Pediatric Nutrition in Practice

Primary and Secondary Malnutrition 143

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cation and empowerment, creating proper liveli-
hoods, social protection schemes, etc. The effects
of stunting on the developing brain may be irre-
versible after the age of 3–4 years. Efforts should
therefore be taken to implement the nutrition in-
terventions at an early age so that stunting and
its negative effects on cognition are reversed.
Growth monitoring and promotion programs
should be implemented at the community level,
where the nutritional status of infants and young
children is assessed every 1–3 months and their
growth is promoted through counseling of the
parents.
Since SAM is associated with an almost 10-
fold increase in risk of death, this condition re-
quires special attention. Children with SAM and
complications should be treated in a hospital un-
til they are fit to continue management at home.
Complications include severe diarrhea, dysen-
tery, hypoglycemia, hypothermia, pneumonia,
urinary tract infection, septic illness or any dan-
ger sign as per the Integrated Management of
Childhood Illness guidelines [unable to drink or
breastfeed, vomits everything, has had convul-
sions (>1 or prolonged for >15 min), lethargy or
unconsciousness or currently convulsing]. The
line of management for this stabilization phase of
treatment of complications is as follows [10] :

• Treat hypoglycemia, which is common in
  these children, with oral or intravenous glu-
  cose if the child is lethargic, unconscious or
  convulsing
  
  
  • Treat and prevent hypothermia by keeping the
    child warm
  
  
  • Treat shock, if present, with oxygen therapy,
    intravenous fluids and glucose and broad-
    spectrum antibiotics
  
  
  • Treat and prevent dehydration. The WHO
    oral rehydration solution (75 mmol sodium/l)
    contains too much sodium and too little potas-
    sium for severely malnourished children. They
    should be given the special rehydration solu-
    tion for malnutrition (ReSoMal). It is difficult
    to estimate the dehydration status of a severely
    malnourished child. All children with watery
    diarrhea should be assumed to have dehydra-
    tion and given the following: every 30 min for
    the first 2 h, ReSoMal at 5 ml/kg body weight
    orally or by nasogastric tube; then, in alternate
    hours for up to 10 h, ReSoMal at 5–10 ml/kg/h
    (the amount to be given should be determined
    by how much the child wants as well as by stool
    loss and vomiting). The liquid food, F-75, is
    given in alternate hours during this period un-
    til the child is rehydrated. If the diarrhea is se-
    vere, then WHO oral rehydration solution
    may be used, because the loss of sodium in
    stool is high and symptomatic hyponatremia
    can occur with ReSoMal. Severe diarrhea can
    be due to cholera or rotavirus infection and is
    usually defined as stool output >5 ml/kg/h
  
  
  • Treat and prevent infection. If the child ap-
    pears to have no complications, give oral
    amoxicillin at 15 mg/kg 8-hourly for 5 days.
  
  
  
  

Ta b l e 2. New terms recommended for childhood malnutrition

Moderate acute malnutrition (MAM) Weight-for-height Z score <–2 but >–3

Severe acute malnutrition (SAM) Mid-upper-arm circumference <115 mm

Weight-for-height Z score <–3

Bilateral pitting edema

Marasmic kwashiorkor

Global acute malnutrition (GAM) The sum of the prevalence of SAM plus MAM at a

population level

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 139–146
DOI: 10.1159/000367880