Malnutrition

Both the number of people affected by malnutrition and highest prevalence of wasting occur in lower-middle-income countries

Aetiology

• Lack of access

• Poor feeding practices

• Infection

Clinical presentation

Kwashiorkor - protein energy malnutrition from only having carbs resulting in oedema

Marasmus - characterized by energy deficiency resulting in low body weight

Investigations

Diagnosis of severe acute malnutrition (kwashiorkor or marasmus)

• Mid-arm circumference <115mm

• Weight for height under 3SD

• Oedema of both feet

Management

Criteria for inpatient or outpatient care

• Children who are identified as having severe acute malnutrition should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite

• Children who have appetite and are clinically well and alert should be treated as outpatients
• Investigate cause
• Vitamin A
• De-worm
• Ready to use therapeutic food (RUTF) - peanut butter, dried milk, vitamins and minerals
• Check vaccinations

• Children who have medical complications, severe oedema, or poor appetite or present with one or more danger signs should be treated as inpatients (as below)

Inpatient management

• Management is the same for kwashiorkor and marasmus

• Involves 10 steps in 2 phases - initial stabilisation and rehabilitation

• All severely malnourished children are at risk of hypoglycaemia - give a feed or 10% glucose/sucrose immediately on admission

• All children with hypothermia should be treated routinely for hypoglycaemia and infection

• Dehydration tends to be overdiagnosed - do not use IV route for rehydration except in shock, rehydrate slowly (orally or NG tube) with a special rehydration solution for malnutrition ReSoMal (ORS not suitable for severely malnourished children)

• Early iron aggregates infection so avoided until rehabilitation phase

• Keep breastfeeding if able but also initiate feeding with F75 milk then catch up with F100