Malnutrition management

Assessment & Classification - Sizing Up the Small

• Primary Tools: Weight-for-Height/Length (WFH/L) Z-score, Mid-Upper Arm Circumference (MUAC), and bilateral pitting edema.

• IAP Classification (2015):

  • SAM: MUAC < 11.5 cm OR WFH/L Z-score < -3 OR bilateral pitting edema.
  • MAM: MUAC 11.5 to 12.5 cm OR WFH/L Z-score -3 to -2.

⭐ WHO definition of Severe Acute Malnutrition (SAM): Any child aged 6-59 months with a Weight-for-Height/Length Z-score < -3, a MUAC < 11.5 cm, or the presence of bilateral nutritional edema.

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WHO 10 Steps in SAM - The Rescue Protocol

Management occurs in two phases: an initial Stabilization Phase (Day 1-7) followed by a longer Rehabilitation Phase (Week 2-6).

⭐ For dehydration (Step 3), use ReSoMal (Rehydration Solution for Malnutrition), not standard ORS. ReSoMal has lower sodium (~45 mEq/L) and higher potassium (~40 mEq/L) to prevent fluid overload and correct K⁺ deficiency.

Therapeutic Feeding - The Refeeding Roadmap

Management involves two distinct phases: initial stabilization followed by rehabilitation for catch-up growth.

⭐ Refeeding Syndrome: A sudden metabolic shift post-feeding causes insulin surge, driving K+, PO₄³⁻, and Mg²⁺ intracellularly. This leads to life-threatening hypokalemia, hypophosphatemia, and hypomagnesemia.

Refeeding Syndrome - The Critical Complication

• Pathophysiology: Potentially fatal fluid and electrolyte shifts in severely malnourished patients during nutritional rehabilitation.
• Mechanism: Chronic starvation depletes intracellular electrolytes. Refeeding → ↑Insulin → massive cellular uptake of phosphate, potassium, and magnesium.

• Key Features:
  • Electrolytes: ↓↓PO₄ (Hallmark), ↓K⁺, ↓Mg²⁺.
  • Vitamins: Acute thiamine (B1) deficiency → Wernicke-Korsakoff syndrome.
  • Systems: Cardiac & respiratory failure, rhabdomyolysis, seizures, edema.

⭐ Hallmark Finding: Hypophosphatemia ($<0.5$ mmol/L) is the most critical and defining laboratory finding.

• Prevention & Management:
  • ⚠️ Start low, go slow: Begin feeds at 5-10 kcal/kg/day.
  • Prophylactically give Thiamine, K⁺, PO₄, and Mg²⁺ before starting feeds.

High‑Yield Points - ⚡ Biggest Takeaways

• Initial stabilization of SAM focuses on hypoglycemia, hypothermia, and dehydration; rehydrate with ReSoMal.
• ReSoMal has ↓ Na+ and ↑ K+ compared to standard WHO ORS.
• Start with F-75 formula (low protein, low osmolarity) in the stabilization phase.
• Transition to F-100 formula for catch-up growth in the rehabilitation phase.
• Beware of refeeding syndrome, marked by severe hypophosphatemia.
• Routine broad-spectrum antibiotics are given to all children with complicated SAM.
• Provide all micronutrients except iron initially; start iron only during the rehabilitation phase.