1. Breast feeding:

• Duration 0-2 yrs.
• Exclusive in the 1^st 4-6 months.

2. Weaning:

• Definition: separation from breast feeding and introduction of mixed diet.
• It should start at 4-6m because at this age the baby require more food items, also to train him for swallowing and digestion.
• It should be gradual, replacing one milk feed at a time then continued until all feeds are replaced at the age of 2yrs.

3. Normal nutrition requirement:

• Energy:
  • 110 Kcal/kg/day (at the 1^st yr).
  • (age x 120) + 1000 (from 2^nd yr).

• Protein: 2g/kg/day
• Balanced meal contains: (50% CHO, 35% fats, 15%protein)
• No. of feeds:
  • 6months-1yr (2-4meals/day).
  • From 1yr and above (3meals + 2snacks).
• Type of food:
  • 4m cereals and vegetables.
  • 6m white meats, egg yolk.
  • 1yr eggs, red meats.
  • 1.1/2yrs family ordinary diet.

4. Classification

• 4.1. WELCOME: (Simple)

Disadvantage: depend on age, not identifying chronic cases.

• 4.2. GOMEZ: (wt./age)

  • 1^st degree 90-75%.

  • 2^nd degree 74-60%.

  • 3^rd degree <60%.

• 4.3. WHO: (wt./ht.)

  • 1Z score  90% of median.

  • 2Z           80%.

  • 3Z           70%.

  • 4Z           60%.

• 4.4. WATERLOW:

• 4.5. MUAC: mid upper arm circumference:

  • Normal (13.5-16 cm).

  • Moderate (12 cm).

  • Sever (<11 cm).

5. Etiology:

1. Infections: (measles, GE, malaria, ARI, TB, parasite.
2. Unavailability of food: (poverty, ignorance, lack of education).
3. Feeding mismanagement: (bottle feeding, poor weaning practice).
4. Family size and spacing.
5. Maternal deprivation.
6. Culture food practice.
7. Protein loss, malabsorption.
8. Metabolic and congenital malformation.

6. Pathophysiology:

• Edema and atrophy of all organs.
• Edema due to hypoalbuminemia, stimulation of rennin-angiotensin, ↑Na, water retention.
• Musculoskeletal: wasting, hypotonia, abd. distention, decrease total bone mass.
• GIT: mouth mucosal atrophy, ulceration, subtotal villous atrophy, lactose intolerance.
• Fatty infiltration of the liver due to ↓β lipoprotein.
• CVS: ↓COP, atrophy of cardiac muscle.
• Blood: anemia (dimorphic, ch. diseases) impair cellular immunity, late bleeding.

Biochemical Changes:

• Reduced basal metabolic rate (BMR).
• Low glucose, impaired GTT, ketonuria.
• Low amino acid, serum albumin -ve nitrogen balance.
• Low cholesterol.
• Low electrolytes (k, mg...).
• Low enzymes.
• Low hormones and high cortisol and growth hormone.
• Low creatinine clearance.

7. Clinical Manifestations:

7.1. MARASMUS:

1. Usually at 1^st 2yrs.
2. Weight loss.
3. Muscle wasting.
4. Emaciation.
5. Loss of subcutaneous fat.
6. Old man appearance.
7. Distended  abdomen.
8. Hypotonia.
9. Irritability.
10. Low temp. and pulse.
11. Decrease appetite.
12. Constipation.
13. Less marked skin changes.
14. Angular stomatitis, oral thrush.
15. Infection signs of vitamins deficiencies.

7.2. KWASHIORKOR (deposed child):

1. After weaning up to 5yrs.
2. Behavioral changes (apathy).
3. Generalized edema & hepatomegaly (due to fatty infiltration).
4. Dermatosis: hypo. and hyper-pigmentation, desquamation (flaky paint sign), ulcerations, fissures.
5. Hair dry thin silky straight brittle, dyspigmented shades of brown, yellow and gray color (flag sign).

8. Anthropometry:

1. Weight.
2. Height.
3. Wt for Ht.
4. Mid-arm circumference.
5. Skin fold thickness.
6. Chest/head ratio.

9. Complications:

1. Infections.
2. Dehydration and electrolyte disturbance.
3. Hypothermia.
4. Hypoglycemia.
5. Severe anemia.
6. H. failure.
7. Lactose intolerance.
8. Severe dermatosis.

10. Investigations:

• S. alb, RBS, electrolytes.
• CBC.
• ESR.
• CXR.
• Mantoux test.
• Stool analysis (parasites, Ph, reducing substance).
• Urine analysis.
• Blood: (C/S, BFFM).

11. Management:

Treatment of acute complications:

1. Dehydration:
   1. Rehydrate orally except in shock pt.
   2. Use Resomal (low Na, high K).
2. Hypothermia:
   1. Keep child beside his mother.
   2. Adjust room temp. sss.
   3. Use hot water bottle.
   4. Increase feeding.
3. Hypoglycemia:
   1. Asymptomatic by oral sugar solution, frequent feeds.
   2. Symptomatic by I.V. dex10%.
4. Heart failure:
   1. Oxygen, cardiac bed, monitoring.
   2. I.V. Frusemide, avoid I.V. fluid.
5. Infection:
   1. Not ill: give metronidazole, co-trimoxazole.
   2. Ill pt.: parentral penicillin, gentamicin.
   3. Rx. malaria, T.B, meningitis.
6. Electrolyte imbalance:
   1. Add to feed mineral mix.
   2. Rx. of hypokalemia by I.V infusion.
7. Severe anemia:
   1. PRBC (packed RBCs), 10ml\kg + lasix.
   2. Folic acid and iron (delay iron after passing the acute phase).

12. Nutritional rehabilitation:

• Give Kwash milk start by small frequent amount, by NGT or syringe.
  • Kwash milk composed of: (in one liter)
    • Milk 1000ml (1000 x 67kcals)
    • Sugar 40gm (40 x 4kcals)
    • Oil 20gm (20 x 9kcals)

• Egg separately.

• Give:
  • 150-200kcal/kg/D.
  • 3-4G/kg/D protein. Calculate from the average weight.

• Start by initial formula F75 (diluted) followed by maintenance formula F100 (75 and 100 kcals per 100 ml).
• After regaining wt give semi-solid food
• Micronutrient: give vit. A, folic acid, multi-vitamins and minerals (Mg, Zn, Cu, Se)
• Health education