Malnutrition and Failure to Thrive

Definitions & Classifications - Defining the Deficit

• Malnutrition: Nutritional imbalance (deficiency/excess) impacting growth, body function, or clinical outcome.
• Failure to Thrive (FTT): Suboptimal weight gain/growth in children.
  • Weight < 3rd-5th percentile.
  • Weight crosses 2+ major percentiles downwards.
  • Weight-for-Length (WFL) < 5th percentile.
• Key Anthropometric Indices (Z-scores):
  • Weight-for-Age (WFA): Underweight (acute & chronic).
  • Height-for-Age (HFA): Stunting (chronic).
  • Weight-for-Height/Length (WFH/L): Wasting (acute).
  • Mid-Upper Arm Circumference (MUAC): Acute malnutrition; predictor of mortality.
• Classification by Severity (WHO, 6-59 months for MUAC):
  • Moderate Acute Malnutrition (MAM): WHZ -2 to -2.9 SD; MUAC 11.5-12.4 cm.
  • Severe Acute Malnutrition (SAM): Defined by criteria below.

⭐ WHO criteria for SAM: WHZ < -3 SD, MUAC < 11.5 cm (6-59 months), OR bilateral pitting edema.

Etiology & Clinical Picture - Roots & Red Flags

• Etiology:
  • Inadequate Intake: Poverty, poor feeding, anorexia, oral motor issues.
  • Impaired Absorption/Utilization: Malabsorption (celiac, CF), chronic diarrhea, IEMs.
  • Increased Needs: Chronic infections (TB, HIV), CHD, malignancy.
• Clinical Red Flags (FTT/Malnutrition):
  • Weight < 3rd percentile or ↓ 2 major centiles.
  • Weight for height < -2 SD (wasting); Height for age < -2 SD (stunting).
  • MUAC < 11.5 cm (SAM).
• Types & Features:
  • Marasmus: Severe wasting, "old man" face, irritable, no edema.
  • Kwashiorkor: Edema, moon facies, apathy, skin (flaky paint), hair (flag sign). 📌 FLAME: Fatty Liver, Anemia/Apathy, Malabsorption/Moon facies, Edema/Electrolyte imbalance.
  • Marasmic-Kwashiorkor: Mixed.

⭐ Flag sign (alternating bands of light and dark hair) is characteristic of Kwashiorkor due to fluctuating protein intake.

Assessment & Management - Measure & Mend

• Assessment:
  • Anthropometry:
    • SAM: WFH/L < -3SD; MUAC < 11.5 cm (6-59m); Bilateral pitting edema.
    • MAM: WFH/L -3SD to < -2SD; MUAC 11.5 to < 12.5 cm.
  • Clinical: Dehydration (Appetite test), infection signs, micronutrient deficiencies.
  • FTT: Detailed history (dietary, medical, social), feeding observation.
• Management (WHO 10 Steps for SAM):
  • Stabilization Phase (Days 1-7):
    • 1-5: Treat/Prevent Hypoglycemia, Hypothermia, Dehydration (ReSoMal), Electrolyte imbalance, Infections.
    • 6: Cautious Feeding: F-75 (~75 kcal/100ml). NO iron initially.
  • Rehabilitation Phase (Weeks 2-6):
    • 7: Catch-up Growth: F-100 (~100 kcal/100ml) or RUTF.
    • 8: Micronutrients (Start iron).
    • 9: Sensory stimulation & emotional support.
    • 10: Prepare for discharge & follow-up.

⭐ In SAM management, oral rehydration with ReSoMal is preferred over standard WHO ORS due to lower sodium (~45 mmol/L) and higher potassium (~40 mmol/L) content.

Complications & Prevention - Dodge & Defend

• Complications:
  • Infections: Pneumonia, sepsis, gastroenteritis (↓ immunity).
  • Electrolyte imbalance: Hypokalemia, hypophosphatemia, hypomagnesemia.
  • Hypothermia, hypoglycemia.
  • Severe anemia (Fe, B12, folate def.).
  • Impaired organ function (cardiac, renal).
  • Long-term neurodevelopmental delay.
  • ⭐ > Refeeding syndrome in severely malnourished children is characterized by severe hypophosphatemia (key electrolyte), hypokalemia, and hypomagnesemia, typically occurring 3-5 days after starting refeeding.
• Prevention:
  • Maternal nutrition & ANC.
  • Exclusive breastfeeding (first 6 months); continued with complementary feeds.
  • Complementary feeding: Timely, Adequate, Safe, Appropriate (TASA) from 6 months.
  • Regular growth monitoring (Wt, Ht, MUAC).
  • Full immunization.
  • Micronutrient supplementation: Vit A, Iron-Folic Acid (IFA), Zinc.
  • Hygiene & sanitation (WASH).
  • Govt. programs: ICDS, POSHAN Abhiyaan.

High‑Yield Points - ⚡ Biggest Takeaways

• Failure to Thrive (FTT): weight < 3rd-5th percentile or crossing two major centiles down.
• Marasmus: severe wasting (Wt/Ht < -3 SD), alert but irritable, no edema.
• Kwashiorkor: edema is key, with dermatosis (flaky paint), hair changes, apathy.
• MUAC < 11.5 cm indicates Severe Acute Malnutrition (SAM) in children 6-59 months.
• Refeeding syndrome risk: monitor electrolytes (K, PO4, Mg) during initial therapy.
• SAM: stabilize with F-75 (low protein, low osmolarity), then F-100 for catch-up growth.