Protein-energy Malnutrition
in Children
Tahmeed Ahmed, M Iqbal Hossain, Munirul Islam,
AM Shamsir Ahmed, M Jobayer Chisti
Key features
l Protein-energy malnutrition (PEM) is the most common
childhood ailment in the world and is primarily caused by
deficiency of energy, protein and micronutrients
l PEM manifests as underweight (low body weight compared
with healthy peers), stunting (poor linear growth), wasting
(acute weight loss) or edematous malnutrition (kwashiorkor)
l Case fatality rates among children hospitalized with severe
wasting or edema (also known as severe acute malnutrition
[SAM]) range from 5% to 30%
l All forms of PEM are associated with increased risk of
infectious illnesses and cognitive deficit
l Management of most forms of PEM can be done in the
community setting by improving household food security,
promoting appropriate complementary food, providing
micronutrients, providing anti-helminthic treatment and
preventing (e.g. by vaccines) and treating infectious illnesses
l Children with SAM and associated acute illnesses should
be treated in a hospital setting using World Health
Organization (WHO) guidelines. Children with SAM who are
not acutely ill and have an appetite can be managed in the
community using ready-to-use-therapeutic foods, preferably
made locally
INTRODUCTION
Protein-energy malnutrition (PEM) includes a number of distinct
disorders of growth in children primarily caused by deficiency of nutri-
ents, notably protein and energy. Micronutrient deficiencies are also
common in these disorders. PEM includes the following conditions:
l Underweight: a child with a body weight less than that of normal
children of same age and sex (more than two standard deviations
[SD] below the median weight of World Health Organization
[WHO] growth standards). Severe underweight is defined as a
body weight less than -3SD.
l Stunting: a child with a height or length less than that of normal
children of same age and sex (more than two SD below the
median height or length of WHO growth standards). Severe stunt-
ing is defined as a height or length less than -3SD.
l Wasting: a child has wasting if the body weight is more than two
SDs below the median weight of normal children of same height
or length of WHO growth standards. A child has severe wasting
if the weight-for-height (WHZ)/length is less than -3SD.
l Severe acute malnutrition (SAM): a serious condition character-
ized by the presence of any of the following features – severe
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138 
wasting, bilateral pedal edema and a mid-upper arm circumfer-
ence (MUAC) of less than 11.5 cm. It includes marasmus, kwash-
iorkor and marasmic kwashiorkor.
Chronic deprivation of nutrients usually results in stunting, while
wasting occurs when there is an acute deprivation of nutrients over a
short interval. An underweight child may also have wasting and stunt-
ing. Wasting and stunting are commonly seen in children between
the ages of 1 and 2 years, but by 3–4 years of age, children in develop-
ing countries are more stunted than wasted. This indicates that these
children have stopped growing in height, but may have a normal
WHZ. The earliest account of kwashiorkor – a severe form of PEM
characterized by edema – was published in 1865 by Hinajosa in
Mexico. The acuteness of kwashiorkor has been the focus of attention
of nutritionists and as many as 70 names have been given to this
condition in different parts of the world. Cicely Williams first intro-
duced the name kwashiorkor in 1935, which in the Ga language of
West Africa means “the disease of the deposed child”. This literally
refers to the child who develops edema after being weaned with
starchy gruels following the birth of a sibling who is breastfed.
EPIDEMIOLOGY AND CONSEQUENCES
About one-third of all children under the age of five years in develop-
ing countries are stunted, while 20% are underweight. An estimated
178 million children are stunted and, of them, 74 million live in
south-central Asia (Fig. 138.1). A total of 36 countries account for
90% of all stunted children worldwide; India alone has more than 61
million stunted children. Most of these children are from the poorest
segments of the population. Wasting, which is also known as moder-
ate acute malnutrition (MAM), has a global prevalence of 10% (55
million children affected).
Underweight, stunting and wasting contribute to 19%, 14.5% and
14.6% of deaths respectively, among children under the age of five
years in the developing world. Case fatality rates among children
admitted to a hospital with severe acute malnutrition are very high
and range from 5% to 30%. Among survivors, comorbidities are
common. Because of reduced immunocompetence (impaired delayed
hypersensitivity to antigens, selective B cell and complement malfunc-
tion), prevalence and severity of infections, notably the infectious
diarrheas, are greater compared with well nourished peers. Impair-
ment of cognitive function commonly occurs in malnourished chil-
dren and this may be irreversible. For every 10% increase in stunting,
the proportion of children reaching the final grade of primary school
drops by 7.9%.
CAUSES OF PROTEIN-ENERGY
MALNUTRITION (PEM)
Malnutrition because of lack of food and the interplay of infections
is known as primary malnutrition, which is responsible for most
malnutrition seen in the developing world. However, there is a host
of basic and underlying causes of malnutrition that operate at national
and societal levels (Fig. 138.2). The root causes of malnutrition are
989
990 HUNTER’S TROPICAL MEDICINE AND EMERGING INFECTIOUS DISEASE

No data
<20%
20–29.9%
30–39.9%
≥40%
FIGURE 138.1 Global prevalence of stunting in children under 5 years of age. Most of the burden of stunting is in South Asia and sub-Saharan Africa.
(From [1]).

Short-term consequences: Long-term consequences:

Mortality, morbidity, disablity Adult size, intellectual ability,
economic productivity,
reproductive performance,
metabolic and cardiovascular disease

Maternal and child

undernutrition

Immediate
Inadequate dietary intake Disease causes

Unhealthy household
Household food Inadequate care environment and lack
insecurity of health services

Income poverty:
Underlying employment, self-employment,
causes dwelling, assets, remittances,
pensions, transfers etc.

Lack of capital: financial, human,

physical, social and natural
Basic
causes
Social, economic
and political context

FIGURE 138.2 Framework of causes of maternal and child malnutrition. (From [1]).

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 Pro te i n - e n e rg y M a l n u t r i t i o n in Children 991

FIGURE 138.3 Severe wasting occurs when there is loss of body fat,
subcutaneous tissues and muscles.

political in nature interlaced with issues of social and gender inequity,

particularly of income and education. Civil conflicts and social ine-
qualities are important precipitating factors. Malnutrition occurring
as a result of chronic diseases, such as chronic kidney, liver or heart
disease, is known as secondary malnutrition.
FIGURE 138.4 “Baggy pants” appearance in severe wasting or severe
acute malnutrition.
CLINICAL FEATURES
Thinness and short stature may be the only features of moderate
underweight, stunting and wasting. The manifestation of severe acute
malnutrition can be quite dramatic and the major signs include severe
wasting, edema, skin changes or dermatosis, and eye signs. Severe
wasting occurs when there is loss of body fat, subcutaneous tissues
and muscles. In a severe case, the body appears to have only skin and
bones with wrinkling of the skin, the head looks disproportionately
large and the ribs are markedly visible (Fig. 138.3). The skin becomes
redundant on the severely wasted buttocks, giving a “baggy pants”
appearance (Fig. 138.4). A WHZ of less than -3SD and a MUAC less
than 11.5 cm indicate severe wasting.
In the absence of other causes of edema, such as nephrotic syndrome,
the presence of bilateral pedal edema is a sign of SAM. A decrease in
serum albumin level is partly responsible for development of edema.
Other factors that contribute to the development of edema in SAM
include decreased body potassium and reduced inactivation of anti- FIGURE 138.5 Detection of pedal edema.
diuretic hormone. Edema is detected by pressing on the dorsum of
the foot for 3–5 seconds; an indentation on release of pressure indi-
cates pedal edema (Fig. 138.5). The extent of dermatosis is described in the following way:
Based on severity, there are three categories of edema: Mild: discoloration or a few rough patches of skin, grade +;
Moderate: multiple patches on arms and/or legs, grade ++;
Mild: both feet (can include ankles), grade +; Severe: flaking skin, raw skin, fissures (openings in the skin),
Moderate: both feet, lower legs, hands or lower arms, grade grade +++.
+ +;
Severe: generalized bilateral pitting edema including both feet, Clinical terms describing severe PEM are used mostly in hospital set-
legs, hands, arms and face, grade + + +. tings. A child with a weight-for-age of less than -3SD and no edema
is said to have “marasmus”, while a child with a weight-for-age of
Dermatosis is a skin condition that is common in severe acute mal- more than -3SD and bilateral pedal edema has “kwashiorkor”. “Mar-
nutrition. A child with dermatosis may have patches of skin that are asmic kwashiorkor” is the condition where weight-for-age is less than
abnormally light or dark in color, shedding of skin in scales or sheets, -3SD and edema is present.
and ulceration of the skin of the perineum, groin, limbs, behind the
ears and in the armpits. There may be weeping lesions. There may be Marasmus has been recognized for centuries. It is usually seen in
severe rash in the distribution of a diaper. Secondary infection can infancy and is characterized by severe weight reduction, gross wasting
occur. of muscle and tissue beneath the skin, stunting and no edema.

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992 HUNTER’S TROPICAL MEDICINE AND EMERGING INFECTIOUS DISEASE
FIGURE 138.6 Bilateral pedal edema in a child with kwashiorkor.
Usually, the child is irritable. Marasmus occurs as a result of severe
deficiency of energy, protein, vitamins and minerals, although the
primary cause is inadequate energy intake. This deficiency often
results when there is a decrease or absence of breastfeeding, feeding
on diluted milk formula or a delay in introducing solid foods in the
diet. In marasmus, the body generally adapts itself to the deficiency
of energy and protein. The muscles provide amino acids leading to
the production of proteins including albumin and β-lipoprotein.
Adequate amounts of albumin and β-lipoprotein prevent the devel-
opment of edema and fatty enlargement of the liver in marasmus.
Kwashiorkor, which occurs mostly in children 1–3 years of age, results
from a deficiency of dietary protein and is usually associated with an
infection. Typically, there are skin lesions (pigmented or de-pigmented
areas with or without ulceration), scanty lustre-less hair, loss of inter-
est in the surroundings and loss of appetite (Fig. 138.6). The edema
is usually noticed in the feet, but can also occur in other parts of the
body. β-lipoprotein is not produced in adequate amounts, resulting
in impaired transport of fat and an enlarged fatty liver.
A child with marasmic kwashiorkor has clinical findings of both
marasmus and kwashiorkor. There may be mild hair and skin changes,
and an enlarged, fatty liver.
MANAGEMENT OF MILD OR
MODERATE MALNUTRITION
Mildly- or moderately-malnourished children account for the major
burden of malnutrition in any developing country. These children
have an increased susceptibility to infections and have impaired intel-
lectual capabilities. They can progress to severe malnutrition so man-
agement of these children is, therefore, important from a public
health perspective. Management of these children takes place at
household and community levels. The focus should be on the coun-
seling of parents on health and nutrition education so that the diet
of the child is improved through breastfeeding and appropriate com-
plementary feeding; that proper care is taken during common ill-
nesses, including diarrhea; that micronutrients are provided, either
through food or by supplementation; that routine vaccines are
administered; and, in many countries, that periodic deworming is
done. This is commonly done in developing countries by a strategy
called growth monitoring and promotion (GMP) where children
under the age of five years are weighed at regular intervals and a
package of interventions provided at the visits for promoting growth.
Potential strengths of GMP are that it provides frequent contact with
health workers and a platform for child health interventions. However,
the success of GMP depends on how sincerely the promotion part,
particularly counseling for changing behavior, is carried out by com-
munity health workers.
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There is now an increased interest in improving water quality, sanita-
tion and hygiene as a means of reducing malnutrition. This is based
on the premise that children in developing countries are continuously
exposed to pathogenic bacteria. These bacteria may not result in
enteric disease, but colonize the small intestine causing atrophy of the
intestinal villi. As a result, there is malabsorption and malnutrition.
This condition is called environmental enteropathy and is believed to
be responsible for 40% of childhood malnutrition in some countries.
Food supplementation through large scale programs has also been
tried with limited success in reducing moderate acute malnutrition.
However, the ultimate goal in the management of moderate malnutri-
tion is to reduce food insecurity through increased availability and
access to food and its utilization.
PHASES OF MANAGEMENT OF SEVERE
ACUTE MALNUTRITION (SAM)
The management of children with SAM can be divided into three
phases.
1. Acute phase: problems that endanger life, such as hypogly-
cemia or an infection, are identified and treated. Feeding
and correction of micronutrient deficiencies are initiated
during this phase. Small, frequent feeds are given (about
100 kcal/kg and 1–1.5 g protein/kg per day). Broad-
spectrum antibiotics are started. The main objective of this
phase is to stabilize the child. Case fatality is highest during
this phase of management, the principal causes of death
being hypoglycemia, hypothermia, infection and water-
electrolyte imbalance. Most deaths occur within the first
1–2 days of admission. This treatment phase usually takes
about 3–5 days.
2. Nutritional rehabilitation: the aim of this phase is to recover
lost weight by intensive feeding. The child is stimulated
emotionally and physically, and the mother is trained to
continue care at home. Around 150–250 kcal/kg and 3–5 g
protein/kg are provided daily during this phase. Micronu-
trients, including iron, are continued. The mothers are
counseled on health and nutrition. This phase takes 2–4
weeks if the criterion of discharge is WHZ -2 without edema.
It can take longer if the child is managed on an outpatient
basis.
3. Follow-up: follow-up is done to prevent relapse of severe
malnutrition and to ensure proper physical growth and
mental development of the child. The likelihood of relapse
into SAM is highest within one month of discharge.
Follow-up visits should be fortnightly initially and then
monthly until the child has achieved WHZ >-1. Nutritional
status and general condition are assessed and the care givers
counseled. Common illnesses are treated.
STEP 1: TREAT/PREVENT HYPOGLYCEMIA
Hypoglycemia and hypothermia usually occur together and are signs
of infection. The child should be tested for hypoglycemia on admis-
sion or whenever lethargy, convulsions or hypothermia are found. If
blood glucose cannot be measured, all children with SAM suspected
to have hypoglycemia should be treated accordingly.
If the child is conscious and blood glucose is <3mmol/l or 54mg/dl:
50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded
teaspoon of sugar in 3.5 tablespoons water) is given orally or
by nasogastric (NG) tube. The starter diet F-75 (see Step 7) is
given every 30 min for two hours (giving one quarter of the
two-hourly feed each time). Thereafter, two-hourly feeds are
continued for first 24–48 hours.
If the child is unconscious, lethargic or convulsing:
sterile 10% glucose (5 ml/kg) is given intravenously (IV), fol-
lowed by 50 ml of 10% glucose or sucrose by NG tube. Then
the starter diet F-75 is given as above (Box 138.1).
 Pro te i n - e n e rg y M a l n u t r i t i o n in Children 993

BOX 138.1  Recipes for F-75 and F-100

If you have cereal flour and cooking facilities, use one of the top three recipes for F-75:
Alternatives Ingredients Amount for F-75
If you have dried Dried skimmed milk 25 g
skimmed milk Sugar 70 g
Cereal flour 35 g
Vegetable oil 30 g
Mineral mix* 20 ml
Water to make 1000 ml 1000 ml**
If you have dried whole Dried whole milk 35 g
milk Sugar 70 g
Cereal flour 35 g
Vegetable oil 20 g
Mineral mix* 20 ml
Water to make 1000 ml 1000 ml**
If you have fresh cow’s Fresh cow’s milk, or full- 300 ml
milk, or full-cream cream (whole) long life milk
(whole) long life milk Sugar 70 g
Cereal flour 35 g
Vegetable oil 20 g
Mineral mix* 20 ml
Water to make 1000 ml 1000 ml**
If you do not have cereal flour, or there are no cooking facilities, use one of the following recipes No cooking is required for
for F-75: F-100:
Alternatives Ingredients Amount for F-75 Amount for F-100
If you have dried Dried skimmed milk 25 g 80 g
skimmed milk Sugar 100 g 50 g
Vegetable oil 30 g 60 g
Mineral mix* 20 ml 20 ml
Water to make 1000 ml 1000 ml** 1000 ml**
If you have dried whole Dried whole milk 35 g 110 g
milk Sugar 100 g 50 g
Vegetable oil 20 g 30 g
Mineral mix* 20 ml 20 ml
Water to make 1000 ml 1000 ml** 1000 ml**
If you have fresh cow’s Fresh cow’s milk, or full- 300 ml 880 ml
milk, or full-cream cream (whole) long life milk
(whole) long life milk Sugar 100 g 75 g
Vegetable oil 20 g 20 g
Mineral mix* 20 ml 20 ml
Water to make 1000 ml 1000 ml** 1000 ml**

*Contents of mineral mix are given in Appendix 4 of the manual. Alternatively, a commercial product called Combined Mineral Vitamin Mix (CMV) may be used.
(From World Health Organization. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. Geneva: World Health Organization;
1999).

**Important note about adding water: Add just the amount of water needed to make 1000 ml of formula. (This amount will
vary from recipe to recipe, depending on the other ingredients.) Do not simply add 1000 ml of water, as this will make the
formula too dilute. A mark for 1000 ml should be made on the mixing container for the formula, so that water can be added
to the other ingredients up to this mark.

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994 HUNTER’S TROPICAL MEDICINE AND EMERGING INFECTIOUS DISEASE
BOX 138.2  Recipe for ReSoMal
Ingredients Amount
Water (boiled and cooled) 1.7 liters
WHO-ORS (hypo-osmolar) One 1 liter sachet
Sugar 40 g
Electrolyte/mineral solution* 33 ml
ReSoMal contains approximately <45 mmol/l sodium,
40 mmol/l potassium and 3 mmol/l magnesium.
l Every 30 minutes for first 2 hours, ReSoMal 5 ml/kg body
weight is given orally or by NG tube.
l Then, in alternate hours for up to 10 hours, ReSoMal is given
5–10 ml/kg/h (the amount to be given should be deter-
mined by how much the child wants, and stool loss and
vomiting). F-75 is given in alternate hours during this
period until the child is rehydrated.
*See Box 138.3.
NG, nasogastric; WHO-ORS, World Health Organization-Oral Rehydration
Solution.
STEP 2: TREAT/PREVENT HYPOTHERMIA
If the axillary temperature is <35.0°C or the rectal temperature is
<35.5°C, the child is given feeds and re-warmed by covering with a
warm blanket or placing the child on the mother’s bare chest (skin-
to-skin) and covering them with a blanket. A heater or lamp may be
placed nearby. The child must be kept dry and away from drafts.
STEP 3: TREAT/PREVENT DEHYDRATION
Assessment of dehydration can be difficult in a severely malnourished
child. All children with watery diarrhea should be assumed to have
dehydration and given ReSoMal, a special rehydration solution
for children with SAM. It contains less sodium and more potassium
and glucose than the standard oral rehydration solution (ORS)
(Box 138.2).
If diarrhea is severe, then the standard hypo-osmolar WHO-ORS
(75 mmol sodium/l) may be used as loss of sodium in stool is high
and symptomatic hyponatremia can occur with ReSoMal. Severe
diarrhea can be caused by cholera or rotavirus infection, and is usually
defined as stool output >5 ml/kg/hr.
Return of tears, moist mouth, eyes and fontanelle appearing less
sunken, and improved skin turgor are signs that rehydration is pro-
ceeding. It should be noted that many severely malnourished children
will not show these changes, even when fully rehydrated. Signs of
over-hydration are increasing respiratory rate and pulse rate, increas-
ing edema and puffy eyelids. If these signs occur, fluids are stopped
immediately and the child reassessed after one hour. IV rehydration
should be used only in case of shock, infusing slowly to avoid over-
loading the heart.
STEP 4: CORRECT ELECTROLYTE IMBALANCE
All severely malnourished children have excess body sodium, even
though serum sodium may be low. Deficiencies of potassium and
magnesium are also present and may take at least two weeks
to correct. Edema is partly caused by these imbalances and must
never be treated with a diuretic. The following are given to a child
with SAM:
l extra potassium 3–4 mmol/kg/day;
l extra magnesium 0.4–0.6 mmol/kg/day.
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BOX 138.3  Recipe for Electrolyte/Mineral
Solution
Amount (g) Molar content of 20 ml
Potassium chloride 224 24 mmol
Tripotassium citrate 81 2 mmol
Magnesium chloride 76 3 mmol
Zinc acetate 8.2 300 µmol
Copper sulphate 1.4 45 µmol
Water up to 2500 ml
The extra potassium and magnesium are not required if electrolyte/
mineral solution is used in preparing ReSoMal and the feeds
(Box 138.3).
STEP 5: TREAT INFECTION
In severe malnutrition, the usual signs of infection, such as fever, are
often absent. Therefore, broad-spectrum antibiotics based on local
antimicrobial resistance patterns are given routinely on admission.
If the child appears to have no complications:
l oral amoxicillin 15 mg/kg eight-hourly for five days
If the child appears sick or lethargic, or has complications (hypogly-
cemia, hypothermia, skin lesions, respiratory tract or urinary tract
infection):
l ampicillin 50 mg/kg intramuscularly (IM)/IV six-hourly for two
days, then oral amoxicillin 15 mg/kg eight-hourly for five days;
l gentamicin 7.5 mg/kg IM/IV once daily for seven days.
If the child fails to improve clinically by 48 hours or deteriorates
after 24 hours, a third-generation cephalosporin (e.g. ceftriaxone
50–75 mg/kg/day IV or IM once daily may be started with gen-
tamicin). Ceftriaxone, if available, should be the preferred antibiotic
in cases of septic shock or meningitis. Anti-malarial treatment is pro-
vided if the child has a peripheral blood film positive for malaria
parasites.
STEP 6: CORRECT MICRONUTRIENT
DEFICIENCIES
All severely malnourished children have vitamin and mineral defi-
ciencies. Although anemia is common, iron is not given until the
child has a good appetite and starts gaining weight (usually by the
second week). Vitamin A should be given orally on day 1 (for age >12
months, 200,000 IU; for age 6–12 months, 100,000 IU; for age 0–5
months, 50,000 IU) unless there is definite evidence that a dose has
been given in the last month. If the child has xerophthalmia, the same
doses of vitamin A are repeated on days 2 and 14, or on day of
discharge.
The following micronutrients are provided daily for the entire period
of nutritional rehabilitation (at least four weeks):
l multivitamin supplements;
l folic acid 1 mg/day (5 mg on day 1);
l zinc 2 mg/kg/day;
l copper 0.3 mg/kg/day;
l iron 3 mg/kg/day, but only when gaining weight.
A combined electrolyte/mineral/vitamin mix for severe malnutrition
is available commercially. This can replace the electrolyte/mineral
solution and multivitamin and folic acid supplements mentioned in

TABLE 138-1  Frequency and Volume of F-75 During
Acute Phase of Treatment
Days Frequency Vol/kg/feed Vol/kg/day
1–2 2-hourly 11 ml 130 ml
3–5 3-hourly 16 ml 130 ml
6–7+ 4-hourly 22 ml 130 ml
Steps 4 and 6. However, the large single dose of vitamin A and folic
acid on day 1 are still given.
STEP 7: START CAUTIOUS FEEDING
During the stabilization phase, a cautious approach is required
because of the child’s fragile physiologic state and reduced capacity
to handle large feeds. Feeding should be started as soon as possible
after admission. The WHO-recommended starter formula, F-75, con-
tains 75 kcal/100 ml and 0.9 g protein/100 ml. Very weak children
may be fed by spoon, dropper or syringe. Breastfeeding is encouraged
between the feeds of F-75. A recommended schedule in which
volume is gradually increased and feeding frequency gradually
decreased is shown in Table 138-1. If intake does not reach 80 kcal/
kg/day despite frequent feeds, coaxing and re-offering, give the
remaining feed by nasogastric tube.
Criteria for Increasing Volume/Decreasing
Frequency of F-75 Feeds
1. If vomiting, lots of diarrhea or poor appetite, continue two-
hourly feeds.
2. If little, or no vomiting, modest diarrhea (less than five
watery stools per day) and finishing most feeds, change to
three-hourly feeds.
3. After a day on three-hourly feeds (if no vomiting, less
diarrhea and finishing most feeds), change to four-hourly
feeds.
In case of SAM infants less than 6 months old, feeding should be
initiated with F-75. During the nutritional rehabilitation phase, F-75
can be continued and, if possible, re-lactation should be done.
STEP 8: ACHIEVE CATCH-UP GROWTH
During the nutritional rehabilitation phase, feeding is gradually
increased to achieve a rapid weight gain of >10 g gain/kg/day. The
recommended milk-based F-100 contains 100 kcal and 2.9 g protein/
100 ml. Modified porridges or modified family foods can be used
provided they have comparable energy and protein concentrations.
Readiness to enter the rehabilitation phase is signaled by a return of
appetite – usually about one week after admission. A gradual transi-
tion is recommended to avoid the risk of heart failure, which can
occur if children suddenly consume huge amounts.
To change from starter to catch-up formula:
1. replace F-75 with the same amount of catch-up formula
F-100 every 4 hours for 48 hours;
2. then, increase each successive feed by 10 ml until some feed
remains uneaten. The point when some remains uncon-
sumed after most feeds is likely to occur when intakes reach
about 30 ml/kg/feed (200 ml/kg/day).
If weight gain is:
l poor (<5 g/kg/day): the child requires full reassessment for other
underlying illnesses, for example tuberculosis (TB);
l moderate (5–10 g/kg/day): check whether intake targets are being
met or if infection has been overlooked;
l good (>10 g/kg/day): continue to praise staff and mothers.
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Pro te i n - e n e rg y M a l n u t r i t i o n in Children 995
STEP 9: PROVIDE SENSORY STIMULATION
AND EMOTIONAL SUPPORT
In severe malnutrition there is delayed mental and behavioral devel-
opment. Just giving diets will improve physical growth, but mental
development will remain impaired. This is improved by providing
tender loving care and a cheerful, stimulating environment. The play
sessions should make use of toys made of discarded material.
STEP 10: PREPARE FOR FOLLOW-UP
AFTER RECOVERY
A child who has achieved WHZ -2SD can be considered to have
improved. At this point, the child is still likely to have a low weight-
for-age because of stunting. Good feeding practices and sensory stim-
ulation should be continued at home. Parents or care givers should
be counseled on:
l feeding energy- and nutrient-dense foods;
l providing structured playtimes for the children;
l bringing the child back for regular follow-up checks;
l ensuring that booster immunizations are given;
l ensuring that vitamin A and anti-helminthic drugs are given every
six months.
TREATMENT OF COMPLICATIONS
Children with SAM may experience a number of severe complica-
tions; supportive treatment for shock, very severe anemia, vitamin
deficiencies, dermatoses, parasitic infection, TB and lactose intoler-
ance are often required.
COMMUNITY-BASED MANAGEMENT
OF SAM
In countries with a heavy burden of SAM, facilities and resources for
taking care of such children are far from being adequate. It is now
agreed that children with SAM who have good appetites but no com-
plications can be treated at the community level. Because the number
of facilities is always sub-optimal in developing countries, facility-
based treatment cannot cater to the huge numbers of severely mal-
nourished children living in the community. In addition, feeding
therapeutic diets including F-75 and F-100 at home is not recom-
mended because of the propensity of these liquid diets to become
contaminated in the home environment. To overcome this problem,
ready-to-use-therapeutic food (RUTF) has been developed and used
in field situations. If prepared as per prescription, RUTF has the nutri-
ent composition of F-100 but is more energy dense and does not
contain any water. Bacterial contamination, therefore, does not occur
and the food is also safe for use in home conditions. The prototype
RUTF is made of peanut paste, milk powder, vegetable oil, mineral
and vitamin mix as per WHO recommendations. It is available as a
paste in a sachet, does not require any cooking and children can eat
directly from the sachet.
RUTF seems to play an important role in the management of severe
malnutrition in disaster and emergency settings. A supplementary
feeding program providing food rations to families of affected chil-
dren should be in place. A stabilization center for taking care of
acutely ill, severely malnourished children who need inpatient care
based on WHO guidelines should also be provided. For countries in
Asia, including India, Bangladesh and Pakistan, which have the
highest burden of child malnutrition, there is a need for research on
cost-effectiveness and sustainability of management of severe malnu-
trition using RUTF. To make a program cost-effective and sustainable,
RUTF made of locally-available food ingredients and pertaining to the
characteristics of an ideal RUTF is always preferable.
Children with SAM being considered for outpatient nutritional reha-
bilitation must fulfill the following attributes:
l free of any acute illness;
l have a good appetite;
996 HUNTER’S TROPICAL MEDICINE AND EMERGING INFECTIOUS DISEASE

should be provided weekly or fortnightly, depending on staff availa-

TABLE 138-2  Minimum Amount of RUTF a Child bility as well as the distance of the child’s residence. At the start of
treatment, oral amoxicillin should be provided, as well as vitamin A
Should Consume to Pass the Appetite Test
and folic acid. There should be adequate facilities in the out-patient
department for counseling regarding preparation and offering of
Weight of the Minimum amount of 1 RUTF sachet homemade nutritious foods, as well as recognition of danger signs of
child (kg) the child should consume willingly acute illnesses.
within 30 min (92 g sachet giving
500 kcal)
1
REFERENCE
<4 8
1. Black R, Allen LH, Bhutta ZA, et al, for the Maternal and Child Undernutrition
4–9.9 1
4 Study Group. Maternal and child undernutrition: global and regional expo-
sures and health consequences. Lancet 2008;371:243–60.
1
10–14.9 2

15 kg and above 3

4 FURTHER READING
RUTF, ready-to-use-therapeutic food.
l have a care giver at home;
l live within a reasonable distance from the outpatient facility.
Testing for a good appetite is done by offering RUTF to the child in
a quiet room. If the child consumes a certain amount of RUTF within
30 minutes, it is assumed that the child has a good appetite (Table
138-2).
DOSE OF READY-TO-USE-THERAPEUTIC
FOOD (RUTF)
A child should be given RUTF to provide 200 kcal/kg/day. The care
giver is counseled to offer the daily ration of RUTF in 5–6 divided
doses and to provide potable water during feeding. Rations of RUTF
Ahmed T, Ali M, Ullah M, et al. Mortality in severely malnourished children with
diarrhoea and use of a standardised management protocol. Lancet 1999;353:
1919–22.
Ahmed T, Begum B, Badiuzzaman, et al. Management of severe malnutrition and
diarrhea. Ind J Pediatr 2001;68:45–51.
Collins S. Treating severe acute malnutrition seriously. Arch Dis Child 2007;92:
453–61.
Sattar S, Ahmed T, Rasul CH, et al. Efficacy of a high-dose in addition to daily
low-dose vitamin A in children suffering from severe acute malnutrition
with other illnesses. PLoS ONE 2012;7(3):e33112. doi:10.1371/journal.pone.
0033112.
World Health Organization. Management of Severe Malnutrition: A Manual for
Physicians and Other Senior Health Workers. Geneva: World Health Organiza-
tion; 1999.
World Health Organization. Management of the Child with a Serious Infection
or Severe Malnutrition: Guidelines for Care at the First-Referral Level in Deve­
loping Countries (WHO/FCH/CAH/00.1). Geneva: World Health Organiza-
tion; 2000.

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