Management of Severe Acute

Malnutrition
JFK pediatric core curriculum

MGH Center for Global Health

Pediatric Global Health Leadership Fellowship
Credits:
Brett Nelson, MD, MPH
Rebecca Bell, MD

Discussion Overview
Defining malnutrition
Physiologic effects of malnutrition by
system
Management of severe malnutrition by
problem
Integrating outpatient management of
severe malnutrition

Causes of Malnutrition

Section 1

From ICH/UNHCR Handout

3

Defining Malnutrition
Malnutrition is diagnosed if one of the following criteria
is met:
Weight-for-height < 70% or <-3 SD
Bilateral pedal oedema
Clinical signs of severe malnutrition

Differentiating between marasmus (characterized by

severe wasting) and kwashiorkor (characterized by
oedema) is not necessary for treatment as many children
display symptoms of both conditions.
It is important to identify the presence or absence of
oedema, as those children tend to do worse than
malnourished children without edema.

From the WHO Management of Severe Malnutrition

Signs of Marasmus

Children with marasmus have severe wasting, particularly of the

arms, shoulders, thighs and buttocks. The lack of adipose tissue
causes skin to hang loosely.

Signs of Kwashiorkor / Oedematous

Malnutrition

This child has oedema of the hands and feet as well as

dermatosis, most prominently on the legs and groin.

Gently press with the thumb, applying pressure to both feet at the same time.
Pitting oedema leaves a small indentation which can be seen and felt

Other Anthropometric Indicators of

Malnutrition
Mid Upper Arm Circumference (MUAC)
Some studies have shown MUAC to be the single best
predictor of mortality in children between 1 and 5
years.
Community volunteers can be easily trained to
measure MUAC.
MUAC is currently recommended for screening in the
community. Children who meet criteria for
malnutrition are referred to a clinic or hospital for
further evaluation.

Measuring
MUAC

Physiological Effects of
Malnutrition By System

Cardiovascular
GI
GU
Immune
Liver
Endocrine
Cellular function
Circulatory/Temperature regulation
Skin, muscles, glands

Cardiovascular System
Effects:
cardiac output and stroke volume
blood pressure
renal perfusion
Concerns:
An increase in blood volume can produce acute heart
failure
A further decrease in blood volume will compromise tissue
perfusion
Management:
If dehydrated, give ReSoMal or F-75
Do not give IV fluids unless child is in shock
If blood transfusion is necessary, restrict to 10 ml/kg and
give a diuretic

Gastrointestinal System
Effects:
production of gastric acid
intestinal motility
production of digestive enzymes secondary to
pancreatic atrophy
secretion of digestive enzymes secondary to small
intestinal mucosa atrophy
absorption of nutrients when large amounts of food
ingested
Management:
Give small, frequent feeds
If fat malabsorption, can give pancreatic enzymes

Genitourinary System
Effects:
glomerular filtration
ability for renal excretion of acid or water load
sodium excretion
urinary phosphate output
incidence of UTI
Concerns:
A large protein load may not be well tolerated by the kidneys
Further protein deprivation will lead to continued tissue breakdown
Management:
Caloric intake should be targeted at 80-100 kcal/kg/day
Avoid nutrients that can lead to an acid load, such as magnesium
chloride
Restrict sodium intake
Avoid excessive water intake

Immune System
Effects:
cell-mediated immunity
secretion of IgA
levels of complement components
efficacy of phagocytes
Atrophy of lymph glands, tonsils, and thymus
inflammatory response and migration of white cells to areas of
tissue damage
Concerns:
Typical signs of infection ( WBC count, fever) are often absent
Hypoglycemia and hypothermia are signs of severe infection
Management:
Although efficacy has been questioned in some studies, current
recommendation is to treat all inpatients with broad-spectrum
antibiotics
In order to decrease risk of cross infection, arrange ward so that
newly admitted children and those with diarrhea are segregated

Liver
Effects:
synthesis of all proteins
bile secretion
ability of liver to take up, metabolize, and excrete toxins
gluconeogenesis
transferrin levels
Concerns:
Risk of hypoglycemia is high, particularly with infection
Management:
Protein intake should be about 1-2 g/kg/day so as to support
synthesis of proteins but not to exceed metabolic capacity of liver
Reduce dosage of meds that are dependent on hepatic metabolism
Ensure sufficient carbohydrate intake to avoid need for
gluconeogenesis
Do not give iron supplements

Endocrine System
Effects:
insulin levels, leading to glucose intolerance
levels of IGF-1
levels of growth hormone
levels of cortisol

Management:
Do not give steroids

Cellular Function
Effects:
synthesis of proteins
activity of sodium pump
permeability of cell membranes
Concerns:
This leads to an increase in intracellular sodium and a
decrease in intracellular potassium and magnesium
Management:
Restrict sodium intake
Give potassium and magnesium to all children

Circulatory System and

Temperature Regulation
Effects:
Heat generation as well as heat loss are impaired
energy expenditure and basic metabolic rate
Concerns:
Child becomes hypothermic in cold environment and
hyperthermic in hot environment
Management:
Keep child dry and warm
Room temperature should be at 25-30 C
If child has fever, cool with tepid water

Skin, Muscles, Glands

Effects:
Skin and subcutaneous fat are atrophied
Atrophy of sweat, tear, and salivary glands
Respiratory muscles are fatigued easily
Concerns:
Typical signs of dehydration (sunken eyes, abdominal
skin pinch) are unreliable due to the loss of
subcutaneous fat
Management:
Rehydrate with ReSoMal when necessary (see protocol)

Inpatient Management Overview

Management phases:

Stabilization phase: defined as the treatment period from

admission to the point where the childs appetite has
returned. Typically lasts 2-7 days.
Rehabilitation phase***: goals for this phase are weight
gain, emotional development, family education, and lack
of oedema, vomiting, diarrhea and fever. Typically,
children are discharged 2-3 weeks after admission.
*** Recent advances in outpatient management have led to a

significant decrease in the length of the rehabilitation phase, and

in some cases, a complete elimination of the phase. Some
institutions instead have a transitional phase where the child
is prepared for discharge after stabilization.

Evaluation at Presentation
Medical history:

Usual diet
Breastfeeding history
Food and fluids in last few days
Time when last urine passed
Duration, frequency, appearance of vomit and diarrhea
Recent sinking of eyes
Contact with TB or measles
Birth weight
Developmental milestones reached
Immunizations

Evaluation at Presentation
Physical exam:

Weight, length
Temperature
Edema
Hepatomegaly, jaundice
Abdominal distension, bowel sounds
Pallor
Signs of circulatory collapse
Thirst
Corneal lesions
Signs of infection in ears, mouth, throat
Inspect skin for signs of infection, dermatosis, purpura
Appearance of stool

Goals for Management of a

Malnourished Child at Admission

Treat or prevent hypoglycemia

Treat or prevent hypothermia
Treat or prevent dehydration
Treat infection or septic shock, if present
Begin feeding
Identify and treat vitamin deficiency, severe anemia, and
heart failure

Hypoglycemia
Important cause of death during first 48 hours
after admission
Signs include low body temperature, lethargy,
limpness, loss of consciousness
Do not wait for lab results before treating:

give first feed of F-75 diet

If F-75 not immediately available, give 50 ml of 10%
glucose or sucrose orally or via NG tube
If unconscious, give 5ml/kg of 10% glucose IV
Give 2-3 hourly feeds, day and night

Hypothermia
Defined as rectal temp less than 35.5C
Keep child clothed, including head, limit exams and
washing, dry immediately after washing, keep heater or
lamp nearby
Check for hypoglycemia any time a child is found to be
hypothermic

Dehydration and Septic Shock

Malnourished children often do not display
typical signs and symptoms of dehydration and
septic shock.
Salivary and lacrimal glands are atrophied so children
will have dry mouth and lack of tears regardless of
fluid status.
Loss of subcutaneous fat makes the skin thin and
loose so a slow skin pinch does not necessarily mean
the child is dehydrated.

Reliable Signs of Dehydration in a

Malnourished Child
History of diarrhea
Thirst
Recent development of
sunken eyes
Weak or absent
peripheral pulses
Cold hands and feet
urine flow
Marasmic child with sunken eyes

Rehydration Solution for Malnourished

Children (ReSoMal)
High sodium and low potassium levels in
malnourished children make standard Oral
Rehydration Salts (ORS) unsuitable.
ReSoMal is commercially available, but can also
be made by diluting one ORS packet in 2 liters of
water instead of 1 and adding 25 g/l of sucrose
and 20 ml/l of mineral mix.

ReSoMal Protocol

(Rehydration solution for marasmic

children)
DO NOT use for oedematous children
To be used ONLY after careful diagnosis of
dehydration (history and clinical signs).
For children with OEDEMA, do not give
ReSoMaL in an outpatient setting, use 10%
sugar water only.
Monitor regularly. If respiratory rate
increases or there is increasing oedema
(e.g. of eyelids) or neck veins become
distended, stop ReSoMaL. Reassess after
the 1st hour. If there is improvement in
symptoms advise carer to continue
breastfeeding and to give extra water at
home (small quantities every hour) until
child is no longer thirsty.
If no improvement or further deterioration
refer to inpatient facility.

weight of
child
(kg)

first 30
minutes
(ml)

second 30
minutes
(ml)

2nd hour (ml)

2.0 - 2.9

10

10

20

3.0 - 3.9

15

15

30

4.0 - 4.9

20

20

40

5.0 - 5.9

25

25

50

6.0 - 6.9

30

30

60

7.0 - 7.9

35

35

70

8.0 - 8.9

40

40

80

9.0 - 9.9

45

45

90

10.0 - 10.9

50

50

100

11.0 - 11.9

55

55

110

12.0 - 12.9

60

60

120

13.0 - 13.9

65

65

130

14.0 - 14.9

70

70

140

15.0 - 15.9

75

75

150

Signs of Septic Shock in a

Malnourished Child
Incipient septic shock:

Limpness, apathy, anorexia, hypothermia, cold hands

and feet, weak peripheral pulses, urine flow

Developed septic shock:

Dilated superficial veins (scalp and external jugular

veins), dilated pulmonary veins leading to grunting,
shallow cough, difficulty breathing
Development of renal, cardiac, liver, and intestinal
failure
Hematemesis, melena, abdominal distension with
abdominal splash

Infection in the Malnourished Child

Malnourished children often have no signs of
infection. Therefore, on admission, all children
should receive antibiotic treatment according to
local resistance patterns.
Suggested regimen:
If no signs of infection and no complications
Cotrimoxazole (25/5) PO BID x 5 days

Antibiotic Treatment in Children with

Complications
Complications include:

Septic shock
Hypoglycemia
Hypothermia
Skin infection
UTI
Lethargy

Suggested regimen:

Ampicillin 50mg/kg IM/IV every 6 hours x 2 days,

followed by amoxicillin 15mg/kg PO every 8 hours x
5 days

More on Infections
If child fails to respond in 48 hours, add:

Chloramphenicol 25mg/kg IM/IV every 8 hours x 5

days

Follow WHO or local treatment protocols for

management of dysentery, candidiasis,
helminthiasis
All children should be tested for malaria upon
admission and treated accordingly
All children should receive a measles vaccine on
admission

Vitamin A Administration
All children should receive vitamin eye on admission
according to age-specific guidelines.
If the child has oedema, severe anorexia, or septic shock,
give IM dose.
If child has evidence of Vitamin A deficiency (eye
complications), follow table below:

Eye Care
Eyes should be examined gently for signs of
xerophthalmia, corneal xerosis and ulceration,
cloudiness and keratomalacia
Management of ocular inflammation or
ulceration:
Cover eyes with pads soaked with 0.9% saline
Apply 1% tetracycline eye drops 4 times a day

Complications of Vitamin A Deficiency

Keratomalacia with Bitot's Spots:

discrete, foamy-appearing spots on
the conjunctiva

Corneal ulcer: small ulcer with

clouding of the central cornea

Copyright Online Journal of Ophthalmology

Severe Anemia
WHO recommends blood transfusion when the
haemoglobin drops below 30g/l (or packed-cell volume
below 10%), or if child is showing signs of lifethreatening heart failure.
Give 10 ml/kg slowly over 3 hours.

Palmar pallor in a severely anemic child.

Dermatosis of Kwashiorkor

Characterized by hypo- or hyperpigmentation, shedding and

ulceration of the skin especially in legs, perineum, and groin.
Bathe affected areas in 1% KMnO4 for 10-15 daily
Apply zinc and castor oil ointment, petroleum jelly, or paraffin gauze
dressings
All children with dermatosis should receive antibiotics. If areas show
signs of candida infection, treat with topical and oral nystatin.

Formula Diets Used in the Treatment of

Malnourished Children
F-75

75 kcal/100 ml
Used during initial treatment

F-100

100 kcal/100 ml
Used during rehab phase, once appetite has returned

RUTF (Ready-to-use therapeutic food)

Mixture of peanut paste, sugar, oil, powdered milk,

and vitamin/mineral mix
Similar composition as F-100, but non-water based so
does not spoil
Can be given at home

Feeding Tips
Strictly follow feeding tables that determine volume
and frequency of feeds for weight.
Feeding by mouth is always better, but if a child will
not take food, an NG tube must be placed.
Children should continue to breastfeed.
Children should be fed with cup and spoon, or
dropper never with a bottle as these can be sources
of infection.
Carefully record food intake. Standard recording
forms are available.

RUTF
Designed by French scientist Andre Briend in 1999 and
manufactured under the brand name Plumpynut by
Nutriset.
In Malawi, RUTF is produced in-country using local
ingredients mixed with vitamin/mineral packs from
Nutriset.

Plumpynut (RUTF)
Paste of groundnut composed of vegetable fat, peanut butter, skimmed milk
powder, lactoserum, maltodextrin, sugar and mineral and vitamin complex.
Instructions for use: Clean drinking water must be made available to
children during consumption of ready-to-eat therapeutic spread. The
product should only be given to children who can express their thirst.
Contra-indicated for children who are allergic to cows milk, proteins or
peanuts and asthmatic people (risk of allergy).
Recommendations for use: In the management of severe acute malnutrition
in therapeutic feeding, it is recommended to use the product in phase 2 (two)
in the dietetic management of severe acute malnutrition. In phase 1 (one) use
milk based diet (F75).
Storage of Plumpynut: Plumpynut has a shelf life of 24 months from
manufacturing date. Keep stored in a cool and dry place.
Packaging: Plumpynut is presented in sachets of 92 g. Each carton (around
15.1 kg) contains 150 sachets. One sachet = 92 g = 500 Kcal.

RUTF in the Field

Child being fed locally

produced RUTF in Malawi

Zambian child eating

imported Plumpynut

Transitioning to
Rehabilitation Phase
When a childs appetite has returned, replace
F-75 with an equal volume of F-100 for 2 days.
Then increase volume.
If RUTF is available, this can be given in place of
F-100.

Management Models
Malnutrition is the result of a combination of
medical and social problems. A management
model that addresses all aspects of malnutrition
will lead to a faster recovery and reduce the
chances of relapse.

Community-Based Therapeutic Care (CTC)

In 2007, a joint statement was issued by the WHO, WFP, and
UNICEF, promoting community-based management of severe acute
malnutrition.
Countries are encouraged to adapt national policies to address:

training for community health workers in identifying malnourished

children
ensuring competency in IMCI at the facility level
establishing referral arrangements for complicated cases
making RUTF available to children with severe malnutrition

The CTC approach to malnutrition management has been shown to

be more successful than traditional methods that focus on inpatient
management.
Malnutrition cases that were previously treated as inpatient can be
managed on an outpatient basis, and severe complicated cases can
be discharged home earlier.

Suggested Update of Management of Severe

Acute Malnutrition Into IMCI Protocol

Andre Briend, WHO, September 2007

http://www.fantaproject.org/downloads/pdfs/D2.S5.Briend.pdf

Case Question #1
A two year-old boy presents with bilateral pedal
oedema and hypothermia. On exam, you are unable to
arouse him.
Your next step should be to:
a)
b)
c)
d)
e)

Check a stat haemoglobin and transfuse if Hb < 30g/l.

Check a stat glucose and replete if necessary
Place the child near a heater to warm his body temperature
Give 10% glucose IV
Give IV ampicillin

Case Question #1
A two year-old boy presents with bilateral pedal
oedema and hypothermia. On exam, you are unable to
arouse him.
Your next step should be to:
a)
b)
c)

Check a stat haemoglobin and transfuse if Hb < 30g/l.

Check a stat glucose and replete if necessary
Place the child near a heater to warm his body temperature

d) Give 10% glucose IV

e)

Give IV ampicillin

Case Question #2
An 18 month-old girl whose mother recently died of
TB is admitted to the hospital for severe wasting and
anorexia x 2 days. Her weight-for-height is -4 SD. She
is alert but refuses food. Her vitals are stable.
Your next step should be to:

Give F-75 by NG tube

Start anti-tuberculosis medicines
Send for chest x-ray
Give ReSoMal by NG tube
Test for HIV

Case Question #2
An 18 month-old girl whose mother recently died of
TB is admitted to the hospital for severe wasting and
anorexia x 2 days. Her weight-for-height is -4 SD. She
is alert but refuses food. Her vitals are stable.
Your next step should be to:

Give F-75 by NG tube

Start anti-tuberculosis medicines

Send for chest x-ray
Give ReSoMal by NG tube
Test for HIV

Resources
WHO, Management of severe malnutrition: a manual for
physicians and other senior health workers.
Available online at:
http://whqlibdoc.who.int/hq/1999/a57361.pdf
Valid Internationals CTC Manual:
http://www.validinternational.org/pages/
Project Peanut Butter RUTF factory and feeding
program in Malawi:
http://www.projectpeanutbutter.org/