Clinical Presentation

Chronic malnutrition is identified by low height for age, also known as stunting. Chronically malnourished children are shorter than other children their age and may fail to meet their long-term growth potential. Acute malnutrition is characterized by low weight for height and low MUAC with or without symmetric edema. Severe acute malnutrition is defined as severe wasting, nutritional edema, or both. An acutely malnourished child has low body fat reserves and may also have limited protein stores. Children with severely low levels of serum protein often develop symmetric edema. Table 14-1 displays criteria used to define moderate and severe malnutrition. This chapter uses the World Health Organization (WHO) definitions to classify the severity of malnutrition. It is common for stunting and wasting to occur concomitantly. Children with combined chronic and acute malnutrition are both short for age and thin for height.

Table 14-1 World Health Organization Criteria for Defining Moderate and Severe Malnutrition

	Moderate Malnutrition	Severe Malnutrition
Height for age	−3 to −2 SD below the mean (85th to 89th percentile)	<−3 SD below the mean (<85th percentile)
Weight for height	−3 to −2 SD below the mean (70th to 79th percentile)	<−3 SD below the mean (<70th percentile)
Symmetric edema	No	Yes

SD, standard deviation.

Scales for assessing weight, stadiometers for measuring height, and tape measures for evaluating MUAC are all essential tools in settings where severe malnutrition is diagnosed and managed. Growth charts (discussed in Chapter 13) are also necessary to allow for the quantification of the degree of malnutrition. In very low-resource settings when scales are not available, MUAC tapes alone may be used to screen for and follow up severe acute malnutrition (Figure 14-1).

The three common forms of protein-energy malnutrition are marasmus, kwashiorkor, and a mixed form called marasmic kwashiorkor. Whereas marasmus is typically considered to be a reflection of caloric deficiency, kwashiorkor is thought to be reflective primarily of a deficiency of protein. Marasmus can be recognized visually by decreased subcutaneous fat leading to prominent bones and the appearance of “loose skin,” especially around the buttocks. Kwashiorkor is characterized by bilateral pitting edema and a protuberant belly (Figure 14-2). Malnutrition is commonly associated with visible hair and skin changes. The hair is commonly thin, scanty, straight, and lightly pigmented. Skin changes are varied and commonly include xerosis, itchy rashes, and poor wound healing.

Other physical examination findings that are commonly seen with severe malnutrition are outlined in Table 14-2.

Table 14-2 Common Physical Examination Findings in Severe Acute Malnutrition

Physical Finding	Significance
Low height for age	• Indicates stunting

Low weight-for-height and low MUAC Edema Extreme pallor Sunken eyes Corneal and conjunctival lesions Weak pulses Hypothermia Cold hands and feet without central hypothermia Mental status changes Dry mouth and absent tears Shedding and ulceration of skin, particularly of the perineum, groin, limbs and armpits

MUAC, mid-upper arm circumference.

Differential Diagnosis

When diagnosing malnutrition, underlying causes should be investigated. Infections with HIV, tuberculosis, malaria, and parasites commonly cause or exacerbate malnutrition. Failure to identify and treat these underlying conditions would prohibit appropriate recovery. Other common causes of severe malnutrition can be found in Chapter 17, specifically Table 17-1.

Physiologic Changes Accompanying Malnutrition

Profound physiologic changes occur in children with severe acute malnutrition. All body systems undergo significant functional changes with severe malnutrition. Table 14-3 outlines some of the most significant physiologic changes that occur with severe acute malnutrition and the treatment approaches that are necessary to avoid complications related to these physiologic abnormalities.

Table 14-3 Major Physiologic Changes with Severe Acute Malnutrition

Body System	Major Physiologic Changes	Treatment Approaches
Cardiovascular	• Decreased cardiovascular output and stroke volume • Low blood pressure • Increase in blood volume may rapidly lead to heart failure • Decrease in blood volume may compromise tissue perfusion

Dermatologic Gastrointestinal Hepatic Immunologic Renal and electrolytes

IV, intravenous.

Micronutrient deficiencies are also common among children with severe malnutrition. Vitamin A deficiency should be assumed to be present, and high-dose vitamin A should be provided on day 1 of treatment. For infants younger than 6 months of age, a high-dose vitamin A is 50,000 IU; 100,000 IU should be given to infants between 6 and 12 months, and 200,000 IU should be given to children over 12 months of age. When clinical signs of vitamin A deficiency are present, an additional large dose of vitamin A should be given on day 2 of rehabilitation and a third dose about 2 weeks later. Ocular signs of vitamin A deficiency are often easily recognizable and include night blindness, conjunctival xerosis with foamy white Bitot’s spots, keratomalacia, and corneal ulceration (Figure 14-3).

Diagnostic Evaluations

In many settings where severe acute malnutrition is endemic, resource limitations prevent any evaluation beyond physical examination and history taking. When available, laboratory evaluation would include tests for suspected causes such as infection, stool for ova and parasites, cultures, serology, complete blood count, and serum electrolytes, as well as any indicated radiographic imaging.

Management

A severely malnourished child is also often severely ill, and management must progress through stages of recovery. The first week of treatment for severe malnutrition is referred to as the stabilization phase because appropriate management during this period makes the child less vulnerable to malnutrition-related death and is critical for survival. There are physiologic differences between a healthy child and a severely malnourished child that must be taken into account in devising management plans during at least the first 6 weeks of rehabilitation. Close follow-up of a malnourished child should continue for at least 6 months after presentation with severe malnutrition. Figure 14-4 outlines the main goals of each phase of management of a severely malnourished child.

Inappropriate stabilization and rehabilitation of a severely malnourished child can have fatal consequences. Severely malnourished children cannot tolerate typical amounts of protein, sodium, or fat found in routine infant formulas, and they require frequent feeds with simple carbohydrates. During stabilization, breast milk and F-75 milk formula (75 kcal and 0.9 g protein per 100 mL) are recommended by the WHO for feeding. For infants with severe malnutrition who are acutely and severely ill, exclusive breastfeeding is often unsuccessful; therefore, supplementation with F-75 should be attempted. Deaths related to an excessive renal solute load during malnutrition recovery can be avoided by using F-75 formula. Between 80 and 100 kcal/kg of F-75 should be given daily during the stabilization phase by way of small feedings every 2 to 3 hours.

After stabilization with F-75, advancement to F-100 (100 kcal and 2.9 g protein per 100) is recommended as a “catch-up” formula to help rebuild wasted tissues. In some areas of the world, easily transportable, ready-to-use therapeutic foods (RUTFs) such as “plumpy nut” bars are used in addition to or instead of F-100.

In addition to high-dose vitamin A supplementation (discussed above), micronutrient supplementation in the form of a vitamin mix containing riboflavin; pyridoxine; thiamine; and vitamins C, D, E, and K should be provided daily. Folate should also be supplemented giving 5 mg on day 1 and then 1 mg/d throughout rehabilitation and follow-up. Iron can have toxic effects during acute severe malnutrition and should not be given during the first week of treatment.

Studies have shown that a high percentage of severely malnourished children have bacterial infections when first admitted to hospitals. Empiric antibiotic treatment of presumed infection in a severely malnourished child has been shown to improve nutritional recovery, lower the incidence of septic shock, and reduce mortality. Clotrimoxazole (25 mg sulfamethoxazole + 5 mg trimethoprim/kg) given twice a day for 5 days is one recommended regimen for severely malnourished children without specific signs of infection.

Children with mild and moderate malnutrition can be treated starting at the rehabilitation phase. Non-edematous children should gain a minimum of 5 g/kg/d of body weight. During rehabilitation, careful attention should be given to assessing the family’s food access, feeding strategies, and food choices. Attention must also be paid to malnourished children’s psychological and intellectual development; emotional and physical stimulation are essential. Successful management of malnourished children requires that both medical and psychosocial problems be recognized and corrected. Without correction of food access issues and behavioral problems, relapse is likely.

Management of Dehydration in Severely Malnourished Children

Dehydration occurs commonly in severely malnourished children, and inappropriate management can be rapidly fatal. Intravenous fluids should be avoided except in cases of shock because of the increased risk of overhydration and heart failure in malnourished children. Children with severe malnutrition require low-sodium rehydration solutions with higher levels of potassium than typically found in oral rehydration solutions (ORS) used for well-nourished children. Use of a ready-made solution (ReSoMal) should be given orally (or via nasogastric tube) at a decreased rate for severely malnourished children. This rate is slower than what would be given to a well-nourished child because of the malnourished child’s increased risk of heart failure from rapid fluid shifts. During rehydration, the child should be monitored closely for signs of cardiac failure.

Future Directions

Children younger than the age of 6 months with malnutrition are at particularly high risk of poor outcomes. HIV-infected children with malnutrition are likewise at increased risk. There is a lack of published information related to the best nutritional rehabilitation strategies for severely malnourished children younger than the age of 6 months. More information is also needed on the optimal treatment of severe malnutrition in HIV-infected children, including changes in antiretroviral drug dosing that may be prudent in severely malnourished children. Experts have hypothesized that severely malnourished children younger than 6 months of age and those with HIV infection may have significant physiologic differences that would make them benefit from care that differs from that offered to older and non–HIV-infected children. Further research in the next few years is likely to lead to different recommendations for the care of these two particularly vulnerable groups.