MANAGEMENT OF

SEVERE
MALNUTRITION

DR. IFIORA F.A

 OUTLINE
 INTRODUCTION
 PATHOPHYSIOLOGY
 EVALUATION
 INITIAL TREATMENT
 REHABILITATION
 FOLLOW UP
 FAILURE TO RESPOND TO TREATMENT
 MALNUTRITION IN DISASTER
SITUATIONS AND REFUGEE CAMPS
 MALNUTRITION IN ADOLESCENTS
 INTRODUCTION 1
 Severe malnutrition is a range of pathologic
conditions that results from imbalance in essential
nutrients.
 Results from- chronic nutritional deprivation
- emotional deprivation
 Predisposing factors-poverty
-ignorance
-family problems
 Hence, recognise and adress medical & social
 INTRODUCTION 2
 Case fatality rates:
 >20% : unacceptable
 11-20%: poor
 5 -10%: moderate

 1 -4 %: good

 < 1% : excellent
 Treatment facilities:
 Hospital care
 Initial treatment

 Beginning of rehabilitation

 Nutritional rehabilitation centre

 Non residential

 Staff trained in nutritional rehabilitation

 PATHOPHYSIOLOGY 1
 When a child’s intake is insufficient, the needs of the body for energy
are met by mobilising tissue reserves of fat and protein from muscle,
skin and the gut. Physiological and metabolic changes also take
place to conserve energy. These changes take place in an orderly
progression called reductive adaptation.
 Through reductive adaptation, energy is conserved by:
 Reducing physical activity and growth
 Reducing basal metabolism by
 slowing protein turnover,
 reducing the functional reserve of organs,
 slowing the sodium and potassium pumps in cell membranes and reducing their number
 Reducing inflammatory and immune responses
 The changes caused by reductive adaptation affect the functioning of
every cell, organ and system .
 PATHOPHYSIOLOGY 2
 Marasmus:
 Marked cortisol response

 muscle protein broken down to a.acids

 A.acids used in lipoprotein synthesis
 Lipoproteins help mobilise triglycerides in liver, preventing
fatty liver
 Adaptive response involves all systems
Adaptation in marasmus
 PATHOPHYSIOLOGY 3
 Kwashiokor
 Impaired cortisol response
 Dysadaptation with failure of biochemical proceses that
protect liver at expense of muscle and fat.
 Defficiency of antioxidants
 Aflatoxin poisoning
Dysadaptation in kwashiokor
Aflatoxin and free radical
theories of kwashiokor
 PATHOPHYSIOLOGY 3
cvs
 Thin cardiac mzl. Fibres with impaired contractility
of myofibrils.
 Decreased cardiac output
 Decreased blood pressure

 Normal plasma volume

 Decreased red cell volume

CAUTION WITH IV FLUIDS

BLOOD TRANSFUSIONS:10mls/kg,post diuretic
 PATHOPHYSIOLOGY 4
LIVER[DIG.SYSTEM]
 ↓protein synthesis
 ↓Σο generation from substrates
 ↓ capacity to metabolise toxins
 ↓ gluconeogenesis
GIVE SMALL MEALS
PROTEIN INTAKE: 1-2 gm/kg/day
↓DOSE OF DRUGS,HEPATOTOXIC/HEPATIC
ELIMINATION
ENOUGH CHO’S TO DECREASE NEED FOR
GLUCONEOGENESIS
 PATHOPHYSIOLOGY 5
DIGESTIVE SYSTEM
 ↓prdn. Of gastric acid
 ↓intestinal motility
 Pancreatic atrophy and ↓ prdn. of digestive enzymes

 Atrophied small int. Mucosa with ↓ sec. Of

digestive enzymes
SMALL FREQUENT FEEDS
 PATHOPHYSIOLOGY 6
URINOGENITAL SYSTEM
 ↓ GFR
 ↓ capacity to excrete acid and water
 ↓ urinary phosphate
 ↓ sodium excretion
 UTI common
↓ RENAL SOLUTE LOAD
↓ TISSUE BREAKDOWN BY TREATING INFECTIONS & PROVIDING
ADEQUATE Σο [80-100 kcal/kg/day]
JUST ADEQUATE HIGH QUALITY PROTEIN[1-2gm/kg/day]
RESTRICT DIETARY SODIUM
AVOID EXCESSIVE WATER INTAKE
 PATHOPHYSIOLOGY 7
IMMUNE SYSTEM
 Atrophied lymph glands
 ↓ cell mediated immunity
 ↓ IgA levels in secretions
 ↓ complement components
 ↓ activity of phagocytes
 ↓ inflammatory reaction to tz damage hence
respond to tz injury by necrosis: pathology of noma.
KEEP ALL NEWLY ADMITED CASES AWAY FROM PATIENTS
RECOVERING FROM INFECTION
TREAT ALL WITH BROAD SPECTRUM ANTIBIOTICS
 PATHOPHYSIOLOGY 8
ENDOCRINE SYSTEM
 ↓ insulin levels with glucose intolerance
 ↓ IGF levels
 ↑ cortisol level

DON’T GIVE STEROIDS

SMALL FREQUENT MEALS
 PATHOPHYSIOLOGY 9
METABOLISM
 BMR ↓ by ≈ 30%
 ↓Σο expenditure
 ↓ heat generation & heat loss: hypothermia in cold
env. ; hyperthermia in warm environment
KEEP IN WARM ENVIRONMENT
TREAT FEVER WITH TEPID SPONGING
 PATHOPHYSIOLOGY 10
CELLULAR FUNCTION
 ↓ Na΅K΅ATPase
 ↑ cell membrane permeability

RESTRICT SODIUM INTAKE

GIVE LARGE DOSES OF Mg & K
 PATHOPHYSIOLOGY 11
SKIN,MUSCLES & GLANDS
 Atrophied skin & subcut. Fat ↓sweating
 Atrophied sweat/salivary glands dry mouth & skin
unreliable signs of d.
 Respiratory muscles easily fatigued
 PATHOPHYSIOLOGY 12
BRAIN AND NERVOUS SYSTEM
 CEREBRAL TZ. USU. PRESERVED
 Severe marasmus: brain atrophy with ↓
cerebral fxn
 Effect more imp. In infants or if malnutrition
occurs in fetal life
 EVALUATION 1
HISTORY
 Birth weight
 Breastfeeding history
 Developmental history
 Immunization history
 Usual diet b/4 current illness
 Food and fluids taken in past few days
 Duration,& freq. of vomitting or diarrhoea;appearance of
vomitus or diarrhoeal stools.
 Recent sinking of eyes
 Time when urine was last passed
 contact with people with measles or tuberculosis
 Any deaths of siblings
 EVALUATION 2
EXAMINATION
 Weight & length/height
 Oedema/severe pallor/hypothermia or fever/jaundice
 abdominal distension,hepatomegaly,abdominal
splash,bowel sounds
 Appearance of faeces
 Signs of shock
 Eyes: corneal lesions indicative of vit. A deff.
 ears,mouth,throat, for evidence of infection
 Skin: evidence of infection
 Signs of pneumoniae and heart failure
 ANTHROPOMETRIC MEASUREMENT
 This is the most commonly used method. It involves
measurement of certain parameter and relating them
to age, height e.t.c. Such parameters include:

 Weight for Age: After birth a normal birth weight (2.5kg)

baby is expected to gain approximately 30g/day in the
neonatal period and 2nd month of life. As a rule, the
should double their birth weight by the 5th month and
triple it by 9 – 12 month.
 SFD 2-5kg may not lose wt at all.
Normal wt gain is 30g/day.

3. Infant:
Wt: 30g/day in 2 months
20g/day – 3-5 months
doubles birth wt at 5months
triples birth wt at 9-12months
10kg at 1yr.

50cm ＋ / － 5

 5] 10 school/middle childhood(6-
12yrs)
Wt Ht OFC
 OFC: 33cm at birth 8kg/yr 6cm/yr 0.5cm/yr
2cm/month(1-3), 1cm/month(4-
6),0.5cm/month(6-12).
 6] Late childhood/Adolescence:
3 phases – 10-13yrs
4]Preschool
14-16yrs
wt/mo Ht/mo OFC/mo
17-20yrs.
240g 1cm 0.25cm (2-3yrs)
Pubertal growth spurt = 10-12cm/yr.
180g 0.25cm 0.1cm (4-5yrs)
  (Nb: the greater the birth weight the greater the doubling
time). There are various standard charts used to
extrapolate weight for age.

This include Olowe's chart for estimating gestational age,

other normogram for children beyond neonatal period.
Measurement:
Infants - Calibrated beam balance
Older children - bathroom scale, spring
balance weighs to accuracy of
0.5kg.

 Advantages are that easy to measure, not expensive.

  Height for Age: This suggests stunting.

 Weight for height: This suggests wasting.

 Weight for height ratio: Normal - ≥ 0.16

Malnourished - < 0.16

 Mid upper arm circumference: This is used only for those between
1 – 5 years of age, when the growth of muscle bulk is relatively
stable. It is measured as the circumference midway between the
acromion and olecranon process. Material used are:

i. Tape rule: 13.5cm and above - Good nutrition

12.5cm – 13.5cm - Under nutrition
< 12.5cm - Malnutrition
ii. Shakir strip: Green colour – Good nutrition
Yellow colour – undernutrition
Red colour - malnutrition.

iii. QUAC STICK: Relates the MUAC and height

Advantage: It is a useful indication of current malnutrition whether or not

stunting is present.
Disadvantage: is that it is affected by bone, skin and fat.

Skin fold thickness:

Instrument used is the Harpenden calliper. It measures in millimetre and
is a measure of fat. Site used includes: -
 Triceps skin fold.
 Biceps skin fold
 Subscapular skin fold
 Suprailiac skin fold
 Values: male - 10mm
Females - 4 – 16mm depending on the age.

OFC :
Reflects combination of skeletal and brain size. It is measured using a
tape rule.
At birth it is 35 ± 2
At 1 year of age : 47 ± 2

BODY MASS INDEX (BMI)

weight (kg)
= _________
Height² (m²)
Values: Up to the 85th centile - risk of overweight.
95th centile - risk of obesity.
SHAKIR STRIP
 WELLCOME CLASSIFICATION (1970)

OEDEMA  

WEIGHT (% OF STANDARD) PRESENT ABSENT

60 - 80% Kwashiorkor Underweight

Marasmic-
< 60 kwashiorkor Marasmus
 ADVANTAGES:
Weight dependent, easy to measure
It clearly presents the forms of malnutrition at a glance.

DISADVANTAGES:
 Criticised for excluding children with overt
kwashiorkor, where weight are above 80%

 Age dependent – Age is not accurately kept and is must

often assumed.

 Says nothing about clinical features.

 MODIFIED WELLCOME CLASSIFICATION

OEDEMA  

WEIGHT (% OF
STANDARD) PRESENT ABSENT

Acute Kwashiorkor
> 80 (sugar baby syndrome) Normal nutrition

60 – 80 Underweight kwashiorkor Underweight

< 60 Marasmic kwashiorkor Marasmus

 CLASSIFICATION FOR COMMUNITY SURVEY
 The most widely used is “Gomez classification” produced in
1956, when He compared weight for age of children in Mexico
with north American standards.
GOMEZ MODIFIED GOMEZ
NUTRITIONAL STATUS CLASSIFICATION CLASSIFICATION
% BODY WEIGHT % BODY WEIGHT
FOR AGE. FOR AGE.

Normal nutrition > 90 >80

Mild or 1st degree 75 - 90 71 – 80

Moderate or 2nd degree 60 - 74 60 – 70

Severe or 3rd degree < 60 < 60

 ADVANTAGES:
1. Useful in assessing the magnitude of the problem in
the community.

DISADVANTAGES:
2. It does not indicate the duration of the malnutrition.
3. Not suitable for classifying forms of malnutrition.
4. Age dependent.

 NB. Jellife proposed a modification of this

classification with 4 groups at intervals of 10% of
the body weight deficit.

 Bengoa included all cases with oedema in 3rd

degree malnutrition regardless of body weight.
 SEOANE AND LATHAMS CLASSIFICATION.
Weight for height is an index of current nutritional status.
Height for Age gives a picture of past nutritional history.
Seoane and Lathams classification is based on this concept. In
this system, malnourished children were classified into 3
major categories:

WEIGHT
WEIGHT HEIGHT FOR FOR
FOR AGE AGE HEIGHT
Acute or current short term
malnutrition (wasted) Low Normal Low
Chronic or long term malnutrition
(wasted and stunted) Low Low Low
Past malnutrition or Nutritional
dwarf (stunted) Low Low Normal

(REPRODUCED FROM JOURNAL OF TROPICAL PAEDIATRICS, 1971;17: 98-104, OXFORD UNIVERSITY PRESS.)
ADVANTAGES:
1. It differentiates acute from chronic malnutrition.

DISADVANTAGES:
2. Age dependent – No good record of age in most
rural communities
3. Not all that are short are as a result of malnutrition.
It may be constitutional.
 WATERLOW CLASSIFICATION. (1972)
Need for rational decision base on classification

WEIGHT FOR AGE

HEIGHT FOR
AGE < 80 80 - 120 > 12O

1. Chronic 2. Stunted but no 3. Stunted but

< 90 malnutrition malnutrition obese

4. Acute
> 90 malnutrition 5. Normal 6. Obese
 Action required:
 1 - Long term socioeconomic development.
 2 & 5 Nil
 3 & 6 Nutritional education.
 4 - Emergency measures to relieve acute
malnutrition.

Advantages:
1. It can differentiate acute from chronic malnutrition.

Disadvantages:
Age dependent.
USE OF Z- SCORE (in assessing nutritional
status) WHO 1983.

TYPE OF
UNDERNUTRITI
ON INDICATOR MODERATE SEVERE

<(-3) Z score
<(-2) Z score or < 80% of or < 70%
Underweight Weight for age median of median

<(-3) Z score
<(-2) Z score or < 90% of or < 85%
stunting Height for age median of median

<(-3) Z score
<(-2) Z score or < 80% of or < 70%
Wasting Weight for height median of median

SD SCORE= [OBSERVED VALUE]—[MEDIAN REFERENCE VALUE]

STANDARD DEVIATION OF REFERENCE POPULATION
 BIOCHEMICAL METHODS IN ASSESSMENT OF
NUTRITIONAL STATUS.
Initial assessment include;
 Haemoglobin; most important and useful test because
besides anaemia, it tells about protein and trace element
nutrition.
 Stool examination for the presence of Ova and/or intestinal
parasites e.g. Hookworm.

More specific ones are;

1. Serum albumin, transferrin, thyroid binding pre-albumin,

serum retinol, serum iron, urinary iodine, vitamin D.

2. Analysis of hair, nail and skin for micronutrients.

 Advantages
1. Detects early changes in body metabolism and
nutrition before the appearance of overt signs.
2. Precise, accurate and reproducible.

Limitation.
3. Time consuming

4. Expensive

5. Cannot be applied on large scale.

6. Needs trained personnel and facilities.

Newer methods of nutritional assessments.
 Hydrodensitometry
 Total body potassium
 Total body water
 Neutron activation
 Photon and x-ray absorptiometry
 Bioelectrical impedance analysis.
 Total body electrical conductivity.
 EVALUATION 3
CRITERIA FOR ADMISSION
 SEVERE MALNUTRITION AS DEFINED BY
 WEIGHT FOR HEIGHT OR
 PRESENCE OF SYMMETRICAL EDEMA
 EVALUATION 4
LABORATORY INVESTIGATIONS
TEST RESULT AND SIGNIFICANCE
RBS <3mmol/L :hypoglycemia
Blood smear for mp
PCV <12%,very severe anemia. Transfuse
Urine MCS
Stool MCS
CXRay Pneumonia causes less shadowing than in nourished
children
Vascular engorgement indicative of heart failure
Bones may show rickets
Manteux Often negative in pts with Tb
OF LESS IMPORTANCE

SERUM PROTEINS May guide prognosis

HIV screening Ensure parents are counselled
Results should be confidential
Electrolytes
 INITIAL TREATMENT 1
PRINCIPLES OF TREATMENT
 INITIAL TREATMENT 2
hypoglycemia
 Imp. Cz of death in ist 2/7 of tx
 Causes
 Systemic infection
 Not fed for 4—6 hours

 Features
 Hypothermia/lethargy/coma
 Treatment
 50mls 10%dextrose orally[via NG tube if oral impossible]
 [If unconsious,5mls/kg, i.v;then50mls via NG tube]

 ½ hourly feeds for 2hours[ie. Vol. Of 2hourly/4]

 Repeat RBS at end of 2 hours; if normal commence 2 hourly feeds; if <3, repeat
above for 2hours.
 Prevention
 2 hourly F 75 feeds
 INITIAL TREATMENT 3
hypothermia
 Definition:[rectal<35.5ºc; axillary<35ºc]
 Common in:infants<12/12
Marasmus
Large areas of damaged skin
Serious infections
Hypoglycemic infants
 Prevention
Maintain room at 25—30 ºc
Cover child;even during examinations
Stop draught,move child away from window
Promptly change wet clothes or bedding
Dry child thoroughly after bathing
 Treatment
Kangaroo technique
Indirect heating with heater or incandescent lamp
 INITIAL TREATMENT 4
dehydration and shock
CLINICAL SIGN SOME SEVERE INCIPIENT DEVELOPED
DEHYDRATION DEHYDRATION SEPTIC SHOCK SEPTIC SHOCK
Watery yes yes Yes or no Yes or no
diarrhoea
Thirst Drinks eagerly Drinks poorly no no
Hypothermia no no Yes or no Yes or no
Sunken eyes yes yes no no

Weak or absent no yes yes yes

radial pulse
Cold hands and no yes yes yes
feet
Urine flow yes no yes no

Mental state Restless;irritabl Lethargic; apathetic lethargic

e comatose
hypoglycemia sometimes sometimes sometimes sometimes
 INITIAL TREATMENT 4
dehydration and shock
 70—100 mls/kg of RESOMAL over 12 hours as 5mls/kg/30mins for
1st 2 hours orally or via NG tube; then 5-10 mls/kg/hr for next 10 hrs.
 Reassess every hr
 Indications for stopping RESOMAL
 ↑ R.R & P.R
 Engorged jugular veins

 ↑ edema eg puffy eyelids

 Signs/symptoms of dehydration disappear
 Commence maintenance till loose stooling stops
 <2yrs: 50-100 mls/loose stool
 >2yrs: 100-200mls/loose stool
 INITIAL TREATMENT 5
dehydration and shock
INTRAVENOUS REHYDRATION
 Indications :circulatory collapse
 Fluids in ↓ order of preference
 ½ strength Darrows in 5% dextrose
 Ringer’s lactate in 5% dextrose
 0.45% saline in 5% dextrose
 Procedure
 15mls/kg over 1 hr,monitoring R.R &P.R. Every 10 mins

 Simultaneous,NG tube, for RESOMAL ,10mls/kg/hr

 Reassess in 1 hr;if R.R&P.R. ↓,child is responding. Repeat 15mls/kg over
1hr, with monitoring
 Give oxygen

 After 2 hrs of IVF, commence RESOMAL, 5-10 mls/kg/hr for next 10

hrs, alternating with F 75.
 If no response after 1st hr of IVF, assume septic shock, then
 IVF, 4mls/kg/hr, while waiting for blood

 When bld arrives,[discontinue all fluids]

 10mls/kg ×3hrs[fresh whole blood]

 5-7mls/kg×3hrs[packed cells]
 I.V furosemide 1mg/kg
 INITIAL TREATMENT 6
dietary treatment
 Feeding chart for volume of 2 hrly feeds[1/2 hrly for 1st 2hrs
in hypoglycemia]
 Above delivers
 Use starting weight to determine feeding volumes
 Refeed vomitting patients with amts vomitted or offer ½
amts of food twice as often
 Minimal acceptable oral intake:80% of offered;if not pass
NG tube and give deficits via tube. remove NG tube when
tolerating> 80% orally.
 Each day, review 24 hr intake chart to know when patient is
ready for larger less frequent meals.
 INITIAL TREATMENT 7
dietary treatment
 Criteria for ↑volume/↓freq. of feeds
 Vomitting,diarrhoea[>5],poor appetite: continue 2 hrly
 Little or no vomitting,modest diarrhoea[<5],finishing
most feeds: change to 3 hrly
 After 1 day on 3 hrly, and no vomitting,less diarrhoea
and finishing most feeds: change to 4 hrly
 INITIAL TREATMENT 8
transition period
 Indications for commencing F 100
 Return of appetite[easily finishes 4 hrly feeds 0f F75]

 ↓edema or minimal edema

 Child may smile
 Transition takes 3 days,during which F100 is given as
 1st 48 hrs:F100, 4hrly, same dose as F75

 3rd day:
 ↑ each feed by 10mls as long as child is finishing feeds
 Offer same amt. at next feed if preceeding feed is
unfinished
 Continue until ≈30mls/kg/feed is attained
 Breastfeed b/w meals of F100
 Monitor child during transition
 REHABILITATION
 Continue 4hrly feeds
 Aim to achieve 150-220 kcal/kg/day[current weight]
 If child doing well,discontinue 24hr food intake
chart after 3-4 weeks
 Continue F100, till child achieves -1SD[90% weight
for height]
 When above occurs, appetite diminishes,increasing
amounts of food left uneaten; child is ready for
discharge.
 REHABILITATION 2
other components of care 1
 Stimulate emotional and physical development
 Involve mothers in care
 Plan feeding for the ward
 How much food to prepare[daily ward feed chart]
 Schedule of feeding

 Daily weighing
 Daily care
 Bathe child daily, unless very sick
 Severe dermatosis
 Daily bathe for 10-15mins with 1% K permanganate[or GV]
 BARRIER CREAM FOR RAW AREAS
 REHABILITATION 3
other components of care 2
 Folic acid supplementation
 After 2/7 on F100
 Anthelminthics
 3mg/kg elemental iron in 2 divided doses]

 Vitamin A[<6/12: 50,000iu;6-

12:100000;>12:200,000]
 DAY 1[ALL SEVERELY MALNOURISHED]
 Additional doses[days 2&15]
 Visible signs of vit.A defficiency[bitot spots,corneal
clouding/ulceration]
 Signs of eye infection
 Active measles or measles in the past 3/12
 REHABILITATION 4
other components of care 3
 Monitoring and problem solving
 Problems could be
 Affecting individual patient
 Affecting a group, or entire ward

 Staff performance

 Food preparation
 Ward procedures
 Process of solving
 Identify problems by monitoring[see charts]

 Individual patient progress

 Overall weight gain for the ward
 Patient outcomes/ Case fatality rate

 ward hygiene
 Food prep. procedures

 Investigate cz of problems
 Determine solutions
 REHABILITATION 5
criteria for transfer to nutritional rehabilitation
centre

 Eating well
 Improved mental state
 Normal temperature
 No vomitting or diarrhoea
 No edema
 Gaining weight[>5gm/kg/day for 3
consecutive days]
 REHABILITATION 6
preparation for discharge
[no NRC]
 Teach parents prevention of malnutrition
 Social worker or nurse to visit child’s home,to
ensure that adequate home care can be
provided
 If condition at home is unsuitable, or child is
abandoned,FOSTER HOME, should be
sought.
 Caregiver to practice recommended feeds
 Immunise child according to national
guidelines
 REHABILITATION 7
CRITERIA FOR DISCHARGE
HOME
CRITERIA
CHILD Weight for height -1SD[90%] of NCHS/WHO median reference
values.
Eating adequate amount of a nutritious diet that mother can
prepare at home
Gaining weight at a normal or increased rate
All vitamin & mineral defficiencies have been treated
All infections & other illnesses have been or are being treated
Full immunization programme started
CAREGIVER Able and willing to look after the child
Knows how to prepare appropriate foods and to feed child
Knows how to make appropriate toys and to play with child
Knows how to treat diarrhoea,fever, &ARI’s ,and knows danger
signs that warrant hospital attendance.
HEALTHWORKER Able to ensure follow –up for child, and support for the mother
 FOLLOW-UP
 See at 1wk,2wks,1mth,3mths,6mths,then twice
yearly till 3yrs of age
 Provided weight for height is not < -1SD,
progress is good.
 At each visit, assess
 Child’s recent health
 Feeding & play

 Anthropometry

 Feeding practices for siblings

Provide vitamins & minerals as needed.

FAILURE TO RESPOND TO TREATMENT
 Primary failure to respond to treatment
 Failure to achieve initial improvement
 Secondary failure to respond
 Deterioration after satisfactory response established
 Causes
 Tx. In general ward
 Inexperienced staff
 Overworked staff
 Inaccurate weighing machines
 Poor food preparation practices
 Feeding problems[regurgitation, etc]
 Infections
 Persistent diarrhoea
 MALNUTRITION IN ADOLESCENTS 1

 Causes
 Extreme deprivation and famine
 Mental illness

 Chronic infections

 Intestinal malabsorption

 Alcohol/drug dependence

 Liver disease

 Endocrine/autoimmune diseases

 Cancer and AIDS

 MALNUTRITION IN
ADOLESCENTS 2
 Principles of management
 As in children
 However, BMI for age used in classification

 Severe malnutrition indicated by

 BMI for age < 5th centile

 Nutritional edema
<18.5
18.5-25
25-30
>30
Thank you