• Above 80% of expected weight for age: Normal
• 60–80% of expected weight without edema: Under nutrition
• 60–80% of expected weight with edema: Kwashiorkor
• <60% of expected weight without edema: Marasmus
• <60% of expected weight with edema: Marasmic-kwashiorkor.

 

• >90%: Normal
  • Grade I—90–75% of expected weight for age
  • Grade II—79–60% of expected weight for age
  • Grade III—<60% of expected weight for age.

 

• Grade I—80–70% of expected weight for age
• Grade II—70–60% of expected weight for age
• Grade III—60–50% of expected weight for age
• Grade IV—<50% of expected weight for age
• Add (K) to presence of edema.

 

• Normal—>90%
  • Grade I—80–90%
  • Grade II—70–79%
  • Grade III—60–69%
  • Grade IV—<60%.
    2

 

Weight/height	Height/age	Labs
≥ 80%	≥ 90% ≤ 90%	Normal Stunted
≤ 80%	≥ 90% ≤ 90%	Wasted Wasted and stunted

 

	MAC (cm)
a. Normal:	≥13.5
b. Mild–moderate:	12.5–13.4
c. Severe:	≤12.4

 

Types of PEM	Weight/age	Height/age	Weight/height
Acute PEM	Decreased	Equivalent	Decreased
Chronic PEM	Decreased	Decreased	Equivalent
Chronic active	Decreased	Decreased	Decreased

• H/O Measles
• H/O Worms in stool
• H/O Tuberculosis contact
• H/O Recurrent UTI
• H/O Recurrent respiratory tract infection
• H/O Ear discharge
• H/O Any surgeries
• H/O Pica (eating stones, soil, waste papers, chalk)
  • Iron deficiency
  • lead poisoning anemia
  • Perverted habit of eating
• H/O Regurgitation (cleft palate)
• H/O Vomiting (GERD) and regurgitation
• H/O Lactose intolerance/malabsorption
  • A: Abdomen distension
  • B: Borborygmi (abnormal bowel sounds)
  • C: Colicky abdomen pain
  • D: Diarrhea
  • E: Excoriation (perianal)
  • F: Flatus
  • H/O: Renal cause/cardiac cause of edema.
    3

 

• Remember 3 I 's
  • I nfection
  • I rradiation
  • I ngestion of drugs
• Booked/unbooked
• Immunization, number of antenatal visits, failure to gain weight, preeclampsia, preterm/IUGR/hypoxia
• Any illness—hospitalization, drug intake, irradiation
• Iron/folic acid tablets given
• H/O Diet
• Working mother
• Mental stress
• Age of mother during pregnancy.

 

• NFTD (normal full term delivery)/preterm/cesarean
• Forceps
• Domiciliary/hospital
• Cried immediately/birth weight
• Breastfeed given after how many hours.

 

• Any infection
• Any H/O neonatal intensive care unit (NICU) admission
• Breastfeeding adequate/duration/adequate means (8–10 feeds/day)
• H/O Bottle-feeding
• H/O Prelacteal feeds
• H/O Weaning (early or late)—complementary feeding habit
  • H/O Loss of appetite
  • H/O Loss of weight.

 

• Milestones
  • Motor
  • Fine motor
  • Social adaptation
  • Language
• Tell the milestone of which age the child belongs to
  • Milestones: Described separately.

 

• Breastfed—how long/times/day/colostrum milk given or not?
• Bottle-fed—what milk/diluted or not/how much?
• How much calories the baby is taking?
• Expected calories?
• Deficit chart/requirement chart.

 

• Consanguineous babies—low birth weight is more
• Socioeconomic status
• Number of siblings—spacing (normal—3 years)
• Occupation of parents
• Per capita income
• H/O Any illness in family
• Area: Rural/urban
• Slum/industrialized zone
• Type of home: Tiles, rooms, hut
• Drinking water source
• Type of latrine
• Waste disposal.

 

• Based on family income, education and occupation
• Symbols:

  –	Non-consanguineous marriage
  =	Consanguineous marriage
  	This baby concerned
  Ø	Dead baby—cause of death
  !	Aborted

• Pedigree chart:
  Model Pedigree chart

  
• Birth spacing
• Family planning.

 

• 9 and 15 months: 2 doses of measles
• 5 years: Again DPT
• At 10 years: Tetanus toxoid should be given (most of them, not aware).
  5

 

• Tuberculosis (no H/O contact with open case of TB).

 

Social classification	Genetic classification
1st degree: Marrying brothers and sisters	1st degree: Sharing 50–50% genes
2nd degree: Maternal uncles	2nd degree: Sharing 75% and 25% genes
3rd degree: Cousins and distant relatives	3rd degree: No sharing

 

• Conscious, cooperative, oriented
• Attitude, look
• Appearance: Irritable/dull/mental apathy/lethargic
  • Old man or monkey appearance—marasmus
  • Moon face—kwashiorkor
  • Not interested in surroundings
• Generalized wasting
• Skin folds
• Anemia, jaundice, clubbing, lymphadenopathy and cyanosis
• Pedal edema
• Fontanelles.

Anterior fontanelle	Posterior fontanelle
Normal size = 2.5 × 2.5 cm (across borders) Normal closure—9–18 months	Closes by 2–4 months
Delayed closure: • Rickets • Hypothyroidism • Hydrocephalus • Down syndrome • Achondroplasia • Mucopolysaccharidosis Early closure: • Craniosynostosis • Primary microcephaly

   

• Apathy: Kwashiorkor (resents examination)
• Irritable: Marasmus (not allowing the examination and becomes angry)
• Generalized wasting.
  6

 

• Space
• Color
• Easy pluckability
• Flag sign
• Alopecia
• Fungal infection.

 

• Wide open, depressed and delayed closure in PEM
• Bulging anterior fontanelle: Increased intracranial tension, while crying (physiological).

   

• Anemia
• Sunken eyes
• Vitamin A deficiency.

     

• Angular stomatitis
• Ulcer, cheilosis
• Anemia, glossitis
• Candidal infection
• Dental caries, tonsil, oral thrush
• Cleft lip and palate (more prone for regurgitation)
• No of teeth (delayed eruption in PEM).

 

• Lymphadenopathy—axillary and cervical.

 

• Dry scaly (decreased proline/hydroxyproline)
• Ulcer in flexors
• Gangrenous lesions
• Skin turgor—loss of elasticity
• Purpuric spots—gram negative sepsis
• Crazy pavement appearance.

 

• Hepatosplenomegaly
• Free fluid
• Umbilical hernia.

   

1. Perianal excoriation
2. Beaver diarrhea
3. Loss of perirectal pad of fat, due to PEM.

   

• Temp: Hypothermia
• BP
• Pulse: Rapid thready/tachy or bradycardia
• Respiratory rate.

 

1. Weight
2. Height
3. Head circumference
4. Mid-arm circumference
5. Chest circumference.

 

• Normal at birth: 2.8 kg
  • Spring balance
  • Infant weighing scale
  • Salter weighing scale
  • Beam scale
• Up to 3 months: Increases at 30–50 g/day
  
• At 5 months—Doubles
• At 1 years—Triples
• At 2 years—4 times
• At 3 years—5 times
• At 5 years—6 times
• At 10 years—10 times
  • 2 years—12 kg
  • Add 2 kg/year thereafter.

 

• New born loses up to 10% of body weight in 1 week
• Regains lost weight by 10 days
• 25–30 g/day (next 3 months)
• 400 g/month
  9

 

• Vertical scale
• Measuring rod
• Stadiometer.

 

Age	Height (in cm)
At birth	50 cm
½ year	62 cm
1 year	75 cm
2 years	87.5 cm
3–5 years	6–8 cm/year
>5 years	5 cm/year

• At 1 year: 75 cm
• 2 years: 87 cm

  Weech's formula for height
  Age	Height (in cm)
  At birth	50 cm
  At 1 year	75 cm
  2–12 years	(Age in years x 6) + 77

• Length measured by infant meter until the child is ambulant
  • 
    10

Age	Weight	Height	Head circumference	Chest circumference	Mid-arm circumference
Birth	2.8 kg	50 cm	33 cm	32 cm	13.5 cm
I year	Triples	76 cm	45 cm	45 cm	13.5 cm

 

• At birth = 32–35 cm (average: 35 cm)
• 1 years = 45 cm
• 2 years = 48 cm
• 12 years = 52 cm
• 18 years = 55 cm
• 1–6 months: 1–1.2 cm/month increase
• 2nd 6 months: 0.5 cm/month increase
  • >2SD = Macrocephaly
  • < 3SD = Microcephaly

• Fix the prominence of occiput cross over the tape and see (Take 3 times).

 

• Baby born of diabetic mother: Chest circumference > head circumference
• In malnutrition: Chest circumference < head circumference (even after 1 and a half years)

 

1. Tape method: Midpoint between acromion and olecranon
2. Shakir's tape: Green color: 13–16 cm = well nourished
   Yellow color: 12.5–13.5 cm = Mild-moderate
   Red color: <12.5 cm = Malnourished
   Normal is 13.5–16.5 cm for 1–4 years
   (It is constant because the subcutaneous tissue and fat replaced by muscles)
3. Logerson's Bangle test:
   Inner diameter of bangle is 4 cm
   If it easily passes and comes out of their elbow = Malnourished
4. Quack stick Method:
   For each height, a corresponding mid-arm circumference can be measured
5. Kanawati's index:
   (To detect PEM between 4 months to 4 years)

>0.32	Normal
0.26–0.32	Moderate
<0.25	Severe

 

1. CVS: Anemia and hyperdynamic in circulation, signs of heart failure, venous hum, tachycardia.
2. RS: Bronchopneumonia, pneumonitis, pyothorax.
3. CNS: Stunting, developmental delay, apathetic, irritable and mental retardation.
4. Abdomen: Hepatosplenomegaly.

 

• Rounded lower margin
• Soft consistency

 

1. Blood: Complete hemogram
   TC/DC/ESR/PS
2. Urine analysis: Associated UTI
   Albumin
   Deposits
   E/s
3. Motion examination: Ova/cysts/occult blood
4. X-ray chest/Mantoux: R/O TB
5. Blood C/S (septicemia)
6. Serum A:G ratio and total proteins [Normal Sr Albumin: 3.5–5 g/dL, Sr Globulin: 2–3.5 g/dL]
7. Serum electrolytes and blood sugar
8. Stool pH (acidic) and Benedict's solution (sugar)—positive in lactose intolerance
9. Blood cholesterol
10. Serum iron/copper
    Diagnosis of lactose intolerance: Stool pH <5.5 for 2 occasions, after giving mild diet.

 

1. Resuscitation: Treatment of emergencies and complications
2. Rehabilitation: Protein/carbohydrates
3. Supportive

   

1. Weight for height:
   
   <90% : PEM
   >90% : Normal
   >120–130%: Obesity
2. 

3. H: 0.88 0.97 <0.79—severemalnutrition

4. Enderberg's Index
5. Mid-arm circumference
6. Skin fold thickness:

Age	Male in mm	Female in mm
5	6.1 + 2.54	9.56 + 1.87
10	9.5 + 3.69	11.5 + 3.58
15	9.03 + 3.07	14.08 + 4.47

• <60% : Severe Malnutrition
• 60–80% : Moderate
• 80–90% : Mild
• 80–100% : Normal
  13

 

• Measure the height
• Compare with height at that age
  • Below 80% : Dwarf
  • 80–93% : Short
  • 93–105% : Normal
• Other H/A based classification:
  • Waterlow: Ht/Age >95% normal
  • Marginal: 90–95%
  • Moderate: 85–90%
  • Severe: 85% below

 

Age	Moderate nutrition	Severe undernutrition
Symmetrical edema Weight for height (measure of wasting) Height for age (measure of stunting)	absent SD score −2 to −3 (70–79% expected) SD score −2 to −3 (85–89% expected)	YesXX SD score <–3 (< 70% of expected) SD score <–3 (<85% of expected)
xx-Includes marasmic kwashiorkor and kwashiorkor

   

• At Birth: 1.8/1
• 3–4 years: 1.3/1
• 9 years: 1/1
• 18 years: 0.9/1

 

• Weight in kg and height in meter square

• Values less than <18 indicates malnutrition
  • >30: Obese
  • 25–30: Overweight
  • 18–25: Normal
  • <18: Undernutrition

 

• Normal value: 0.14–0.16
• <0.14 = Gross malnutrition

 

• Normal value of C = 0.40
• Age independent upto = 13 years

 

• Normal Value: 0.88–0.97
• <0.79: Severely malnourished

 

• Weight measuring rod calibrated in MAC rather than height
• Values of 80% MAC for height are marked on stick
• If a child is taller than his MAC = Malnourished.

 

> 0.32	Normal
0.28–0.32	Mild undernutrition
0.25–0.28	Moderate undernutrition
< 0.25	Severe undernutrition

   

• At birth—67%
• 1 year—64%
• 20 years—50%

 

• Triceps: Skin fold is picked up in the posterior surface of triceps muscle
• Subscapular: Skin is picked immediately below inferior angle of scapula
• Biceps: Over the belly of biceps.

 

• Young children: 1–2 cm < height
• At 10 years: Arm span = height
• After 10 years: Arm span (1–2 cm) > height.

     

• Poor diet
• Poor hygiene
• Poor education
• Dietary origin: Inadequate diet
• Infections: Gastroenteritis
• Poor socioeconomic group—maternal malnutrition
• Lack of parents education.

 

1. Age: Common in infants than in old children
2. Chronic vomiting:
   • Congenital hypertrophic pyloric stenosis
     

     Figure 1.2: Loss of weight; more than 50% of expected weight/age with marked wasting of muscle subcutaneous fat
     16
   • Achalasia cardia
   • Diaphragmatic hernia
3. Repeated diarrhea
4. Chronic infections: Congenital syphilis, empyema thoracis, tuberculosis and URI
5. Congenital diseases:
   • Cleft palate
   • Micrognathia
   • Hydrocephalus
   • Congenital penal disorders
   • Hirschsprung's disease (megacolon)
6. Organic disorders:
   • Brain, heart, kidney
   • Celiac disease
   • Mucoviscidosis
7. Metabolic disorder:
   • Infantile renal actions
   • Galactosemia
   • Diabetes.

 

1. Grade I : Loss of fat in axilla and groin.
2. Grade II: Loss of fat in axilla and groin and even the abdomen, and gluteal.
3. Grade III: 1 and 2 in addition, even in chest and spine.
4. Grade IV: Buccal pad of fat is lost.

 

• Because it contains more of saturated fatty acids.

 

• Primitively aged look (old man look)
• Cheeks and temples are hollow, due to complete loss of fat.

 

• Loose and wrinkled
• Loses of elasticity purpura.

 

• Distended/Scaphoid
• Intestinal peristalsis visible (VIP).

 

• Grossly wasted.

 

• Irritable and cry loudly (since, he is hungry)
• Later when infection sets in becomes apathetic and less active
  • Constipation (early)
  • Recurrent
  • Dehydration + (difficult to identity)
  • Severe electrolyte imbalance—neurologic signs and convulsions.

 

• Moniliasis
• Cancrum oris
• Bronchopneumonia.

 

• Plasma proteins are not severely reduced
• BMR increased
• Plasma volume increased.

 

• Weight of many organs decreases: Spleen, liver, gonads
  • Liver does not show fatty vacuolation
  • Pancreatic acini appear normal.

 

1. Diet history
2. Physical: Congenital disorders: R/O achalasia cardia
   Infections (GIT, renal, lungs)
3. Investigations: R/O TB
   X-rays for evidence of any infections
   Pyloric stenosis
   Cardiac malformation.

 

• Diet to be gradually increased for 2–3 weeks
• To start with high protein/thickened milk given by gavage feeding
• Treat infections
• Surgical correction (pyloric stenosis, cleft palate, diaphragmatic hernia, megacolon)
• Balanced diet and drugs.

     

• Triad of
  • Edema
  • Lethargy
  • Growth failure
• Kwashiorkor means red hair boy
• Syndrome of changeling

 

• South India (most common)
• 1–2% of preschool children in India
• Suffer from kwashiorkor

     

• Poor socioeconomic factors
• Unable to get animal–protein foods
• Non-availability of protein-rich foods
  • Poverty index: Expressed in term of deficient caloric intake.
    70% Indians are below poverty line.

 

• Ignorance
• Superstitions
• Prejudices.

• Infections
• Disposed child
• Increased demand
• Seasonal.

 

• It actually protects against PEM (Protein energy malnutrition)
• Prolonged breastfeeding leads to ‘addiction’ and ‘relativism’ develops against food.

 

• Healthy child→Infection→Undernutrition→PEM

• H/O
  • Recurrent diarrhea
  • Dysentery
  • Warm infestations
  • Measles
  • Tuberculosis
  • Respiratory infections

           

• Gradual loss of interest and activity
• Children first becomes peevish
• Degree of unresponsiveness is directly proportional to severity.

 

• 2/3 have looseness of stool
• Steatorrhea in some cases.

 

• Acquired intolerance to lactose may result in diarrhea—improve by excluding carbohydrate in diet
• Magnesium deficiency may also be responsible for chronic diarrhea.

 

• Pitting type
• Marks the muscle coating (if present)
• Ascites is rare
• Both physiochemical and hormonal factors play a part in pathogenesis.

• No relation between edema and albumin.

 

• Weakness
• Flabbiness
• Hypotonic

 

1. Dry and Scaly Skin:
   • Appears cracked over large areas of trunk and limbs
   • “Mosaic pattern”
2. Crazy–pavement dermatosis:
   • Seen in 50% cases
   • ‘Jet black patches’ appear over certain localized areas, especially the pressure sites and flexures.
     • This peeling plaques of dormitory resemble peeling of paint ‘Flaky Paint Dermatosis’
     • Discoloration is red or purple but not black.
3. Deep fissures (ulcers)
   • Elbows, groins, knees, behind ears
4. Multiple puncture pinkish areas:
   • Over the legs due to perifollicular hemorrhage(petechia/ecchymosis)
5. Angular stomatitis
   • Riboflavin deficiency
6. Gangrenous dermatitis:
   • If complicated: by severe pyogenic skin infection
   • Note phrynoderma: Look for vitamin A-deficiency, essential fatty acid deficiency. Deficiency of tyrosine, melanin and copper.

 

• Scanty
• Lusterless
• Brownish/less black in Indians.

• Flag sign: Patients who have been cured show segmental discoloration of hair, corresponding to period of deprivation
• Eye lashes/brows may also be affected
• Record hair growth (N-8 mm/month)

 

• ‘Fatty infiltration’ of liver normal consistency.

 

• Cheeks appear full
  (Due to hydration of cells of buccal fat)
• Moon face (baggy cheeks of trawell)

 

• 1/3 cases vitamin A deficiency
• 53% angular stomatitis
• Manifestations of Rickets (vit D deficiency) and
  • Scurvy (vit C deficiency) are extremely rare in these babies because of delayed osseous growth.

 

• Normochromic/normoblastic
• 1/3rd have megaloblastc bone marrow

• Decreased white cell response to infection
• Hypoplastic bone marrow
• Abnormalities of clotting

 

• Underweight in spite of edema
• Height is less affected than weight
• Bone growth decreased
• Severe malnutrition in early part of life results in permanent and irreversible growth retardation.

   

• Heart X-ray: Small head
• During recovery: Heart size increases
  (indicating poor cardiac reserve)
• Severe kwashiorkor: Poor peripheral circulation
  • Cyanosis
  • Hypotension
  • Feeble pulse
• Tachycardia and often bradycardia
• Evidence of CCF (after infusions)
• Arrhythmias (after digitalis) (due to decreased k+/mg++)

 

1. Serum protein
   • Invariably reduced
   • Serum albumin <1.5 g
   • Alpha 1, 2 globulin: Increased
   • Beta globulin: Decreased
   • Gamma globulin: Increased
   Normal:

   Serum albumin: 4–5.3 g/dL

   Serum globulin: 2–3.5 g/dL

   A:G ratio is reversed in PEM (Increased globulin and decreased albumin)
2. Amino acids:
   • Decrease in essential amino acids
   • Decreased amino nitrogen/total nitrogen
   • Aminoaciduria +
   HOP index: Hydroxyproline index: Increased (Normal: 4.7)
   Marasmus: This ratio is decreased.
   Hydroxyproline is an important constituent of collagen.
3. Blood Cholesterol: Low and reduced to 90–120 mg%
4. Pancreatic enzymes: Trypsin, lipase and amylase decreased.
5. Serum iron/copper: Decreased (due to reduced transferrin).
6. Water and electrolytes: Disturbed, hypomagnesemia, phosphorous depletion.

   

• Fat accumulates first at periphery
• Fat vacuolation is reversible and regresses with treatment
• Necrosis never occurs
• Fibrosis 2% present is minimal
• Never progresses to cirrhosis usually.

 

• Small with severe atrophy of acinar cells with severe atrophy of cells
• Islets are normal.

 

• Atrophic changes occur in stomach
• Intestinal villi show marked atrophy.

 

• Flabby, pale and thin with enlarged ventricular chambers
• Histology—atrophy of muscle fibers, fatty degeneration, mural thrombi in ventricles.

 

• Initial stabilization phase
• Longer rehabilitation phase

1. Hypoglycemia correction
2. Hypothermia correction
3. Dehydration correction
4. Electrolyte correction
5. Infection control
6. Micronutrients without iron in early phase and with iron in late phase
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow up

1. Protein: 4 g/kg body weight
   Study of children with PEM showed, they need:
   • 2 g milk protein/kg
   • 150 cal/kg/day
   5–6 g/kg needed in infections.
2. Calories: 120–150 cal/kg/day
   Severely affected: Require IV infusion of proteins and calories
   Glucose + electrolytes: Infused with great care as not to cardiac load
   Therefore, use diuretics to prevent edema with cardiac failure.
3. Control of infections: Diarrhea by fluid therapy
4. Correction of metabolic derangements:
   1. Hypoglycemia: IV infusion 10% (cure 5–10 mg) (kg)
   2. Hypokalemia: Potassium 5 Eq/kg
   3. Hypothermia: Electric bulbs, wrapping with two fold cloth
      24
   4. Magnesium deficiency: Parenteral magnesium sulfate for 3–7days
   5. Anemia: Blood transfusion. Iron and other hematinics (Folic acid/B₁₂)
   6. Vit A def: IM 50,000 to 1,00,000 Units

 

• Most deaths occur without warning on 1–3 days of the admission.

 

• 3H
  • Hypothermia
  • Hypoglycemia
  • Heart failure

 

• N- Nutrition
• I- Immunization
• M- Medical care
• F- Family health
• E- Education on nutrition and health
• S- Stimulation and development

 

• C/F – Excessive appetite
  • Distension of abdomen
  • Reappearance of mild edema
  • Shining skin over legs
• O/E – Liver enlarged
  • Moon facies
  • Rapid weight gain
  • Apathetic child starts smiling
  • Weight gain = 2–3 kg/week
• Appetite is voracious and mothers hesitate to feed for fear of diarrhea.

 

• BP increases
• 17-ketosteroid in urine increased

1. Recovering function of adrenals
2. Increase in size and increased steroid secretion

 

• Why there is mental retardation in kwashiorkor?
  • Hypoalbuminemia
  • Hypoglycemia—decreased supply to brain of nutrients leading to MR
    25
• What are the causes of hepatomegaly in kwashiorkor?
  • CCF
  • Fatty liver
  • Infections
  • Tuberculosis
  If ascites is present—think of other complication
• Why there is a distended abdomen in PEM?
  • Hypokalemia → Hypotonia
• Zinc deficiency manifests as acrodermatitis enterpathica (Necklace dermatitis)
• What is the 1st sign of recovery?
  • Child becomes active and starts to eat well
• What are the early features of vitamin A deficiency? (Fig. 1.4)
  Early sign—loss of guttural pigmentation
  Early symptom—night blindness.

1. What is Pica?
   Craving for non-edible substance
   Complications:
   • Calculi
   • Lead poisoning
   • Worm infestations
   • Anemia
   • Stone formation
   • Suffocation.
2. What is the extra requirement in antenatal period?
   +14 g protein

   +300 kcal energy
3. What is the supplement in mid-day meal program?
   1/3 calories and 1/3 protein requirement of that child.
4. What do you infer from?
   Instable child –Depletion of calories more
   Lethargic child – Depletion of proteins more
5. Endocrine causes of PEM?
   Diabetes mellitus and insipidus.
6. Pseudoparalysis is seen in:
   • Congenital syphilis
   • Osteomyelitis
   • Scurvy
   • Septic arthritis
7. Vit A supplementation program:
   Between: 6 months–3 years26
   • Why not given less than 6 months? Breast milk contains 53 microgram which is sufficient for infants.
   • Why not given greater than 2 years? Child starts taking food of adult value.
   Vit A dose: <6 months—50,000 IU

   6 months–1 year—1 lakh IU

   1–5 years—2 lakh IU
8. What is the prophylaxis for vit A?
   Every 6 months: 2 lakh IU of Vitamin A
   
   Parenteral Vit supplement:
   
9. WHO classification:
   XN: Night Blindness

   X1A: Conjunctival xerosis

   1B : Bitots spot (Fig. 1.5)

   X2: Corneal xerosis

   X3A: Corneal ulceration (cornea < 1/3 surface)

   X3B: Keratomalacia (cornea >1/3 surface)

   XF: Xerophthalmic fundus

   XS: Corneal scars
10. What is the contraindication for ORS?
    • Persistent vomiting in an unconscious child.
    

    Figure 1.5: Bitot's spot
    27
11. Why is there hypothermia?
    1. Edematous tissue—do not maintains heat preservation
    2. Skin changes
    3. Ulcers
    “common in kwashiorkor”
12. Gopalan's theory of adaptation and dysadaptation:
    Kwashiorkor and marasmus does not depend on qualitative or quantitative deficit of protein and calories. It is the response of (adaptation) the child to stress of undernutrition.

     

• History examination
• Recent intake of food and fluids
• Usual diet (before the current illness)
• Breastfeeding
• Duration and frequency of diarrhea and vomiting
• Type of diarrhea (watery/bloody)
• Loss of appetite
• Family circumstances (to understand the child's social background)
• Chronic cough
• Contact with tuberculosis
• Recent contact with measles
  

  Figure 1.6: SAM
  28
• Known or suspected HIV infection
• Immunizations

 

• Anthropometry—weight, height/length, mid-arm circumference
• Edema
• Pulse, respiratory rate
• Signs of dehydration
• Shock (cold hands, slow capillary refill, weak and rapid pulse)
• Severe palmar pallor
• Eye signs of vitamin A deficiency:
  • Dry conjunctiva or cornea
  • Bitot's spots
  • Corneal ulceration
  • Keratomalacia
• Localizing signs of infection, including ear and throat infections, skin infection or pneumonia
• Fever (temperature ≥37.5°C or ≥99.5°F) or hypothermia (axillary temperature <35.0°C or <95.0°F)·
• Mouth ulcers
• Skin changes of kwashiorkor:
  • Hypo or hyperpigmentation
  • Desquamation
  • Ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)
  • Exudative lesions (resembling severe burns) often with secondary infection (including candida)

 

• Hemoglobin or packed cell volume in children with severe palmar pallor
• Blood sugar
• Serum electrolytes (sodium, potassium)
• Screening for infections:
  • Total and differential leukocyte count, blood culture (If possible)
  • Urine routine examination
  • Urine culture
  • Chest X-ray

• Stabilization rehabilitation
• Hypoglycemia
• Hypothermia
• Dehydration
• Electrolytes
• Infection
• Micronutrients: No iron with iron
  29
• Initiate feeding
• Catch-up growth
• Sensory stimulation
• Prepare for follow-up

 

	Stabilization		Rehabilitation
	Days 1–2	Days 3–7	Weeks 2–6
Hypoglycemia Hypothermia Dehydration Electrolytes Infection Micronutrients Initiate feeding Catch-up growth Sensory stimulation Prepare for follow-up

 

Status	Antibiotics
All admitted cases	Inj ampicillin 50 mg/kg/dose 6 hourly and Inj gentamicin 7.5 mg/kg once a day for 7 days Add Inj cloxacillin 50 mg/kg/dose 6 hourly if staphylococcal infection is suspected Revise therapy based on sensitivity report
For septic shock or worsening/ no improvement in initial hours	• IV Cefotaxime 50 mg/kg/dose 6 hourly or Inj cerftriaxone 50 mg/kg/dose 12 hourly plus Inj amikacin 15 mg/kg/once a day
Meningitis	• IV cefotaxime 50 mg/kg/dose 6 hourly or Inj cerftriaxone 50 mg/kg/dose 12 hourly plus Inj amikacin 15 mg/kg/once a day
Dysentery	• Inj ceftriaxone 100 mg/kg once a day for 5 days

 

Days	Freq	Vol/kg/feed	Vol/kg/day
1–2	2 hourly	11 mL	130 mL
3–5	2 hourly	16 mL	130 mL
6 onwards	4 hourly	22 mL	130 mL

 

Diets contents (per 100 mL)	Starter formula	Starter formula (Cereal based) Ex: 1	Starter formula (Cereal based) Ex: 2
Fresh cow's milk or equivalent (mL) (Approximate measure of one cup)	30 (1/3)	30 (1/3)	25 (1/4)
Sugar (g) (Approximate measure of one level teaspoon)	9 (1 + 1/2)	6 (1)	3 (1/2)
Cereal flour: Powdered puffed rice (g) (Approximate measure of one level teaspoon)	- -	2.5 (3/4)	6 (2)
Vegetable oil (g) (Approximate measure of one level teaspoon)	2 (1/2)	2.5 (1/2+)	3 (3/4)
Water: Make up to (mL)	100	100	100
Energy (kcal)	75	75	75
Protein (g)	0.9	1.1	1.2
Lactose (g)	1.2	1.2	1.0

 

Diets contents (per 100 mL)	Catch-up formula	Catch-up formula (cereal based) Ex: 1
Fresh milk or equivalent (mL) (Approximate measure of one katori)	95 (3/4+)	75 (1/2)
Sugar (g) (Approximate measure of one level teaspoon)	5 (1)	2.5 (1/2-)
Cereal flour: puffed rice (g) (Approximate measure of one level teaspoon)	- -	7 (2)
Vegetable oil (g) (Approximate measure of one level teaspoon)	2 (1/2)	2 (1/2)
Water to make (mL)	100	100
Energy (kcal)	101	100
Protein (g)	2.9	2.9
Lactose (g)	3.8	3

 

	Criteria
Child	Weight for height reached—ISD of median of WHO standards Eating adequate amount of nutritious food that mother can prepare at home Consistent weight gain All vitamin and mineral deficiencies have been treated
31
	All infections and other conditions have been treated or are being treated like anemia, diarrhea, malaria, tuberculosis Full immunization program started
Mother or caretaker	Able to take care of the child Able to prepare appropriate foods and feed the child Has been trained to give structured play therapy and sensory stimulation Knows how to give home treatment for common problems and recognized danger signs warranting immediate medical assistance

 

	Criteria
Child	Has a good apetite, eating at least 120–130 kcal/kg/day and receiving adequate micronutrients Has lost edema Consistent weight gain (at least 5 g/kg/day for 3 consecutive days) Completed antibiotic treatment Completed immunization appropriated for age
Mother or caretaker	Trained on appropriate feeding Has financial resources to feed the child Motivated to follow the advise given

   

• 0 months = 500 kcal
• 2 months = 600 kcal
• 4 months = 700 kcal
• 6 months = 800 kcal
• 8 months = 900 kcal
• 10 months = 1000 kcal
• 12 months = 1100 kcal
• 1 year = 1100 kcals
  (Add by 100 kcal/year up to 5 years)
  • 1 year = 1100 kcal
  • 2 years = 1200 kcal
  • 3 years = 1300 kcal
  • 4 years = 1400 kcal
  • 5 years = 1500 kcal

• <10 kg: 100 calories/kg
• 10–20 kg: Add 50 calories/kg to the previous
• >20 kg: Add 20 calories/kg to the above

 

• Normal: 2 g/kg BW
• PEM infant: 4 g/kg BW
  (or) 2 g/kg BW of expected weight

 

Foof stuffs/preparation	Amount	Protein (g)	Calories (kcal)
Cooked rice	1 cup (100 g)	2	100
Wheat chapati	1	2	50
Pooris	2	2	50
Idly	1	2	50
White bread	1 slice	2	50
Dosai	1	2	50
Upma (rava/wheat)	1 cup	6	250
Barley (raw)	1 tsp	0.5	1.1
Ragi	6 tsp	2	100

 

Food stuff	Amount	Protein	Calories
Cooked dal	1 tsp	1/2 (0.5)	15
Soya bean	100 gms	43	430
Bengal/green gram	1 tsp	1	18

 

Araikeerai	100 g	2.8	44
Drum stick leaves	100 g	6.7	92
Beet root	100 g	1.7	48
Potato	100 g	1.6	97
Carrot	100 g	0.9	48
Radish	100 g	0.7	17

 

Food	Amount	Protein	Calories
Human milk	100 mL	1.1	65
Milk powder	1 tsp	2	18
Cow's milk	(100 mL)	1.3–3.5	60
Butter milk	10 Z (30 mL)	0.25	5
Curd	10 Z	1	20

 

Food	Amount	Protein	Calories
Apple	100 g	0.2	60
Banana	100 g	0.6	50
Grapes	100 g	0.5	70
Guava	100 g	0.9	50
Lemon	100 g	0.7	35
Orange	100 g	0.7	60
Orange juice	100 g	0.2	10
Papaya	100 g	0.6	32
Brinjal	100 g	1.4	24
Cluster beans	100 g	3.2	60
Cucumber	100 g	0.4	10
Lady's finger	100 g	1.9	75
Johnston	100 g	1.4	21

 

Food	Amount	Protein	Calories
Ghee (cows)	1 tsp	0	45
Butter (salt)	100 g	0	730
Coconut	100 g	4.5	444
Cashewnut	100 g	21	600
Groundnut	100 g	26	570
Grand nut	100 g	9	200
Fish (shark)	100 g	22	0
Prawn	100 g	19	0
Fish (in general)	100 g	0	60
Beef	100 g	23	115
Pork	100 g	19	114
Goat	100 g	22	118
Egg (hen)	1 (50 g)	6–7	70–80
Biscuits	1	½	25
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Cane sugar	1 tsp	0	20
Brown sugar	1 tsp	0	15
Coconut water	100 mL	1.4	24
RISAM	1 cup	0	20
Coffee	1 cup	1.4	60
Ice cream	1 heaping	2	200
Oil	5 mL (1 tsp)	2	45

 

• Cereals −6.5–7 g%
• Rice −6.4 g%
• Wheat ∓12 g%
• 6 g of protein
  • 1 egg
  • 1 tumbler milk
  • 3 idlies
  • 3 chapati
  • 3 dosa
  • 3 bread slice
  • 12 tsp cooked dal
  • 10Z meat/fish
  • 3 cups cooked rice
  • 50 groundnuts

 

1. Before admission
2. At present in hospital
3. Recommended diet

 

Time	Food item and amount	Protein (G)	Calories
7 am 7.01–8.00 am	Milk 150 mL sugar 2 idlies/ghee 1 tsp
1.00 pm
4.00 pm
8.00 pm 10.00 pm
Total

1. Energy derived from cereals not more than 75%
2. Ratio of cereal protein to pulse protein to be kept between 1:1
3. Minimum leafy 2 other vegetables not to exceed 150 g/day in adult
4. Minimum milk:100 mL/day
5. Energy from refined sugar: Kept around 5%
   Calories from fats/sugar not to exceed 20%
6. Level of food items suggested should be consumed by average child

 

1. Pancreatic amylase appears
2. Baby starts drooling saliva that is ready to digest starch
3. Taste buds that are present from birth are connected to cortex
4. Chewing movements appear indicating neuromuscular coordination
5. Breast milk maximum level (600–700 mL) at 3 months:
   Thereafter no increase but there is a decrease gradually.
   So to satisfy the growth of baby, wean at 6th month.
6. Body store of Iron and vitamin A are exhausted by 6th month
7. Period of negativism after 6 months develops
   Therefore, food items that he will be taking in future should be given by small amounts after 6 months of age.

 

1. Weaning foods prepared with milk:
   1. Rice and milk payasam
   2. Green gram and milk payasam
   3. Carrot and milk as carrot kheer
   4. Dry banana powder and milk
2. Weaning foods without milk: Khichedi, idiappam and idli
3. Family diet modified and given to infants
   1. Rice and dal
   2. Pongal and Upma

 

1. Primary lactase insufficiency in infant (absolute CI)
2. Galactosemia in infant (absolute CI)
3. Active TB in mother
4. Serious ill health
5. Postpartum psychosis in mother
6. Mother on following drugs
   • Anticoagulants
   • Narcotics
   • Antineoplastic
   • Radioactive drugs