Deficiencies, excess or imbalances of energy and/or nutrients leading to wasting (acute) or stunting (chronic).
History taking
- • Feeding history (breastfeeding, weaning), recent illness, growth pattern
- • Diarrhoea, recurrent infections, family socio-economic status
- • Immunisation, deworming, micronutrient supplementation
Examination
- • Weight, height, MUAC, oedema bilateral
- • Look for signs: visible severe wasting, pitting oedema, dermatosis, hepatomegaly, anaemia, vitamin deficiencies
- • Vital signs, hydration
Red flags
- • Severe acute malnutrition (SAM): WHZ < -3, MUAC <11.5 cm, bilateral pedal oedema
- • Medical complications: hypothermia, hypoglycaemia, severe dehydration, sepsis
Differential diagnosis
- • Marasmus, kwashiorkor, marasmic kwashiorkor
- • Coeliac, TB, HIV, malabsorption
Recommended investigations
- • Hb, blood sugar, electrolytes, Mantoux, HIV, urinalysis
- • Stool exam if diarrhoea
Diagnosis
- • WHO classification (SAM vs MAM) based on anthropometry and oedema
Initial treatment / management
- • SAM with complications: inpatient WHO 10-step protocol
- • Uncomplicated SAM: outpatient RUTF (ready-to-use therapeutic food)
- • Treat infection (empirical amoxicillin), micronutrients, deworming
- • Cautious feeding (F-75 then F-100) to avoid refeeding syndrome
Prescription examples
- • F-75 starter formula 130 mL/kg/d in 8 feeds (stabilisation)
- • F-100 or RUTF 200 kcal/kg/d (rehabilitation)
- • Tab Amoxicillin 25 mg/kg PO BD x 5 d (uncomplicated)
- • Vitamin A, folic acid, zinc, multivitamin supplementation
- • Albendazole 400 mg single dose after stabilisation
Follow-up advice
- • Weekly weight, MUAC until recovered
- • Continue nutritional support and counselling
Patient counselling
- • Breastfeeding promotion, complementary feeding after 6 months
- • Hand hygiene, safe water, immunisation
- • Recognise growth faltering early
Referral criteria
- • SAM with complications, infants <6 months with SAM
- • Failure to gain weight after 2 weeks of RUTF
Clinical pearls
- • Beware refeeding syndrome — start feeding slowly, correct electrolytes (esp. K, Mg, PO₄)
- • Hypoglycaemia and hypothermia are common silent killers in SAM
References
- • WHO Guideline: Updates on management of SAM in infants and children 2013
- • IAP National Guidelines on Management of SAM
Educational outpatient guide — verify against local guidelines before clinical use.
