Protein-Energy Malnutrition
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Direct answer
Oedema is the fork in severe malnutrition: a severely wasted child with wizened limbs, no oedema and an old-man face has marasmus, while a child with pedal oedema, flaky discoloured skin, thin hair and an apathetic, moon-faced look has kwashiorkor; both together make marasmic-kwashiorkor. Severe acute malnutrition in a 6–59-month-old is defined by mid-upper arm circumference below 11.5 cm, weight-for-height below minus three z-scores, or bipedal oedema. Treatment follows the WHO ten steps — stabilise first with F-75, antibiotics, warmth and cautious fluids, rehabilitate later with F-100 or ready-to-use therapeutic food — and rushing the second phase into the first kills children.
What you must remember
- Anthropometry: wasting (weight-for-height) marks acute malnutrition, stunting (height-for-age) chronic, underweight (weight-for-age) both; MUAC 11.5–12.5 cm is moderate acute malnutrition, below 11.5 cm or any bipedal oedema is severe.
- Kwashiorkor: oedema beginning at the feet, "flag sign" hair that pulls out in tufts, flaky-paint dermatosis, moon face, hepatomegaly from fatty change, apathy with a miserable appetite.
- Marasmus: severe wasting without oedema, "monkey face", baggy-pants folds over the buttocks, a hungry, alert child — the mirror image of kwashiorkor's apathy.
- Admission threats: hypoglycaemia and hypothermia (both checked in the first hour), dehydration, severe infection often without fever, and potassium depletion despite oedema.
- The ten steps in two phases: stabilisation (treat or prevent hypoglycaemia and hypothermia, treat infection, correct micronutrients — vitamin A, zinc, copper, folate, but no iron yet — cautious rehydration, F-75), then rehabilitation (transition, F-100 or ready-to-use therapeutic food, catch-up growth, stimulation, discharge preparation).
- F-75 (75 kcal per 100 mL) is the starter feed, 2–3 hourly; the move to F-100 or RUTF waits for a passed appetite test and settling oedema.
- Catch-up growth means more than 5–10 g per kg per day; failure to gain signals missed infection, inadequate feeding or another problem.
- Refeeding discipline: no iron in stabilisation, small initial volumes, and extreme caution with IV fluids in the oedematous child whose heart fails easily.
The first 48 hours, step by step
A 16-month-old with oedema to the knees, dull and refusing feeds, MUAC 10.8 cm, is admitted. Hour one: dextrostix 40 mg per dL gets 50 mL of 10 per cent dextrose then a feed; temperature 35.4°C means kangaroo care, a hat and a heater — hypoglycaemia and hypothermia travel as a pair and are treated together. Amoxicillin starts even without fever, with gentamicin added for any danger sign, because malnourished children mount no fever. Feeding begins with F-75, 2–3 hourly in small volumes; vitamin A, zinc, copper and folate are given and iron deliberately withheld. IV fluids are a last resort, given slowly and small, because the oedematous heart fails. Around day four to six the child brightens and takes feeds greedily — the appetite test is passed, transition to F-100 and ready-to-use therapeutic food begins, targeting more than 5 g per kg per day, and the mother is taught before discharge. The examinable ordering never changes: the deaths happen in week one, from hypoglycaemia, hypothermia, infection and over-enthusiastic feeding.
Where students slip
Oedema is read as overnutrition — a kwashiorkor child labelled "well fed but swollen" when the oedema is hypoalbuminaemic wasting. The ten steps are recited but the sequencing is lost: F-100 or iron in the stabilisation week, or a rapid IV bolus in an oedematous child, are punished answers. Appetite is under-used — readiness for catch-up feeding is decided by an appetite test and alertness, not the calendar. And MUAC is forgotten: the single coloured band on a bare arm identifies severe acute malnutrition anywhere in India without a scale or chart, which is why Anganwadi workers carry it.
Frequently asked questions
How is severe acute malnutrition diagnosed?
Mid-upper arm circumference below 11.5 cm in a 6–59-month-old, weight-for-height below minus three z-scores, or bipedal oedema — any one criterion suffices.
What separates kwashiorkor from marasmus?
Kwashiorkor has oedema, flaky-paint skin, hair changes, hepatomegaly and apathy with poor appetite; marasmus has severe wasting without oedema and typically a hungry, alert child.
Why is F-75 used before F-100?
F-75 is a low-protein, low-sodium starter feed meeting maintenance needs without overwhelming fragile homeostasis; F-100 and RUTF start only after stabilisation.
Why is iron withheld initially in SAM?
Iron during stabilisation promotes free-radical damage and infection; it is added during rehabilitation once infection is controlled.
What are the immediate threats to life on admission?
Hypoglycaemia, hypothermia, severe infection and dehydration — each detected and treated in the first hours, before any thought of rapid weight gain.
What weight gain defines adequate catch-up growth?
More than 5 g per kg per day during rehabilitation; less prompts a search for infection, feeding error or an untreated condition.