Management of malnutrition

1. Initial Treatment of
Malnutrition

2. Follow WHO Guidelines
–1. Treat/prevent hypoglycaemia
–2. Treat/prevent hypothermia
–3. Treat/prevent dehydration
–4. Correct electrolyte imbalance
–5. Treat/prevent infection
–6. Correct micronutrient deficiencies
–7. Initiate re feeding
–8. Facilitate catch-up growth
–9. Provide sensory stimulation and emotional
support
–10. Prepare for follow-up after recovery

3. Hypoglycemia
–<54mg/dl
–Imp cause of death in first 2 days of treatment
–To prevent, child should be feed every 2 or 3 hours day
and night.
–Signs: hypothermia,lethargy,limpness, LOC.
–Treatment:
•If conscious: give 50 ml of 10% D/W or F-75 diet by mouth
(whichever is available)
•If not conscious: 5ml/kg of 10% D/W I/V then 50 ml 10 %
D/W by NG tube.
•When gains consciousness then immediately start F-75 diet or
glucose in water (60g/l)
•Continue frequent diets to prevent recurrence
•Should also be treated with broad spectrum antibiotics.

4. Hypothermia
–Rectal temp. <35.5 C (95.5 F) or axillary temp 35 C (95
F)
–Temp should be measured ½ hrly during rewarming
–All hypothermic should also be treated for
hypoglycemia.
Dehydration and septic shock
–Difficult to differentiate in severely malnourished
–Dehydration tends to be over diagnosed and its severity
over estimated
–Some :5% wt loss
–Severe : 10 % wt loss

5. Reliable points
–History of diarrhoea
–Thirst
–Hypothermia
–Recent sunken eyes
–Weak or absent radial
pulse
–Cold hands and feet
–Urine flow
Not reliable points
–Mental status
–Mouth tongue tears
–Skin elasticity
Incipient septic shock
–Limp, apathic,
anorexic
Developed septic
shock
–Engorged superficial
veins
–Engorged lung vein
leading to resp. distress
cough, grunting,
groaning
–Liver, kidney, cardiac
failure
–Hemet emesis, blood in
stool, abd distension.

6. Treatment of dehydration
Whenever possible should
be rehydrated orally. IV
infusion easily causes
overhydration and heart
failure should only be
used when definite signs
of shock
RESOMAL
(Recommended ORS
solution for severely
malnourished
children)
ComponentRESOMAL
(mmol/l)
Reduced
osmolarity
ORS
Glucose 125 75
Sodium 45 75
Potassium 40 20
Chloride 70 65
Citrate 7 10
Magnesium 3 ----
Zinc 0.3 ----
Copper 0.045 ----
Osmolarity 300 245

7. How to prepare
–Commercially available
–One pack of standard ORS in 2 litre of water +50 gm
sucrose + 40 ml mineral mix solution.
Amount
–70-100 ml/kg in 12 hour
–5 ml/kg every 30min in first 2 hours orally or NG then
5-10ml/kg per hour
–Add acc. to loss in stool, vomiting. Add 50-100ml after
every stool for under 2 years of age and 100-200ml for
older children
–Immediately stop if signs of overhydration
appears( Resp rate & pulse rate increase, engorged
jugular veins, puffy eyelids)
–Rehydration completed : if no thist, urine passed, signs
of dehydration disappeared.

8. How to give
–Sip by sip or spoon every few minutes.
–If exhausted then NG
–NG should be used in all children who are exhausted, weak
enough, who vomit, have fast breathing, stomatitis.
IV rehydration
–Only indication in circulatory collapse
–Use in preference
•1- Half strength Darrow’s solution with 5%glucose
•2- R/Lactate with 5% glucose
•3- 0.45% ( Half normal) saline with 5%glucose
–Give 15ml/kg over 1 hr monitor for overhydration
–Meanwhile continue NG RESOMAL (10ml/kg per hr)
–If still severely dehydrated afer 1
st
bolus then repeat IV 15ml/kg
over 1 hr and switch to RESOMAL.
–If still no improvement then consider septic shock and treat
accordingly.
Feeding
–Continue feeding during rehydration. Start F-75 diet orally or NG
as possible within 2-3 hrs after starting rehydration.
–Diet and RESOMAL are given in alternate hrs.

9. Treatment of septic shock
Who should be treated as septic shock
–Signs of dehydration without history of diarrhoea
–Hypothermia, hypoglycemia
–Edema and signs of dehydration
Immediately give broad spectrum antibiotics, treat
hpothermia,hypoglycemia.
Incipient septic shock
–Fed promptly, use F-75 with mineral mix.
–As these children are anorexic, so use NG.

10. Developed septic shock
–Begin IV rehydration immediately 15ml/kg in 1 hr.
continously observe for overhydration. As soon as radial
pulse become palpable start orally or NG.
–If signs of congestive heart failure develop or does not
improve after 1
st
hr, give blood transfusion(10ml/kg) iover at
least 3 hrs.
–If blood is not available, give plasma.
–If there are signs of liver failure ( purpura, jaundice, tender
hepatomegaly), give a single ose of 1 mgVit K IM.
–During the blood transfusion, nothing should else be given,
to minimize risk of congestive heart failure. If there is any
sign of congestive heart failure( distension of jugular veins,
increasing resp rate or resp distress), give a diuretic and slow
rate of transfusion.
–After transfusion begin F-75 diet by NG. If child develops
increasing abd. Distension or vomit repeatedly give the diet
slowly if problem does not resolvr, stop feeding the child
give fluid at rate of 2-4ml/kg per hour.
–Also give 2ml of 50% Mg sulphate IM.

11. Dietary Treatment
Formula diets
–Two formula diets, F-75 and F-100.
–F-75 (75kcal/100ml) is used during initial phase of
treatment.
–F-100 (100kcal/100ml) is used during rehabilitation phase,
after the appetite has returned
How to prepare
Ingredient Amount
F-75 F-100
Dried skimmed milk 25gm 80gm
Sugar 70gm 50gm
Cereal flour 35gm ----
Vegetable oil 27gm 60gm
Mineral mix 20ml 20ml
Vitamin mix 140mg 140mg
Water to make 1000ml 1000ml

12. Mineral mix solutionVitamin mix
Substance Amount
Potassium chloride89.5gm
Tripotassium citrate32.4gm
Magnisium chloride30.5gm
Zinc acetate 3.3gm
Copper sulfate 0.56gm
Sodium selenate 10mg
Potassium iodide 5mg
Water to make 1000ml
Substance Amount per lt
of liquid diet
Water soluble
Thiamine (B1) 0.7mg
Riboflavin (B2) 2.0mg
Nicotinic acid 10mg
Pyridoxine (B6) 0.7mg
Cyanocobalamine (B12) 1 µg
Folic acid 0.35mg
Ascorbic acid( Vit C)100mg
Pantothenic acid (B5) 3mg
Biotin 0.1 mg
Fat soluble
Retinol( vit A) 1.5mg
Calciferol (vit D) 30 µg
Tocopherol (vit E) 22mg
Vit K 40 µg

13. Composition
Constituents Amount per 100 ml
F-75 F-100
Energy 75kcal 100kcal
Protein 0.9gm 2.9gm
Lactose 1.3gm 4.2gm
Potassium 3.6mmol 5.9mmol
Sodium 0.6mmol 1.9mmol
Magnesium 043mmol 0.73mmol
Zinc 2.0mg 2.3mg
Copper 025mg 0.25mg
Percentage of energy from
Protein 5% 12%
Fat 32% 53%
osmolarity 333mOsmmol/l 419mOsmol/l

14. How to give feed
–To avoid avoid overloading intestine, liver, kidneys;
frequent and small feeds should be given. Every 2,3 or
4 hourly, day and night.
–If can’t take orally, then use NG.
–If vomiting occurs, then amount and interval should
be reduced.
–F-75 diet should be given during initial phase.
–Child should be given at least 80kcal/kg but not more
than 100kcal/kg.
–If <80kcal/kg per day are given, tissue will continue to
break and child will deteriorate.
–And if >100kcal/kg per day are given, then child may
develop serious metabolic imbalance.

15. Amount of diet to give at each feed to achieve a daily
intake of 100kcal/kg.
Weight of child
(Kg)
Volume of F-75 per feed (ml)
Every 2 hr
(12 feeds)
Every 3 hrs
(8 feeds)
Every 4 hrs
(6 feeds)
2 20 30 45
3 35 50 65
4 45 70 90
5 55 80 110
6 65 100 130
7 75 115 155
8 90 130 175
9 100 145 200
10 110 160 220

16. Child should be fed with cup and spoon, not by feeder as
it is an important source of infection.
Very weak may be fed using a dropper and syringe.
NG feeding
–Many children will not take sufficient diet by mouth during first
few days of treatment due to poor appetite, weakness,
stomatitis.such patients should be given thru NG tube.
–At each feed,the child should first be offered the diet orally.
After the child has taken as much he or she can, the remainder
should be given thru NG.
–NG should be removed when child is taking ¾ of day’s diet
orally, or takes 2 consecutive feeds fully by mouth.
–If next 24 hrs child fails to take 80kcal/kg then reinsert tube.
–And if child develops abd distension during NG feed, give 2 ml
of Mg sulfate IM.
–NG should be always aspirated before feeds Are administered.
–Should be passed by trained staff to avoid aspiration

17. THE INITIAL PHASE OF TREATMENT ENDS
WHEN THE CHILD BECOMES HUNGRY.
This indicates that
–Infections are under control
–Liver is able to metabolize diet
–Other metabolic abnormalities are improving.
–Child is now ready to begin rehabilitation phase.
This usually occurs after 2-7 days of treatment.
While children with complication takes longer time while
some are hungry from the start and can be shifted to F-
100.
Replace the equal amount of F-75 diet with F-100 for 2
days before increasing the volume.
Type of feed given, amount offered and taken date time
must be recorded accurately after each feed. If child
vomits, the amount lost should be noted in terms of whole
feed, half of feed etc.

18. Treatment of infection
Nearly all severely malnourished children have bacterial infections
when first admitted. LRTI is especially common. Unlike well
nourished children, who respond like fever and inflammation,
malnourished children with serious infection may only be drowsy
and apathetic.
Early anti microbial treatment improves nutritional response, prevent
septic shock, reduce mortality.
These are divided into
–First line treatment.
•Which is given empirically to all.
•Co-trimoxazole BD 5 Days
•Ampicillin 2 days then amoxicillin for 5 days
•Gentamycin 7 days
–Second line treatment
•If no response, add chloramphenicol for 5 days.
•If specific infection is detected like dysentery, candidiasis, malaria, intestinal
helminthiasis, then treat accordingly
•Tuberculosis is also very common, ATT should be given only when TB is
daignosed.
–Measles and other viral infections
•All should be given measles vaccine on admission and on discharge

19. Vitamin deficiencies
Vitamin A deficiency
–Signs of vit A def
•Night blindness
•Conjuctival xerosis
•Bitot’s spots
•Corneal xerosis
•Corneal ulceration
•Keratomalacia
Other vitamin def
–Folic acid should be given to all ( 5mg on day 1and
then 1mg daily.
–While other vit are added in vitamin mix solution.

Timing Dosage
Day 1
<6 months 50,000IU
6-12 months100,000IU
>12 months 200,000IU
Day 2 Repeat same dose
2 weeks later Repeat same dose

20. Treatment of severe anemia
If Hb is less than 4gm/dl or packed cell volume is less
than 12 %, the child has severe anemia which can cause
heart failure.
Needs immediate blood transfusion. Give 10ml/kg of
packed red cell or whole blood slowly over 3 hrs
Don’t give iron during initial phase, as it can have toxic
effects and may reduce resistance to infection.

21. THANKS