2. DEFINITIONS
Malnutrition refers to deficiencies or excess or
imbalances in a person’s intake of energy and or
nutrients required for body's demand for them to
ensure growth, maintenance, and specific functions
( WHO, 2016)
It covers 2 broad categories
Under nutrition: Results from not getting enough
proteins, calories or micronutrients to meet the
metabolic demands of the body
Over nutrition: Results from getting too much proteins,
calories or micronutrients than what the body requires.
3. UNDER NUTRITION
It is a major public Health concern in Uganda that
affects both children and adults
It is estimated that 6% of Ugandan children have
acute malnutrition, 2% of them have SAM
> 40% of acutely malnourished children present to
health facility have HIV.
4. UNDER NUTRITION…
It can be acute (recent) or chronic ( long term)
There are 4 forms of under nutrition
Acute malnutrition
Stunting
Under weight
Micronutrient deficiencies
The 4 forms can be categorized as either moderate or
severe.
5. UNDER NUTRITION
PEM: it is a group of body depletion disorders
which include kwashiorkor, marasmus and the
intermediate stages
MARASMUS: represents simple starvation . The
body adapts to a chronic state of insufficient caloric
intake
KWASHIORKOR: it is the body’s response to
insufficient protein intake but usually sufficient
calories for energy.
6. Most often features of marasmus and kwashiorkar
overlap.
Henceforth, Jellife suggested PEM to include both
enteties
Due to the over lapping, acute oedematous and acute
non oedematous malnutrition has been used to describe
severe forms of PEM
7. Underweight : weight for age < -2SD of the median
age-sex specific weight of the NCHS/WHO
reference
•Stunting: height for age < -2SD of the median age-
sex specific height of the NCHS/WHO reference
•Wasting: Weight for height <-2SD of the median
weight at a given height of the NCHS/WHO
reference
8. WHO CLASSIFICATION OF PEM
MODERATE
MALNUTRITION
SEVERE
MALNUTRITION
Symmetrical edema NO YES
[edematous
malnutrition]
Weight for height -3 < SD-score <-2d
(70–79%)
SD-score <-3 (<70%)
[severe wasting]
Height for age -3 < SD-score <-2
(85–89%)
SD-score <-3 (<85%)
(severe stunting)
10. AETIOLOGY OF PEM
Several combinations of factors can lead to PEM in
children:
Social and Economic Factors
Biological factors
Environmental factors
11. PEM IN SUB-SAHARAN AFRICA
PEM in Africa is related to:
The high birth rate
Subsistence farming
Overused soil, draught & desertification
Pets & diseases destroy crops
Poverty
Low protein diet
Political instability (war & displacement)
12. ROLE OF INFECTIONS
Infections play a role in the causation of malnutrition
by:-
Decreasing intake
Causing malabsorption
Metabolic losses during infections
Frank protein losing enteropathy
13. PEM AFFECTS VIRTUALLY ALL ORGAN SYSTEM
CVS
Heart size may be reduced
C.O and SV reduced
Blood pressure reduced
Caution: -IV fluids –only in shock
-Blood transifusion if in severe anemia
14. Liver –
protein synthesis reduced
gluconeogenesis is reduced
risk of hypoglycemia
bile secretion is reduced
ability to excrete toxins reduced
caution: - small fragment meals
- sufficient carbohydrate
- No Fe supplements
15. GUT:
Glomerular filtration reduced
Na excretion reduced
UTI common
Caution:- restrict dietary Na+
GIT:
Intestinal motility is reduced
gastic acid production reduced
exocrine pancrease reduced
villi atrophy
16. IMMUNE SYSTEM
All aspects of immunity diminished
Impaired cell mediated immunity due to thymus
atrophy
Reduced Secretory levels of IgA
Components of complement except C4 are low
Lysozyme content in leucocytes is reduced
Granulocyte and lymphocyte suppression due to
reduced hematopoiesis
Phagocytic and bactericidal activity of leucocytes
is reduced ( energy is needed for phagocytosis)
17. ASSESSMENT OF UNDER NUTRITION
Under nutrition is identified through anthropometric
measurements, clinical signs and biochemical tests
The body measurements are compared to
reference value.
18. NUTRITION INDICATORS
Mid upper arm circumference (MUAC)- a marker of
wasting
Weight for height (WFH)- Marker of wasting
Height for age (HFA) –Stunting
Weight for age -(Under weight)
19. MEDICAL HISTORY:
• Usual diet before current episode of illness
• Breastfeeding history
• Food and fluids taken in past few days
• Recent sinking of eyes
• Nature, duration and frequency of vomiting /
diarrhoea,
• Time when urine was last passed
• Contact with people with measles or tuberculosis
• Any deaths of siblings
• Birth weight
• Milestones reached
20. PHYSICAL EXAMINATION:
Weight and length or height. MUAC
Edema/ severe pallor/ signs of dehydration/ tepm
instability
Eyes: drynes, conjunctival/corneal lesions
Ears, mouth, throat: evidence of infection
Skin: evidence of infection or purpura
21. Enlargement or tenderness of liver, jaundice
Abdominal distension, bowel sounds, “abdominal
splash”
Signs of circulatory collapse: cold hands and feet,
weak radial pulse, diminished consciousness
Respiratory rate and type of respiration: signs of
pneumonia or heart failure
22. INVESTIGATIONS
TEST RESULT/SIGNIFICANCE
Blood glucose Glucose concentration <54 mg/dl (3 mmol/l) is indicative
of hypoglycaemia
B/S for malarial
parasites
Presence of malaria parasites is indicative of infection
Haemoglobin or
packed-cell
Haemoglobin <40g/l or packed-cell volume <12% is
volume indicative of very severe anaemia
Urine culture &
microscopy
Presence of bacteria on microscopy (or >10 leukocytes
specimen per high-power field) is indicative of infection
Stool analysis Presence of blood is indicative of dysentery
Presence of Giardia cysts or trophozoites is indicative
of infection
Chest X ray Pneumonia causes less shadowing of the lungs in
malnourished children. Vascular engorgement is indicative
of heart failure. Bones may show rickets or fractures of the
ribs
24. The ten point management plan
of SAM
hypoglycemia
hypothermia
dehydration
electrolyte imbalance
infection
micronutrient deficiencies
re feeding syndrome ( if no cautious
feeding)
catch-up growth
sensory stimulation and emotional
support
follow-up after recovery
26. Hypoglycemia
Hypoglycaemia- blood sugar less than
3mmol/l, lethargy, hypothermia, LOC.
Secondary to disturbed metabolism,
defective gluconeogenesis and
glycolysis, infections and reduced
appetite
10% dextrose 5ml/kg ,followed by
feed, every 30min and treat infections.
27. Hypothermia
hypothermia- temperature less than
35 degrees centigrade.
RX: Kangaroo care, warm with
blanket ,don't bathe, feed the child,
treat hypoglycaemia, and infections.
Close monitoring, preferably half
hourly.
28. Severe Dehydration:
History of diarrhoea, or vomiting,
infrequent feeds.
No dehydration- resomal 5ml/kg per
motion.
Some dehydration-5ml/kg every
30min,for 2hrs, then alternate with
feed unto 10hrs
29. Severe Dehydration and
shock
Severe dehydration-no shock, 5ml/kg
for 2hrs.
If shock (hypovolemic/septic)- iv
ringers lactate 15ml/kg /hr made up to
5%detrose for up to 2hrs.( mix- 1/2SD
+ 5%Dex in equal proportion)
If no improvement, treat as septic
shock with whole blood and
antibiotics.
30. Infections
For no complications- Give oral
antibiotics ( amoxyl)
For presence of a complication, give
IV antibiotics- ampicillin/gentamycin.
For no improvement after 24hrs, the
switch to chloramphenical.
31. Micronutrient & Electrolyte
◦ Correct micronutrient deficiencies
Multivitamins, folic acid, Vitamin A
Zn acetate 2mg/kg or in Resomal
Cu SO4 0.2mg Cu/kg or in Resomal
◦ Correct electrolyte imbalance
Potassium 2-4 mmol/kg/d
Magnesium 0.3-0.6mmol/kg/d or
resomal and feeds
32. Severe Anemia, Hb< 4g/dl
Look for signs of congestive Cardiac
Failure
If present, stop all fluid in take and
transfuse with packed cells 5-
7ml/kg/over 3 hrs.
If not give whole blood 10ml/kg/over 3
hours
Give a diuretic (frusemide 1mg/kg IV )-
when in CCF.
Avoid giving digoxin.
Do not give iron in phase 1 .
33. Corneal Ulceration:
Caused by deficiency in Vitamin A .
suspect it in case of extremely red
eyes ,bleeding, photo phobia.
Rx- vitamin A days 1 ,2, and 14
Instil one drop of atropine in the
affected eye.
Apply drops of CAF or T.E.O
Bandage the affected eye.
35. Impaired liver & intestinal function + infection
Food must be given in small amounts, frequently
(PO/NG)
Unable to tolerate usual amounts of dietary protein,
fat, Na
Diet low in above, hi in carbohydrates
F-75
75kcal or 315kj/100ml
Initial phase treatment, 130ml/kg/d
Feed q 2-3hr (8 meals/d)
F-100
100kcal or 420kj/100ml
Feed q 4-5 h (5-6 meals/d)
Rehabilitation phase (appetite returned)
36. Composition of F75 & F100
F-75 F-100
Dried skimmed milk 25g 80g
Sugar 70g 50g
Cereal flour 35g -
Vegetable oil 27g 60g
Mineral mix 20ml 20 ml
Vitamin mix 140ml 140 ml
Water 1l 1l
Protein 0.9g 2.9g
Lactose 1.3g 4.2g
K 3.6mmol 5.9mmol
Na 0.6mmol 1.9mmol
Mg 0.43mmol 0.73mmol
Zn 2.0mmol 2.3mmol
Copper 0.25mg 0.25mg
Osmolarity 333mOsmol/l 419mOsmol/l
Energy from protein 5% 12%
Energy from fat 32% 53%
37. Oral feeds.
Provided according to patient’s weight
and requirement of 100kcal/kg/day
including protein.
Record on a milk card as well as
clinical monitoring form (CMF)
Supervise each feed and make sure
child is only fed on F75 and not any
other feed.
38. Phase 2
Transfer to phase 2 when;
Childs appetite has returned
No severe medical complications.
Oedema has began to disappear.
Give F100 only,8 times a day. No
other feeds.
Continue exclusive B/feeding.
39. Phase 3
Change to phase 3 when there is no
oedema , good appetite ,no acute
medical problem , less apathetic.
Aim at gradual weight gain.
Reduce frequency of feeds from 8 to 3,
and have a porridge meal introduced.
Do gradual introduction of family foods.
Start iron supplements and stimulate
child. (play & group education)
40. Discharge.
Ideally, weight for height 85%, MUAC
120mm, no oedema, ascending
weight curve.
In crisis, discharge can be at 80%,
phase two complete, antibiotics
completed, child eating well, gaining
weight.
Schedule follow up, at supplementary
feeding centres.
41. Follow up
First month Every week
Second month Twice monthly
Third month Once monthly
Supplementation of 1500 Kcal /day
42. Prevention:
Growth monitoring
Oral rehydration salts for diarrhoea
Family planning
Immunization
Breast feeding supplemented at 6
months.
Education of individuals
Ensure food security
