ASSESING MALNUTRITION IN CHILDREN

6 months to 5 years

The 4 key features used to diagnose acute malnutrition are:

  • Weight-for-Height/Length (WFH/L) using WHO growth standards charts (see section 17.5). It is the best indicator for diagnosing acute malnutrition.
  • Mean Upper Arm Circumference (MUAC) in mm using a measuring tape (see section 17.5)
  • Oedema of both feet (kwashiorkor with or without severe wasting)
  • Appetite test: ability to finish portion of ready-to-use therapeutic food (RUTF).

WEIGHT FOR AGE (WFA) reflects both long term (stunting) and short term (wasting) nutritional status, so
it is not very useful for diagnosis of acute malnutrition. It can also miss out oedematous children, who are very
malnourished but may have a near-normal weight because of fluid retention.

Diagnostic criteria

TYPE CRITERIA
Moderate
Acute
Malnutrition
  • WFH/L between -3 and -2 z-scores
  • Or MUAC 115 up to 125 mm
  • Or low weight for age
Severe Acute
Malnutrition

Without complications

  • Oedema of both feet (kwashiorkor with
    or without severe wasting) OR
  • WFH/L less than -3 z scores OR
  • MUAC less than 115 mm OR
  • Visible severe wasting
    AND
  • Able to finish RUTF

With complications

  • Oedema of both feet OR
  • WFH/L less than -3 z scores OR
  • MUAC less than 115 mm OR
  • Visible severe wasting
    AND
  • Any one of the following:
    • Medical complication present OR
    • Not able to finish RUTF
Specific
micronutrient
deficiencies
  • Vitamin A: xerophthalmia
  • Vitamin C: scurvy
  • Vitamin B12 and folic acid:
    megaloblastic anaemia (see section
    11.1.1.2)
  • Iron: iron-deficiency anaemia (see
    section 11.1.1.1)

Investigations

Children with SAM should always be first assessed with a full clinical examination to confirm presence of any danger
sign, medical complications, and tested for appetite.

  • Assess patient’s history of:
  • Recent intake of food, loss of appetite, breastfeeding
  • Usual diet before current illness (compare the answers to the Feeding Recommendations for the Child’s age
    • Duration, frequency and type of diarrhoea and vomiting
    • Family circumstances
    • Cough >2 weeks and contact with TB
    • Contact with measles
    • Known or suspected HIV infection/exposure
  • Initial examination for danger signs and medical complications:
    • Shock: lethargy or unconscious, cold hands, slow capillary
      refill (<3 seconds), weak pulse, low blood pressure
    • Signs of dehydration
    • Severe palmar pallor
    • Bilateral pitting oedema
    • Eye signs of vitamin A deficiency: dry conjunctiva, corneal
      ulceration, keratomalacia, photophobia
    • Local signs of infection: ear, throat, skin, pneumonia
    • Signs of HIV (see WHO Clinical Staging section 3.1.1)
    • Fever (≥37.5°C) or hypothermia (rectal temp <35.5°C)
    • Mouth ulcers
    • Skin changes of kwashiorkor: hypo- or hyperpigmentation, desquamation, ulcerations all over the body, exudative lesions (resembling burns) with secondary infection (including candida)
  • Laboratory tests
    • Blood glucose
    • Stool microscopy for ova and cysts, occult blood, and parasites
  • Chest X-ray: Look for evidence of tuberculosis or other chest abnormalities
  • Conduct an appetite test
    • Assess all children ≥6 months for appetite at the initial visit and at every follow up visit to the health facility
  • Determine WFH/L: Measure the child’s height and weight and plot the score on the appropriate chart (boy or
    girl). Match the value to the z-score on the right y-axis to determine the child’s z-score (see section 17.5)
  • Measure MUAC: Using a MUAC tape, measure the circumference of the child’s upper arm and plot the score
    on the appropriate chart (boy or girl). Please note: 1 cm=10 mm, so 11.5 cm = 115 mm.

HOW TO DO APPETITE TEST

  • Arrange a quiet corner where the child and mother can take their time to eat RUTF. Usually the child eats the
    RUTF portion within 30 minutes

Explain to the mother

  • The purpose of assessing the child’s appetite
  • What RUTF is
  • How to give RUTF
    • Wash hands before giving RUTF
    • Sit with child and gently offer RUTF
    • Encourage child to eat without feeding by force
    • Offer plenty of water to drink from a cup during RUTF feeding

Offer appropriate amount of RUTF to child to eat:

  • After 30 minutes, check if the child was able to finish or not able to finish the amount of RUTF given and decide:
    • Child ABLE to finish at least one third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes
    • Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30
      minutes