Malnutrition in Children

:Presented By
DR. MONA MOHAMMED ALI
 Objectives
Definitions and classifications of
malnutrition
Risk factors and causes of malnutrition
Management of pt with PEM
Complication of malnutrition
 IMPORTANT BIOLOGICAL ROLES OF
:VARIOUS NUTRIENTS
1) Proteins: needs 45-55g
-for growth and repair of tissue cells
-plasma proteins
-enzymes… etc
2) CHO: needs31-35Kcal/kg Wt
-source of energy
- structure of cells
3) Fat: needs 5% of total calories (poly un sat.)
-structure of cell membrane & nuclei
-vehicle for absorption of fat sol. Vitamins
4) Water:
-transport of nutrients & waste product
-homeostatic function
5) Minerals and trace elements :
1) Calcium: skeletal rigidity, muscle function, and
regulation of cell metabolism.
2) potassium: potassium deficit contributes to
hypotonia, apathy, and impaired cardiac
function.
3) Copper: aerobic metabolism, iron handling, and
collagen synthesis.
4) Fluoride: dental protection.
5) Iodine: thyroid hormone synthesis.
6) Iron: cellular respiration. Iron deficiency leads to
Hypochromic microcytic anaemia
7) Magnesium: growth control, muscle
function.
8) Phosphorus: bone metabolism, cardiac,
respiratory and neurological function.
9) Selenium: antioxidant.
10) Zinc: nucleic acid and membrane
metabolism. Its deficiency leads to growth
retardation and Dermatosis.
6)VITAMINS:
Vit A: visual integrity, cell differentiation.
Vit D: control of calcium and phosphorus metabolism. Its deficiency leads
to rickets.
Vit E: antioxidant.
Vit K: integrity of coagulation cascade. Its deficiency leads to bleeding
manifestations.
Vit B1: ATP synthesis, cell membrane integrity.
Vit B2: red-ox reaction co-factor.
Vit B6: amino acid and lipid metabolism.
Vit B12: DNA synthesis.
Vit C: reducing agent critical to collagen synthesis. Its deficiency leads to
scurvy.
Folate: DNA synthesis.
 Rules of Thumb for Growth

Weight
Weight loss in first few days by 5%-10% of birth weight.
Return to birth weight by 7-10 days of age
Double birth weight at 4-5 mo
Triple birth weight at 1 yr
Quadruple birth weight at 2 yr
Average weights: 3.5 kg at birth ,10 kg at 1 yr ,20 kg at 5 yr and 30 kg at 10 yr
Height
Average length: 20 inches at birth
30 inches at 1 yr
At age 4 yr, the average child is 40 in tall (double birth length)
Average annual height increase: 2-3 inches between age 4 yr and puberty
Head Circumference (HC)
Average HC: 35 cm at birth (13.5 inches)
Head circumference increases by 2 cm per month in the first 3 moths of age ,
1cm per month for second 3 months of age , then only 0.5 cm per month for the last
6 month of infancy .
that means during the first year of age head circumference increase by 12 cm
It increase by 10 cm for rest of life
:DEFINITION of Malnutrition

The inappropriate intake of one or more of the

nutrients essential for normal growth and
development of the body.

A condition characterized by relative or absolute

deficiency in one or more of the essential
nutrients sufficient to produce disease.
The World Health Organization defines
malnutrition as "the cellular imbalance
between supply of nutrients and energy
and the body's demand for them to ensure
growth, maintenance, and specific
functions.
• Malnutrition refers to deficiencies, excesses, or
imbalances in a person’s intake of energy and/or
nutrients. The term malnutrition addresses 3 broad
groups of conditions:
1. Undernutrition: which includes wasting (low weight-for-
height), stunting (low height-for-age) and underweight
(low weight-for-age)
2. Micronutrient-related malnutrition: which includes
micronutrient deficiencies (a lack of important vitamins
and minerals) or micronutrient excess; and
3. Overweight, obesity and diet-related noncommunicable
diseases (such as heart disease, stroke, diabetes and
some cancers).
The term protein-energy malnutrition
(PEM) applies to a group of related
disorders that include marasmus,
kwashiorkor (see the images below), and
intermediate states of marasmus-
kwashiorkor
:Malnutrition is either
primary : related to quality & quantity of )1
nutrition
secondary to illnesses or disabilities that )2
affect the body consumption of nutrient
RISK FACTORS FOR DEVELOPING PEM MALNUTRITION

I. Recurrent gastroenteritis or infection or chronic illness.

II. Poverty (inadequacy & poor supplementation of food).
III. Poor breast feeding, late supplementation, or poor
quality or quantity or both.
IV. Bad housing sanitation, environmental condition &
overcrowding.
V. Short spacing and large family.
VI. Mother ignorance, lack of basic health education &
nutritional knowledge (poor practicing, food taboos &
believes).
VII. None or partially vaccinated.
VIII. Preterm, low birth wt & twins.
IX. Metabolic diseases.
X. Inappropriate weaning practice.
Classifications of
PEM
There are many classifications for
malnutrition that depend variably on
weight for reference age ,height for
reference age, weight for height, muscle
wasting, presence of oedema and body
mass index.
 WHO Classification of
Malnutrition
Evidence of
Moderate Severe (type)
Malnutrition
Symmetric
No Yes (edema PEM)
edema
SD score <-3
SD score 3
-
Weight for (ie,severe
SD score <-2
height wasting)
(70-90%)
(<70%)
SD score <-3
SD score -3
(ie,severe
Height for age SD score <-2
stunting)
(85-89%)
(<85%)
 WELLLCOME
CLASSIFICATION
Depend on Wt / Age plus presence or absence of edema

Body wt as
classification % of edema
standard
Under weight 60-80% no

Marasmus <60% no

Kwashiorkor 60-80% with

Marasmic Kwashiorkor <60% with

 Disadvantages:-
1.cann’t apply when the age of pt is not
known .
2. doesn't consider the chronicity of the
disease .
Sever edematous kwashiokor can be above
80%
M.U.A.C CLASSIFICATION
*Mid way b/w the acromion & olecranon. For up to 5 years
old. *It is very good indicator, quick and more reliable
classification.*

classification
MUAC
cm 16-13.5 normal

cm 13.5-12.5 Mild malnutrition

cm 12.5< Severe malnutrition

WATERLOO CLASSIFICATION
Using height / age

Classification Ht/age

NORMAL .of stand 95%>

MILD .90-95%of stand
MODERATE .of stand 85-89%
SEVERE .of stand 85%<
GOMEZ CLASSIFICATION
It is based on wt/ age.

WT for
reference age interpretation
90-110 % normal
75-89 % I :mild Grade
60-74 % II :moderateGrade
<60 % III : severeGrade
 MARASMUS
It is a severe form of PEM that may occur at any
age particularly early infancy.
It is characterized by severe wasting ,Wt less than
60% of expected, loss of subcutaneous fat and
absence of oedema
 Etiology:

1. Inadequate diet deficient in both proteins & calories.

This may be due to: (nutritional marasmus)

i. failure of breast feeding

ii. inadequate amount of formula milk- use of contaminated
utensils causing infective diarrhoea.
iii. feeding difficulties as M.Retardation, C.P, and congenital
anomalies such as cleft palate.
iv. Prematurity due to poor suckling in the presence of rapid
growth.
v. Starvation therapy for diarrhoea if prolonged and
repeated.
Secondary marasmus
2.Chronic severe infections : T.B, UTI
3.Chronic diarrhoea and /or vomiting
4.Malabsorption syndrome
5.Congenital malformations: pyloric stenosis, cyanotic
congenital H.D,
6.Metabolic disorders: galactosaemia
7. Endocrinal disease ( hyperthyrodism, DM)
8.Psychological disturbance: maternal deprivation
syndrome.
 Clinical Manifestations
Growth failure:
Initially there is failure to gain wt followed by loss of wt.

* Length, H.C also affected but need longer duration .

Loss of subcutaneous fat:
*from the abdominal wall , limbs and buttocks and from
the buccinator pad of fat which is the last to
disappear leading to hollowing of cheeks and
appearance resembling old man face.
Muscle wasting
this together with loss of subcutaneous fat lead to:
1. stick like appearance of the limbs
2. scaphoid abdomen with marked thinning of
 Psychological changes:
*anxious, irritable, cry excessively & sleep little.
However the pt is less miserable than kwash infant.
* Anorexia is less common in marasmus & appetite is
often good.
Hypothermia (due to loss of subcutaneous fat).
Chronic diarrhea with or without vomiting
Recurrent infections (OM,UTI,bronchopneumonia).
Associated deficiency of iron, Vit A and D.
BUT
NO edema,
NO dermatosis,
NO hair changes,
NO fatty infiltration of the liver.
 Chemical finding
Plasma protiens are normal
Blood urea is low
Blood glucose level is low
Serum enzymes and menerals are within
normal
Iron deficiency anaemia
 Laboratory tests adapted from the WHO
:include the following

1. Blood glucose: Hypoglycemia <3 mmol/L.

2. blood smears by microscopy or direct
detection test: Presence of parasites is
indicative of infection. Direct test is suitable
but expensive.
3. Hemoglobin: < 40 g/L is indicative of severe
anemia.
4. Urine examination and culture, Multistix:
More than 10 leukocytes HPF is
indicative of infection. Nitrites and
leukocytes are tested on Multistix also.
5. Stool examination by microscopy: Parasites and blood
are indicative of dysentery.
6. Albumin: it is a guide to prognosis; if albumin < 35 g/L,
protein synthesis is massively impaired.
7. HIV test: HIV test should not be routinely performed; if
completed, it should be accompanied by counseling of the
child's parents and the result should be confidential.
8. Electrolytes: Measuring electrolytes is rarely helpful and
it may lead to inappropriate therapy. Hyponatremia is a
significant finding.
Chest X-ray
Pneumonia causes less shadowing of the lungs in
malnourished children than in well-nourished
children
Vascular engorgement is indicative of heart failure
Bones may show rickets or fractures of the ribs
Skin test for tuberculosis Often negative in children
with tuberculosis or those previously vaccinated
with BCG vaccine
Knee X-ray
 Complications

1. Complications of diarrhea: dehydration,

electrolytes and acid- base disturbance.
2. Infections: thrush stomatitis,
bronchopneumonia, empyema, TB and UTI.
3. Purpura and bleeding diathesis: due to
vascular fragility, Vit K deficiency and DIC .
4. Hypoglycemia.
5. Hypothermia.
6. Mental sub normality due to early
prolonged malnutrition.
 Causes of death

1. Dehydration & electrolyte disturbance.

2. Infections particularly
bronchopneumonia.
3. Hypothermia.
4. Severe hypoglycemia.
 KWASHIORKOR
 Means the deposed child that is not longer
suckled.
 It is severe form of PEM occurring principally
in the weaning and post-weaning period when
the diet is persistently deficient in essential
proteins.
 Etiology
1. Dietary inadequacy: when there is rapid transition
from the balanced diet supplied by the breast milk to an
unbalanced inadequate diet, which consists mainly of
CHO and deficient in proteins of good biologic value.
2. Impaired absorption of proteins such as in
chronic diarrheal states.
3. Abnormal losses of proteins in proteinuria
(nephrosis), infections, hemorrhage and burns.
4. Failure of protein synthesis such as in chronic
liver disease.
5. Acute infections e.g. acute infantile diarrhea and
measles can precipitate the appearance of Kwashiorkor
due to the catabolic effect of infection, anorexia & the bad
habit of withholding food during measles and diarrhea up
to the degree of starvation.
6. Malaria and severe helminthes infections .
 Clinical manifestations
They are divided into 3 groups:
1. Constant or cardinal manifestation.
2. Usual manifestation.
3. Occasional manifestation.
 The Constant manifestation
1)Edema:
most constant clinical sign of kwashiorkor.
starts in the feet & legs then becomes generalized.
It is pitting and dependent
The cheeks become bulky, pale and waxy in appearance (doll- like
cheeks).
Ascites is unusual.
2)Growth failure:
wt is 60-80% of the expected wt for age.
The length, head circumference and bone age are also retarded.
3) Disturbed muscle/ fat ratio:
There is generalized muscle wasting with preservation of some
subcutaneous fat. This can be demonstrated clinically by
measuring the M.U.A.C that is diminished in these cases.
The children are often weak, hypotonic and unable to stand and
walk.
4)Children are apathetic, irritable, weak and inactive. They lack
interest in the surroundings, do not move, look sad, weak cry and
never smile.
 The usual manifestation
1)Hair changes:
Hair is sparse (temples and occipital regions). Dispigmented
(hypochromotrichia), due to deficiency in pantothenic
acid ,sulfur containing aa (cysteine and methionine), defect
in melanin formation. .atrophic, easily puluckable and lose
its curl and tapered near the scalp
Flag sign : bands of lighter & darker zones in the hair when it is combed.

2) G.I.T manifestation:
. Anorexia and vomiting are usual in severe cases.
.Diarrhea is common and is due to:
i- Infection with intestinal pathogens or parasites.
ii- Reduction of intestinal and pancreatic enzymes lead to
inadequate digestion of food and passage of loose stools.
iii- Malabsorption of fat, CHO and minerals.
iv- Disaccharidase deficiency leads to fermentative diarrhea
v-Defect in conjugation of bile salts  Malabsorption of lipids.
 The occasional manifestation
A) Skin changes:

* Dermatosis: seen on the buttocks, perineum, inguinal

region, back of the thighs and axillae.
* hyperpigmentation desquamate hypopigmented skin
or even ulceration.
* weeping dermatitis resembling burns may be seen.
*Dermatitis of kwashiorkor is pathognomic and may be due to
deficiency of essential amino acids, Vit A, niacin and zinc.
* Fissures behind the ear, angular stomatitis and petechiae
(particularly over the abdomen)
B) Hepatomegaly:
This is due to fatty infiltration of the liver. It is due to:-
* Increased mobilization of free fatty acids from
adipose tissue to the liver.
* Decreased oxidation of fatty acid in the liver.
* Decrease synthesis of apolipoproteins  decrease
release of fat from the liver.
C) Anemia:
It is multifactorial due to deficiency of proteins, iron,
zinc, copper, folic acid, Vit A, E, B1, B12 and/or C.
So anemia of PEM could be:-
Hypochromic microcytic due to iron deficiency.
Megaloblastic due to folic acid and Vit B12 deficiency.
Dimorphic due to combination of the above
mentioned two factors.
Aplastic rarely occur in severe malnutrition due to
inhibition of the bone marrow.
D) Associated deficiencies
of vitamins, minerals and trace elements. (Vit A, D,
C, K, riboflavin, niacin, thiamin, iron, zinc, cobalt.

E) Poor resistance and liability to infections:

*Which is due to defect in phagocytic and complement
system, reduced number of circulating T- lymphocytes
and markedly defective cell mediated immunity.
*Humoral immunity is less affected, natural barriers
are impaired due to Vit A deficiency which affects
epithelium leading to defective secretions of mucus,
lysozymes, IgA and HCL in stomach.
*Common sites of infections include ear, chest, urinary
tract and GIT.
 Biochemical findings
1. Reduced total plasma protiens(< 4 g/dl)
Reduced plasma albumin ( < 2 g/dl ) with reversed
alb/glob ratio .
2. Reduction of serum amino acids
3. Serum enzymes are low
4. Urea markedly reduced
Complications of kwashiorkor
The same as marasmus in addition to
Septicaemia
Heart failure, which may be iatrogenic due to
overload by excess IV fluids, plasma and blood
transfusion.
Dehydration & Electrolyte imbalance as
hypokalaemia.
Jaundice
Blindness due to Vit A deficiency.

Causes of death
Same as in marasmus.
 MARASMIC
KWASHIORKOR
It is syndrome, which has the
characteristics of both marasmus and
kwashiorkor and considered as an
intermediate form b/w the two, happening
usually on top of marasmus.
 Clinical Manifestations
Growth failure as the body wt is <60% of the
expected wt for age.
Loss of subcutaneous fat from the abdominal
wall, thigh, buttocks and shoulders.
Marked wasting of muscles.
Edema of feet, legs and dorsum of hands.
Others as psychological changes, dermatosis
and hair changes.
 UNDERWEIGHT

The underweight child is characterized by

failure to thrive as judged by retarded
growth and development.
In addition, sign of infection and anaemia
may be present.
 Clinical Manifestations
1. Growth failure as the body wt is 80% of the
standard for age. There is slowing in the
linear growth (height) and delayed bone
maturation.
2. Infection: gastroenteritis, pneumonia,
measles, malaria, hookworm infections and
schistosomiasis.
3. Anaemia due to deficiency of iron, folic acid
and proteins.
4. Retardation of development (retarded
milestones).
5. Diminished activities and restlessness.
 The most common and clinically
significant deficiencies of
micronutrients include the following:
 Iron - Fatigue, anemia, decreased cognitive
function, headache, glossitis, and nail changes

 Iodine - Goiter, developmental delay, and

mental retardation
 Vitamin D - Poor growth, rickets, and
hypocalcaemia
 Folate - Glossitis, anemia (megaloblastic), and
neural tube defects (in fetuses of women
without folate supplementation)

 Zinc - Anemia, dwarfism, hepatosplenomegaly,

hyperpigmentation and hypogonadism,
acrodermatitis enteropathica, diminished
immune response, poor wound healing
Vitamin A - Night
blindness, xerophthalmia,
poor growth, and hair
changes
 Evaluation of the
malnourished child

Take history --------- identify risk factors

Examine the patient
Classify the pt
Start treatment
 Important points
Growth charts*

:Clinical examination*
MUAC
Head/chest circumference ratio
 MANAGEMENT OF PEM

Objectives:
A)Child:
1. To treat the life threatening conditions.
2. To deal with the complications.
3. To identify & treat other problems e.g vaccination.
B) Mother:
TO identify –ve attitudes & wrong or none active
practices, and try to teach her about all of these
and about early management of diarrhoea at home
and to know her strength (financially), which usually
solved at the community level e.g. income-
generating acts.
How to manage this child: (W.H.O)

Management divided into 3 phases:

1. Stabilization {Initial treatment}: include
treatment of life threatening conditions, specific
deficiencies are corrected, metabolic abnormalities are
reserved, and feeding is begun.
2. Rehabilitation: intensive feeding, emotional and
physical stimulation, mother is trained to continue care at
home.
3. Follow up: to prevent relapse.
 Initial treatment
Begin with admission and lasts until the child’s condition is
stable and the appetite has returned (usually 2-7
days).
*If longer than 10 days this indicate failure to respond.
*Principle tasks during initial treatment:
1. Treat & prevent hypoglycaemia.
2. Treat hypothermia.
3. Treat & prevent dehydration & electrolyte imbalance.
4. Treat septic shock if present.
5. Start to feed the child.
6. Treat infections.
7. Treat other problems ( Vitamins deficiency, severe anaemia,
heart failure).
A) Hypoglycaemia:
Common in malnourished with serious
infections (<54mg/L). The signs are lethargy,
sweating, convulsions and loss of
consciousness. It could be prevented by
giving the child regular frequent meals.
Treatment:
*If the pt is conscious and able to drink give 50 ml of
10% glucose or sucrose.
*If the pt is unconscious give 5 ml/kg 10% glucose IV
followed by 50 ml of 10% glucose by NG tube
B) Hypothermia:
It is rectal temperature < 35.5 C or axillary <35 c. It is
common with hypoglycaemia and infections.
Treatment:
Prevented by admission of frequent diet and breast feeding &
keeping the pt in warm (put child on mother’s bare breast or
abdomen and cover them with warm blanket).
C) infection :
The child should immediately be given broad
spectrum antibiotics
First-line treatment

Children with no apparent signs of infection and no

complications
 Cotrimoxazole (25 mg of sulfamethoxazole + 5 mg
trimethoprim/kg) orally BD for 5 days.

Children with complications (septic shock, hypoglycaemia,

hypothermia, skin infections, respiratory or urinary tract
infections, or who appear lethargic or sickly)
 Ampicillin, 50mg/kg IM or IV Q6 for 2 days, followed by
amoxicillin,15mg/kg orally Q8 5 days
(if amoxicillin is unavailable, give ampicillin,25mg/kg orally every 6
hours) and
 Gentamicin, 7.5 mg/kg IM or IV once daily for 7 days.
D) Rehydration:
Diagnosis of severe dehydration is difficult .assessment
should include
1)pulse 2) BP 3)urine output 4) thirst
Dehydration in malnourished pt should be corrected within
12 hours (to avoid rapid introduction of electrolytes which lead to
cerebral edema).
Whenever possible, rehydration should be orally. IV
infusion should be used only when there are signs of
shock.
Severely malnourished children have low potassium &
high sodium so ORS should contain less sodium & more
potassium. Magnesium, zinc, copper should also be
added.
In malnourished child special rehydration solution for
malnourished child used. ( RESOMAL).
How can we make RESOMAL?

1 envelope ORS
+ 2 liters water
+ 50 gm. sugar
+ 40 ml Electrolyte/mineral solution
= ORS in 2L water with added potassium
Give Resomal orally
1. give 5 ml/kg every 30 minutes for the
first 2 hours
2. Then give 5-10 ml/kg/hour for the next
4-10 hours
How to give RESOMAL?
*If the child is able to drink, RESOMAL is
given by spoon every few minutes.
*Exhausted child is given by NG tube.
Intravenous rehydration
Use one of the following solutions (in order of
preference):

 half-strength Darrow’s solution with 5%

glucose (dextrose)
 Ringer’s lactate solution with 5% glucose
 0.45% (half-normal) saline with 5%
glucose.
During the blood transfusion, nothing else
should be given, so as to minimize the
risk of congestive heart failure

If there is any sign of congestive heart

failure (e.g.distension of the jugular veins,
increasing respiratory rate or respiratory
distress), give a diuretic and slow the rate
of transfusion
 MACRONUTRIENTS
Consist of high caloric diet & high
biological value protein

High caloric diet:

Start with dietary formula F 75, then
shift to100
But if dietary formulas are not
available make kwash milk yourself
 DIETARY FORMULAS
Named according to it’s caloric content
used in different steps of management
given in frequent feeds
prepared from :water+ milk powder(or full
cream cow’s milk)+ sugar + oil +
electrolytes/meneral solution .{soy oil used
in cases of lactose intolerance}
 F- 75 (starter formula)
Used in stabilization phase
Start with small , frequent feeds
Orally or NGT
130ml/kg/day with increase of feed volume gradually
days frequency vol/kg/feed vol/kg/d
1-2 2-hourly 11ml 130ml
3-5 3-hourly 16ml 130ml
6-7+ 4-hourly 22ml 130ml
Within 7 days pt shift to cath-up formula
 Catch-up formulas
Start when the pt appetite is improved
Replace F75 with F100 and increase
every successive feed by 10 ml until
some feed uneaten
Monitor for sign of heart failure ( RR,PR)
If RR increase by 5/min or PR increase by
25 /min for successive 4- hours readings
reduce the volume per feed
 KWASH MILK

1- milk (cow or even powder milk  500ml = 325Kcal.

2-Vegetable oil  15g = 135 Kcal.
3-Sugar  25g = 100Kcal.
* In the past 1 egg 70Kcal= 7-8g protein added to kwash milk,
now this has been stopped for fear of salmonellosis.
500 ml kwash milk - 560Kcal (112 Kcal/100ml)
SO approximately (1ml of kwash milk = 1Kcal)
*While the kwash milk give 112Kcal/100ml & the breast milk gives
65-66Kcal/100ml
*So the kwash milk has double the amount of Kcalories of each of
the cows milk or breast milk
 Cow milk 500ml
.325Kcal

Sugar 25g Vegetable oil

100Kcal 15g

Kcal 135
500ml = 560Kcal l
DOSE CALCULATION:
* The daily requirements of calories for normal growth
is 90Kcal/kg/day
*The daily requirements of protein for normal growth is
3-5g/kg/day
*In malnourished child, this amount should be
increased to reach the catch-up period ( high velocity
growth period during which the child should grows rapidly to reach the
expected wt).
*in this period use the average wt to calculate the dose:
AVERAGE Wt = Actual wt+ expected wt
2
Here the wt start to increase gradually till it reach the expected
wt .
If weight gain is:
* poor(<5g/kg/d) child required full
reassessment
*moderate (5-10g/kg/d) check whether
intake targets are being met or if infection
has being overlooked
*good (>10g/kg/d) continue to praise staff
and mothers
 Desirable daily Electrolytes intake during initial
phase
of treatment
Amount per kg of body weight

Zinc 30mmol (2.0mg)

Copper 4.5mmol (0.3mg)
Selenium 60 nmol (4.7mg)
Iodine 0.1mmol (12mg)

Sodium 1.0 mmol (23 mg)

Potassium 4.0 mmol (160 mg)
Magnesium 0.6 mmol (10 mg)
Phosphorus 2.0 mmol (60 mg)
Calcium 2.0 mmol (80 mg)
Treatment of Vit A deficiency:
0-6months  50,000 IU of Vit A
6-12 months  100,000 IU of Vit A
>12 months  200,000 IU of Vit A

Dose in day 0, 1 then day 7 or day 1,2 then day 8.

Prophylaxis: from birth up to 5 yrs one tablet every 6 months,
according to age as above. Plus food sources of Vit A as
fish, milk, egg & green vegetables.
Other problems
Management of severe anaemia:
If Hb less than 4g/dl or PCV less than 12% the
child has severe anaemia which can cause
heart failure . Give 10ml/kg of packed red cells
or whole blood slowly over 3 hrs.

Management of congestive heart failure

Occur as a complication to over hydration,
very severe anaemia & high sodium diet,
when due to fluid over load stop oral & IV
fluids also give diuretics as furosemide.
 Rehabilitation phase
This phase begins when the child appetite
return.
Continue feeding
Encourage breast feeding.
Stimulate emotional & physical development.
Prepare the mother to look after the child
following discharge.
Vaccinate the child if not or partially vaccinated.
Signs of recovery

Return of psychomotor changes i.e returns of

social behaviour ( change of mood, no

irritability, smiling with mother & react with

surrounding).
Appetite improvement
Gaining weight in marasmic patient & losing
wt in Kwash pt due to subsiding of edema.
Improvement of hepatomegaly
*After that the mother is given ROAD GROWTH
CHART( for growth monitoring from 0-5 yrs)
targeting the illiterates & mothers in deprived areas
which contains GOBIAF (Growth, ORS, Breast
feeding, Immunization, Vit A & supplementary
Feeding)
*Then discharge the child and send him to
rehabilitation center to teach the mother how to
prepare the child meal within her family meal.
 Criteria for discharge
Child
1. Appropriate weight for height (-1 SD)
2. Eating well and gaining weight
3. Infections properly treated
4. Immunization started
Mother
1. Able to look after the child
2. Able to prepare appropriate food
3. Able to provide home treatment for
diarrhea
4. Able to recognize the signs that mean
she must seek medical assistance
 Follow up
At each visit, the health worker must be sure
that all the points mentioned above are
assessed.
The child must be measured, weighed, and
the results recorded.
Immunization should be performed according
to national guidelines.
Because risk of relapse is greatest soon after
discharge, the child should be seen after 1
week, 2 weeks, and 1 month.
THANK YOU