RUTF
◻ Alternate foods listed above have many additional
advantages.
❖ They promote local agricultural practices as they use
millets and locally available foods.
❖ They promote local livelihoods amongst the very families
what may be harbouring children with SAM in a milieu of
general poverty and food insecurity thus conferring more
than food supplementation: an opportunity to raise
economic status.
❖ By being much more decentralised a process, they allow
greater community participation and control.
DRAWBACKS
◻ Evidently, though there are few formal studies
documenting their efficacy.
◻ The very fact that these pre existing attempts have not
been properly studied, analysed and documented by
research and expert bodies on nutrition is a matter of
concern.
◻ Perhaps it leads us into our long standing
recommendation and demand, that the country needs
to develop a well discussed and debated policy of
child nutrition rather than have to combat each
contingency as it arises
◻ Adequate thought, planning and research should go into
developing such policies rather than succumbing to
various pressures in haste and allowing unsustainable
processes that may prove difficult to reverse and will
cause long term harm to the communities and families
whose children we aim to ‘treat.’
◻ We also need to continuously remind ourselves of the
comprehensive set of strategies that will bring about the
ultimate goal of child health, nutrition and well being
through services of general care, health and nutrition in
an environment of overall food, economic and social
security.
UNCOMPLICATED SAM
◻ NUTRITION THERAPY
1. What to feed: Home foods. Continue breast feeding

2. How much to feed: 175kcal/kg/day

3. How often: 6-8 times per day

4. How to feed : With love and cure, ensuring hygiene.

◻ OTHER TREATMENT

1. Oral amoxicillin for 5 days

2. Vitamin A supplementation

3. Albendazole 400mg single dose

4. Age appropriate vaccines

◻ SENSORY STIMULATION
Play, physical activity , interaction
◻ SUPERVISION AND SUPPORT

1. Home visits by health workers, initially daily, later

twice a day. More if necessary
2. Involve a peer counselor, a volunteer woman friend/
neighbor to support the family.
◻ MONITORING BY HEALTH WORKERS

1. Evaluate for medical problems: treat or refer

2. Assess growth weekly.

◻ Management at home only if
1. Family is counseled and fully engaged

2. Community health workers and peer counselor are

involved to support the family.

3. Periodic monitoring of growth and medical

condition can be ensured.

 Criteria for Inpatient care
Presence of any one of the following any medical complication
◻ Failed appetite test

◻ Presence of any of emergency signs

◻ Edema
◻ Persistent vomiting
◻ Fever (axillary temperature >38.5degree centigrade)
◻ Extensive skin lesions/eye lesions/post measles state
◻ Diarrhoea with dehydration based on history and clinical signs
◻ Severe anemia
◻ Hypothermia (Axillary temperature <35 degree centigrade)
EMERGENCY SIGNS
◻ Gasping ventilation
◻ Central cyanosis
◻ Severe respiratory distress
◻ Obstructed breathing
◻ Shock
◻ Coma
◻ Convulsions
Why severely malnourished children
should be treated differently ?

◻ Reductive adaptation
When intake is insufficient, the body conserves energy by

◻ reducing physical activity and growth

◻ Reducing basal metabolism by

slowing protein turnover
reducing functional reserve of organs
slowing and reducing of Na/ K pumps

◻ Reducing inflammatory and immune response

CONSEQUENCES OF REDUCTIVE
ADAPTATION

ORGAN EFFECT IMPLICATION

LIVER Risk of: Avoid long gaps

1)Hypoglycemia
2)Hypothermia. Give frequent feeds
KIDNEY decreased ability to Fluid overload
excrete excess Cardiac failure
fluid and Na Give low sodium in
fluids
HEART (atrophy of cardiac Avoid excess fluids in
muscles) circulation
Cardiac output is
reduced
ORGAN EFFECT IMPLICATION

GUT decreased acid and Initiate with small

enzymes production. frequent feeding
Villi flattened>motility
reduced bacterial
overgrowth damage
the mucosa and
deconjugate bile acids
MUSCLE MASS Reduced wasting
Smaller reserves of
muscle glycogen
ORGANS EFFECT IMPLICATION

ELECTROLYTES Decrease in number Restrict Na+ and

of Na/K Pump Na provide K+
leaks into and
potassium out of the cell Provide Magnesium to
electrolyte imbalance help the K+
anorexia, fluid get into cells
retention and heart
failure
RED CELL MASS Reduced iron During initial feeding,
liberates free iron withhold iron
promotes growth of and provide vitamins
pathogens and and minerals
production of free to help mop up free
radicles radicals.
MANAGEMENT OF COMPLICATED
SAM
 1.HYPOGLYCEMIA
◻ Blood glucose < 54 mg/dL
◻ If blood glucose cannot be measured,
hypoglycemia is assumed
◻ May be a sign of serious underlying infection

CONSCIOUS CHILD
◻ Always give correction orally or via NG 50 ml
bolus or 10% glucose or sucrose solution (1 tsp of
sugar in 3 1/2 tbsp water);
◻ then start diet Q 30 min X 2 hrs (1/4th feed each
time)
UNCONSCIOUS CHILD/CONVULSING/LETHARGIC
◻ Intravenous 10% dextrose (5 ml/kg), followed by

50 ml of 10% glucose by N/G tube.

◻ Start feeding starter diet 30 minutes after giving

glucose and give it every 30 mins during the first

2hrs.
Monitoring :

◻ Blood glucose: Repeat RBS after 2 hrs.

◻ If low, then repeat 5ml/kg of 10% glucose/sucrose solution.

◻ Continue feeding Q30 min till blood glucose level is stable.

Repeat blood glucose level if,

◻ Rectal temperature <35.5°C;

◻ Deterioration of level of consciousness.

 2.HYPOTHERMIA
◻ Axillary temperature <35°C or Rectal temp. <35.5 °C.
Rewarm:

◻ Clothe the child including head

◻ Cover with pre-warmed blanket

◻ Provide heat with an overhead warmer/ incandescent lamp/ radiant heater

◻ Place bed in warm draught free area

◻ Place on mother’s bare chest (kangaroo mother care)

◻ Maintain room temperature of 25-30 degree centigrade.

If the rectal temperature<32 deg centigrade, child has
severe hypothermia
◻ Give warm humidified oxygen
◻ Give 5ml/kg of 10%dextrose IV immediately or 50 ml of
10% dextrose by nasogastric route
◻ Start IV antibiotics
◻ Re-warm: Provide heat using radiation(overhead warmer),
or conduction (skin contact).
◻ Give warm feeds immediately, if clinical condition allows the
child to take orally, else administer the feeds through a
naso/orogastric tube. Start maintenance fluids, if there is
feed intolerance or contraindication for nasogastric feeding
◻ Rehydrate immediately, when there is a history of diarrhea
or there is evidence of dehydration
3. DEHYDRATION

Assessment
Some signs unreliable
◻ Lethargy, sunken eyes may be present in these children all of the
time, whether or not they are dehydrated.
◻ Edema and hypovolemia can coexist

Useful signs/ features :

◻ History of diarrhea ( with large volume of stools)

◻ Increased thirst

◻ Recent sunken eyes since the diarrhea started

◻ Prolonged CFT, weak/absent radial pulse, decreased or absent

urine flow
◻ Restless/irritability
◻ Difficult to estimate hydration using clinical signs
alone.
◻ DO NOT USE IV ROUTE FOR REHYDRATION,
EXCEPT IN CASE OF SHOCK
◻ Treat with ORS unless shock is present.
◻ IAP recommends reduced osmolarity ORS with
additional potassium supplements
◻ WHO recommends Rehydration Solution for
malnutrition, which is not available commercially
◻ component REDUCED ReSoMal
OSMALARITY
ORS
sodium 75 45
Chloride 65 70
Potassium 20 40
Citrate 10 7
Glucose 75 125
Osmalarity 245 300
 TREATMENT

◻ 5ml/kg ORS every 30 minutes for 1 st 2 hours

◻ 5- 10 ml/kg/hr (alternate hour)ORS for next 10 hours
◻ Initiate feeding within 2 hours of starting rehydration
◻ Monitor progress of rehydration and be alert for signs of
overhydration 
◻ Stop ORS when 3 or more hydration signs are present-
Child less thirsty,
passing urine,
moist oral mucosa,
eyes less sunken,
faster skin pinch, tears,
less lethargic.   
◻ After rehydration, stop giving ORS routinely in
alternate hours. If diarrhea continues, give ORS
after each stool to replace stool losses:
❖ For children < 2yrs, give approximately 50 ml
after each loose stool
❖ For children > 2yrs, give approximately 100 ml
after each loose stool
SEVERE DEHYDRATION WITH SHOCK
Lethargy, cold peripheries, prolonged CFT,
low pulse volume 

RL+5%D or N/2 saline + 5 D or RL alone

(15ml/kg over one hr).

Improvement No improvement

15 ml/kg/hr next one hour

if accept orally, Clinically better not accepting
start ORS orally, give 10ml/kg/hr ORS
through NG till child accepts
orally.
Consider diagnosis of septic
shock
1.Start dopamine
2. Maintenance fluid(4ml/kg)
3. Review antibiotics
4. Initiate re-feeding as early
as possible
4. Electrolyte imbalance: 
POTASSIUM
 3-4 meq/kg/day for at least 2 weeks.

 
MAGNESIUM –
❑ On day 1 give 50 % Magnesium sulphate IM once ( 0.3 ml/ kg)
upto a max of 2 ml.
❑ Thereafter, give injection magnesium sulphate (50 % has 2
mmol/ml) 0.2-0.3ml/kg orally mixed with feeds for 14 days.

Food should be prepared without added salt to avoid sodium

overload.
 5. INFECTIONS
◻ Usual signs of infection, such as fever are usually absent.
◻ All severely malnourished children should receive broad spectrum antibiotics 

Ampicillin 50 mg/kg/ dose 6 hourly I.M with 

Gentamycin 7.5 mg/kg or Amikacin 15 to 20 mg/ kg I.M
or I.V 24 hourly for 7 days 
                               
If no improvement in 2 days 

                       
                      IV Cefotaxime 100 mg/ kg/ day 6-8 hourly or 
                        ceftriaxone 50-75 mg/kg/day 12 hourly 
◻ Revise therapy based on culture senstivity report
◻ If meningitis is suspected, LP should be done and cefotaxime ( 200 mg/kg
6 hourly) or ceftriaxone (100 mg/kg 12 hourly and amikacin ( 15 mg/ kg
8 hourly ) is to be given for 14 to 21 days
◻  If staphylococcal infections are suspected IV cloxacillin is given at 100
mg/kg/day 6 hourly or iv vancomycin ( 15mg/kg/dose every 8 hourly)
◻ Add antimalarial treatment / anti TB treatment if diagnosed 
❑ If dysentery is present give ciprofloxacin at 15 mg/ kg in 2 divided doses
for 3 days 
◻ In case of septic shock, give third generation cephalosporins ( cefotaxime/
ceftriaxone) with iv gentamicin 7.5mg/kg in single dose.
Duration of antibiotic therapy
◻ Depends on the diagnosis i.e.
✔ Suspicion of clinical sepsis: at least 7 days
✔ Urinary tract infection: 7–10 days
✔ Culture positive sepsis: 10–14 days
✔ Meningitis: at least 14–21 days
✔ Deep seated infections like arthritis and
osteomyelitis: at least 4 weeks.
 6. MICRONUTRIENT
SUPPLEMENTATION
◻ Mutivitamin supplement - Should be given daily for at least 2 weeks at
twice the RDA
◻ Folic acid – 5 mg on day 1, then 1 mg/ day
◻ Elemental zinc -  2 mg/ kg/ day
◻ When weight gain commences and there is no diarrhea , add 3 mg/kg/
day of elemental iron in 2 different doses.
◻ Vitamin A: Give Vitamin A in a single dose to all SAM children
unless received in last 1 month
< 6 months 50 000 IU
6–12 months or weight <8Kg 100 000 IU
>12 months 200 000 IU
If vit. A def., then repeat dose on day 2 and 14.
• IM treatment should be used in children with severe anorexia,
oedematous malnutrition, or septic shock. Only water-based
formulations and half of oral dose should be used.
7. MEDICAL NUTRTION THERAPY
◻ Feeding is a critical part 
◻ To be started cautiously and in frequent small amounts 
◻ Nutrients should be well titrated- 
Stabilisation phase- low protein, low sodium ,
moderate fat and high digestible carbohydrate diet
Transition phase- transitioning through with  close
monitoring
Rehabilitation phase gradual shifting to normal diet
◻ Maintain 24 hour food intake chart
 STABILIZATION PHASE
◻ F-75 starter diet is used initially –
contains 75 kcals of energy and
0.9 gram of protein per 100 ml
to be started at 130 ml /kg/day ( 100ml/kg/day  if there is
edema)
Determine frequency of feeds 
◻ Day 1 – feeds given every 2 hours. 

◻ If child is hypoglycemic ¼’th the 2 hourly amount can be

given every ½ hour for 1’st 2 hours or till child is euglycemic 
◻ Night feeds should always be given

◻ After first day, increase volume per feed and as child starts
accepting larger volumes decrease the frequency to every 3
to 4 hours
 Determine amount of starter diet needed 
◻ Calculated on the basis of actual starting body weight of the child

◻ 130 ml/ kg of actual body weight/ Day is the daily total

requirement 
◻ Amount per feed is Daily total amount required by number of
feeds to be given in 24 hours 

What to do if child has severe edema ? 

◻ Childs weight may be 30 % higher due to excess fluid, so not
more than 100 ml/kg of actual B. Wt / Day of F-75 diet is
recommended 
 
Oral vs NG feeds 
◻ Best to feed the child with a cup, with the child seated in the
mothers lap and sitting straight . Child should never be force fed.
NG feeds
◻ If child is not accepting orally 

◻ Oral ulcers, 

◻ Cannot consume 80 % of starter diet by mouth for 2 or 3

consecutive feeds  
◻ NG tube can be removed  when child consumes 80 % of the days
amount orally or consumes 2 consecutive feeds fully by mouth 

◻ Never stop breastfeeding and number of starter feeds should not

be reduced even if child is breastfeeding adequately 
F-75 Recipe
DIET CONTENTS(PER F 75 STARTER F 75 STARTER (cereal
100ML) based)
COW MILK (ml) 30 30
SUGAR (g) 9 (1 ½ tsp) 6 (1/2 tsp)
CEREAL (powdered - 2.5 (3/4 tsp)
puffed rice)
VEGETABLE OIL (g) 2 (1/2 tsp) 2.5 (1/2 tsp)
WATER make up to (ml) 100 100
ENERGY (kcal) 75 75
PROTEIN (g) 0.9 1.1
LACTOSE (g) 1.2 1.2
STARTER DIET IN CASE OF LACTOSE
INTOLERANCE
CONTENTS AMOUNT
EGG WHITE 5g
GLUCOSE 3.5g (3/4 tsp)
POWDERED PUFFED RICE 7g (2tsp)
VEGETABLE OIL 4 g (1tsp)
WATER 100ml
ENERGY (kcal) 75
PROTEIN 1g
 Feeding patterns in the initial days of rehabilitation

Volume / kg/ Volume / kg/

Days Frequency
feed day

1-2 2 hourly 11 ml 130 ml

3-5 3 hourly 16 ml 130 ml

6 4 hourly 22 ml 130 ml

Source : WHO guidelines

83
 TRANSITION PHASE
◻ Usually takes 3 to 7 days 
◻ Signs of readiness for transition 

          1) Return of appetite- easily finishes 4 hourly feeds

of F-75 
         2) reduced edema or minimal edema 
◻ First 48 hours : Give catch up F-100 diet every 4 hours
in the same amount as the last F-75 diet 
◻ On 3rd Day : Increase feed by 10 ml as long as child is
finishing feeds. If not, offer same amount at next feed.
Increase the amount till 30 ml/ kg/ feed is reached 
◻ Protein – 3gm/kg/day
F-100 DIET
DIET CONTENTS F- 100 CATCH UP F100 CATCH UP
(per 100 ml) (cereal based)
COW MILK/TONED 95 75
DAIRY MILK (ml)
SUGAR (g) 5 (1 tsp) 2.5 (1/2 tsp)
CEREAL (puffed rice) 7 (2 tsp)
(g)
VEGETABLE OIL (g) 2 (1/2 tsp) 2 (1/2 tsp)
WATER to make (ml) 100 100
ENERGY (kcal) 100 100
PROTEIN (g) 2.9 2.9
LACTOSE (g) 3.8 3
CRITERIA TO MOVE BACK FROM TRANSITION PHASE TO
STABILIZATION PHASE

◻ Child gains weight rapidly more than 10g/kg/day.

◻ Increasing edema
◻ Rapid increase in size of the liver
◻ Signs of fluid overload overlap
◻ Child gets significant refeeding diarrhea so that
there is weight loss
◻ Any complication necessitating iv infusion
◻ Nasogastric tube is required
◻ It is common for children to get some change in
stool frequency when they change diet. This does
not need to be treated unless the child loses weight.
CRITERIA FOR TRANSFER TO
REHABILITATION PHASE
◻ Eating well
◻ Responds to stimuli, interest in surroundings
◻ Minimal or no edema
◻ No nasogastric tube
◻ Gaining weight > 5gm/kg/day for 3 successive
days.
 8. REHABILITATION PHASE
◻ Encourage child to eat as much as he wants 
◻ Child should be able to feed freely on F-100 diet
to an upper limit of 220 Kcal /kg/day and 4-6 gm/
kg/day of protein
DAILY CARE
◻ Sensory stimulation and play therapy
◻ Handling a child appropriately
◻ Caring for the skin of a severely acute malnourished
child
◻ Giving prescribed antibiotics and other medications
and supplements
◻ Caring for the eyes
◻ Monitoring vitals and looking for danger signs
◻ Preparing and maintaining a weight chart
◻ Completing and interpreting the daily care page.
 Stimulation, Play and Loving Care

SAM affects mental and behavioral

development, which can be reversed
by appropriate treatment including
sensory stimulation and emotional
support.

◻ Tender, loving care (smiling, laughing,

talking, touching)
◻ Structured play therapy for 15 – 30
minutes / day and physical activity
as soon as the child is well enough
◻ A cheerful, stimulating environment.
◻ Encourage mother’s involvement
Structured play therapy
◻ Due to lack of interaction and play, children with
SAM have delayed mental and behavioral
development.

◻ Play therapy is intended to develop language and

motor skills aided by simple, inexpensive toys.
Examples of simple toys (adapted from WHO guidelines)

Ring on a string
(from 6 months)

Blocks
Nesting toys
In-and-out toy (from 9 months)
 Push-along toy
Pull-along toy
Doll
Rattle
Stacking bottle
tops
Posting bottle
Drum
(from 12 months)

Book
Puzzle
Mirror
(from 18 months)
◻ Weight gain,
- if poor,(<5g/kg/day) child requires full
assessment
- moderate(5-10g/kg/day), check whether the
intake targets are being met or if infection has
been overlooked
- good(10g/kg/day) continue and praise staff and
mother
FAILURE TO RESPOND TO TREATMENT

CAUSES
◻ Inadequate feeding

◻ Untreated infection

◻ Specific nutrient deficiencies

◻ Tuberculosis and HIV

◻ Psychological problems
10. PREPARE FOR FOLLOW UP CARE
AFTER RECOVERY
◻ All children who are 90% weight for length can be
considered to have recovered
◻ Show parent or caregiver how to
- feed frequently with energy dense or nutrient dense
foods
- give structured play therapy
◻ Advise parent or caregiver to
- Bring child for regular follow up check ups
- ensure booster immunizations are given
- ensure vitamin A is given every six months
 CRITERIA FOR DISCHARGE
◻ Absence of infection 
◻ Eating adequate amount of nutritious food that the
mother can prepare at home.
◻ Consistent weight gain (of at least 5 g/kg/day for
3 consecutive days) on exclusive oral feeding
◻ No edema 
◻ Completed immunization appropriate for age
◻ Caretakers should be sensitized for home care
Criteria for early discharge before
recovery
◻ Child >1yr, good appetite, weight gain, no edema,
antibiotic completed.
◻ The mother-available at home, motivated and
trained to look after, have resources, reside near
hospital
◻ Local health worker –can provide support, trained,
motivated
Criteria for early discharge
MONITORING FEEDING AT HOME ESSENTIALS
◻ Frequent feed at least 5 times a day

◻ Modify home food to fit F 100

◻ High energy snacks between feed

◻ Assistance to complete each meal

◻ Give electrolyte/mineral solutions

◻ Breastfeeding should continue

FOLLOW UP
◻ Before discharge, make a plan with the parent for
a follow up visit at 1 week after discharge.
Regular check ups should also be made at 2 weeks
in first month and then monthly until weight for
height reaches -1SD or above. If problem is found,
visits should be made more frequent
◻ At each follow up, the child should be examined,
weighed, measured and results recorded. The
mother should be asked about the child’s recent
health, feeding practices and play therapy.
 Complications of treatment 

◻ NUTRITONAL RECOVERY SYNDROME

Occurs by third week after starting treatment. Self limiting
condtion and often regresses by 6 weeks

PATHOGENESIS

◻ Excess hormone secretion during recovery

◻ Demyelination
◻ Vitamin deficiency
◻ Neurotransmitter imbalance
◻ High solute load on kidneys
CLINICAL FEATURES
◻ Apparent deterioration with gynacomastia and parotid
swelling
◻ Abdominal distension

◻ Hepatomegaly

◻ Hypertrichosis

◻ Congestive heart failure

◻ Tremors

◻ Spasticity

INVESTIGATION : Eoisnophilia
◻ ENCEPHALITIS LIKE SYNDROME
It is a self limiting condition seen after 3-4 days of
initation of dietary therapy. Too much protein in the
diet result in this condition
FEATURES
1. Coarse tremors
2. rarely progress to unconsciousness
3. Rigidity
4. Bradykinesia
5. Myoclonus
REFEEDING SYNDROME
◻ Metabolic disturbances that occurs as a result of
reinstitution of nutrients to the patients who are
starved, severely malnourished.
◻ When too much food or liquid nutrition is consumed
during the initial days, this triggers synthesis of
glycogen, fat and protein in cells in determinant to
low levels of K+,Mg2+ and Phosphorous.
Pathogenesis
◻ During refeeding, insulin secretion resumes in
response to increased blood sugar resulting in
increased glycogen, fat and protein syntheis. This
process requires phosphates, magnesium and
potassium which are already depleted and the
stores becomes rapidly used up.
◻ Intracellular movement of electrolytes occur along
with a fall in serum level, including phosphorous
and magnesium.
SAM: UNDER 6 MONTH OF AGE
◻ Infants under 6 months of age should receive same
general medical care as infants above 6 months
of age
◻ Manage hypoglycemia, hypothermia, dehydration,
infection, septic shock
◻ Breastfeeding is generally preferred. For non
breastfed babies, give starter diet prepared
without cereals
◻ Re-establish breastfeeding as soon as possible.
◻ Give good diet and micronutrient supplements to
the mother.
◻ Mother should be supported to give breastfeed to infant
where possible. Supplementary suckling techinique can be
used to enhance and support breastfeeding.
❑ In the rehabilitation phase, establish exclusive breast
feeding. In artificially fed without any prospects of
breastfeeds, the infant should be given diluted Catch-
up diet. [Catch-up diet diluted by one third extra
water to make volume 135 ml in place of 100 ml].
❑ On discharge the non-breastfed infants should be
given locally available animal milk with cup and spoon.
◻ Discharge the infant from the facility when gaining
weight for 5 days and has no medical complications.
SUPPLEMENTARY SUCKLING
TECHINIQUE
◻ The supplementation is given using tube feedings: the same size as 8NGT
(5NGT can be used and is better for the infant, but the milk should be
strained to remove any small particles that block the tube). The
appropriate amount of supplemental suckling milk is put in a cup. The
mother or assistant holds it.
◻ The end of the tube is put in the cup.
◻ The tip of the tube is put on the breast at the nipple and the infant is
offered the breast in the normal way so that the infant attaches properly.
◻ At first, cup should be placed about 5 cm to 10 below the level of the
nipples so the SS-milk can be taken with little effort by a weak infant. It
must NEVER be placed above the level of nipple, or else it will flow quickly
into the infant’s mouth by siphon with a major risk of inhalation
◻ As the infant becomes stronger the cup should be lowered
progressively to about 30 cm below the breast. It may take a
day or two for the infants to get used to the tube and the taste
of the mixture of milks, but it is important to persevere.
PREVENTION OF UNDERNUTRITION IN
CHILDREN
INDIVIDUAL LEVEL OF ACTION
◻ MOTHER

1. Care of the adolescent girl

2. Childbirth after 20 years

3. Spacing between pregnancies

4. No more than 2 children

5. Iron and folic acid to ensure good hemoglobin

6. Antenatal checks as per national program

7. Additional food and micronutrients in pregnancy

◻ CHILD
1. Initiation of BF within one hr and EBF for first 6months and continuing till
2 years or more.
2. Special support LBW babies for BF and KMC
3. Complementary feeding introduced at 6 months
4. Hygiene, hand washing
5. Full immunization according to schedule
6. Prompt treatment of diarrhea , pneumonia and other illness
7. Growth monitoring and periodic check up
◻ ADOLESCENT GIRLS: Future mothers
1. Optimum nutrition
2. Education in parenting and mother craft
3. Marriage after 18years of age
◻ SOCIETY LEVEL ACTION
1. Safe water and sanitation

2. A culture of good nutrition

3. Maternity and child care leave

4. Creches for children of working women

5. Cash support to pregnant and lactating women

6. Socio economic development , high income, equity

7. Education of women and men

8. Women’s empowerment

9. Food security at the household level

10. Nutrition promoting agriculture

ICDS
ICDS
◻ To reach out to children below 6 years and services are
provided at ‘Anganwadi’ centre through community
based workers and helpers
1. Supplementary nutrition for mother and the child

2. Immunization for pregnant women and infants as per

NIS
3. Non formal preschool education

4. Health check up

5. Referral services

6. Nutrition and health education

POSHAN ABHIYAAN
◻ Under the POSHAN Abhiyaan, a flagship mission
of the PM launched in February 2018. The goals
for this three year mission are to:
1. Reduce stunting and undernutrition in
children(0-6yrs) @2% per annum.
2. Reduce LBW @2% per annum.

3. Reduce prevalence of anemia amongst young

children(6-59month) @3% per annum
4. Reduce prevalence of anemia amongst women
and adolescent girls (15-49yrs) @3% per annum
 HOME BASED FOOD ITEMS
Age (months) Food

Up to to 6 months • Breastfeed as often as the child wants, day and night, at

least 8 times in 24 hours
• Do not give any other foods or fluids not even water
Remember
• Continue breastfeeding even if the child is sick

6-12 months • Breastfeed as often as the child wants.

• Give at least one katori serving at a time of : Mashed roti /
bread / biscuit mixed in sweetened undiluted mild or
mashed roti / rice / bread mixed in thick dal with added ghee
/ oil or Khichri with added oil / ghee. Add cooked vegetables
also in the servings or dalia /halwa / kheer prepared in milk
or any cereal porridge cooked in milk or mashed boiled /
fried potatoes.
• Offer banana / biscuit / cheeko / mango / papaya as snacks
in between the serving
Frequency : 3 times per day if breastfed ; 5 times per day
if not breastfed
Remember :Keep the child in your lap and feed with your
own hands
Wash you own and child’s hands with soap and water
 Age (months) Food

12 months to 2 • Breastfeed as often as the child wants

years • Offer food from the family pot
• Give at least 1½ katori serving at a time of
• Mashed roti / rice bread mixed in thick dal with added ghee / oil or
khichri with added oil / ghee. Add cooked vegetables also in the
servings or
Mashed roti / rice / bread / biscuit mixed in sweetened undiluted
milk or
dalia / halwa / kheer prepared in milk or any cereal porridge cooked in
milk or
Mashed boiled / fried potatoes
Frequency : 5 times a day
Offer banana / biscuit / cheeku / mango / papaya / as snacks in
between the servings
Remember
sit by the side of child and help him to finish the serving
Wash your child’s hands with soap and water every time
before feeding

2 years and older • Give family food as 3 meals each day

• Also, twice daily, give nutritious food between meals, such as :
banana / biscuit / cheeku /mango / papaya as snacks
Remember
• Ensure that the child finishes the serving
 

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