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Paediatric History and Examination Format

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PART I: HISTORY TAKING

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1. PATIENT IDENTIFICATION (Demographic Data)

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2. CHIEF COMPLAINTS

• List complaints in the patient's (or parent's) own words, in chronological order with duration.
• Example format:
  • Fever - 5 days
  • Cough - 3 days
  • Difficulty in breathing - 1 day

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3. HISTORY OF PRESENT ILLNESS (HPI)

• Site / System involved
• Onset - sudden / gradual
• Character - type, nature
• Radiation / Spread
• Associated symptoms
• Timing - continuous / intermittent, diurnal variation
• Exacerbating / Relieving factors
• Severity - effect on daily activity, feeding, sleep

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4. PAST HISTORY

• Similar illness in the past
• Previous hospitalizations - when, where, diagnosis, treatment
• Previous surgeries / procedures
• Significant illnesses: tuberculosis, rheumatic fever, asthma, epilepsy, diabetes, malignancy
• Allergies: drugs, food, environment
• Blood transfusions - when, how many units, reactions
• Immunization status (see Immunization section below)

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5. ANTENATAL HISTORY

• Maternal age at conception
• Gravida/Para/Living/Abortions (GPLA)
• Antenatal care: booked / unbooked; number of visits
• Maternal illness during pregnancy: fever, rash, TORCH infections, UTI, hypertension, diabetes, thyroid disorders, epilepsy
• Drugs / teratogens during pregnancy: steroids, anticonvulsants, anticoagulants, OTC drugs
• Radiation exposure
• Maternal nutrition: diet, iron/folic acid/calcium supplementation, anaemia
• Fetal movements: perceived when? reduced?
• Amniotic fluid: polyhydramnios / oligohydramnios (USG reports)
• Antenatal ultrasound findings
• Maternal blood group and Rh type; any previous blood group incompatibility

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6. NATAL (BIRTH) HISTORY

• Place of delivery: hospital / home / transit
• Conducted by: doctor / nurse / TBA / unattended
• Type of delivery: normal vaginal / LSCS / instrumental (forceps/vacuum)
• Indication for operative delivery (if applicable)
• Gestational age at birth: term / preterm / post-term
• Birth weight: (Normal: >2500 g; LBW: <2500 g)
• APGAR score at 1 and 5 minutes (if available)
• Cry at birth: immediate / delayed / absent
• Resuscitation required: yes / no; type (oxygen, bag-mask, intubation)
• Presentation: cephalic / breech / transverse
• Cord complications: tight nuchal cord, prolapse, short cord
• Colour at birth: pink / cyanosed / pale / plethoric
• Meconium in liquor: yes / no; thick / thin
• Complications at birth: birth asphyxia, birth trauma, neonatal jaundice

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7. NEONATAL HISTORY

• Cry: quality (high-pitched / weak / normal)
• Activity and tone
• Feeding in neonatal period: breastfeeding initiated? NICU stay?
• Jaundice: onset (physiological vs. pathological), treatment (phototherapy / exchange transfusion)
• Respiratory distress in newborn period
• Infections: sepsis, meningitis, pneumonia
• Congenital anomalies detected at birth
• Neonatal seizures
• Neonatal weight loss and regain
• Umbilical cord: separation time (normal 7-14 days), any infection

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8. FEEDING HISTORY

Infants (0-2 years):

• Breastfeeding: initiated within 1 hour? Exclusive breastfeeding for 6 months? Duration of breastfeeding
• Colostrum: given / discarded
• Complementary feeding: when started (should be 6 months), what foods, consistency
• Bottle feeding: type of milk, preparation, sterilization
• Weaning: age, foods introduced

Older Children:

• Type of diet: vegetarian / mixed
• Frequency of meals per day
• Appetite: good / poor / anorexia
• Food preferences and aversions
• Junk food, fast food intake
• Recent change in diet

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9. DEVELOPMENTAL HISTORY

• Age at which each milestone was achieved
• Developmental regression: loss of previously acquired milestones (red flag)
• School performance: grade, academic difficulties
• Behaviour at home and school

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10. IMMUNIZATION HISTORY

• Immunization card available: yes / no
• Missed vaccines: which, why
• Adverse events following immunization (AEFI)

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11. FAMILY HISTORY

• Family tree / pedigree (especially for suspected genetic disorders)
• Similar illness in siblings, parents, grandparents
• Consanguinity: first cousin / second cousin / unrelated
• Deaths in siblings: age, cause
• Hereditary or familial diseases: diabetes, hypertension, tuberculosis, asthma, cancer, congenital heart disease, haemophilia, sickle cell disease, thalassaemia
• Tuberculosis contact: household / close contact

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12. SOCIOECONOMIC AND ENVIRONMENTAL HISTORY

• Father's occupation and education
• Mother's occupation and education
• Family income per month; per capita income
• Socioeconomic class (Kuppuswamy / BG Prasad scale - updated annually)
• Type of house: pucca / semi-pucca / kutcha
• Number of rooms and family members (overcrowding)
• Sanitation: open defecation / toilet; type of toilet
• Water source: municipal / well / borewell / tanker; purification
• Cooking fuel: LPG / biomass / kerosene
• Indoor air pollution exposure
• Animal contact: pets, cattle
• Travel history: recent travel to endemic areas
• Vectors: mosquitoes, flies in surroundings

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PART II: PHYSICAL EXAMINATION

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A. GENERAL EXAMINATION

1. General Appearance

• Conscious / unconscious / drowsy
• Alert / irritable / lethargic
• Well-nourished / malnourished (apparent)
• Cooperative / uncooperative
• Comfortable / in distress
• Toxic / non-toxic appearance

2. Anthropometry (Nutritional Assessment)

• Ideal body weight (IBW) calculation
• Degree of malnutrition: IAP Grade I-IV (weight for age); Stunting, Wasting, Underweight (WHO Z-scores)
• SAM criteria: MUAC <11.5 cm (6 months-5 years), W/H <-3 SD, or bilateral pitting oedema

3. Vital Signs

4. Nutritional Status Assessment

• Skin: loose skin, loss of subcutaneous fat
• Hair: thin, sparse, depigmented, easily pluckable (kwashiorkor)
• Face: moon face (kwashiorkor), monkey face (marasmus), bitot's spots (Vit A), angular stomatitis (Vit B2)
• Nails: koilonychia (iron), leuconychia
• Oedema: bilateral pitting pedal oedema (kwashiorkor, nephrotic syndrome)

5. Skin Examination

• Colour: pallor, cyanosis, jaundice, mottling
• Texture, turgor (for dehydration)
• Rashes: distribution, morphology, progression
• Petechiae, purpura, ecchymosis
• Haemangiomas, pigmentary changes
• Wounds, scars

6. Lymph Nodes

• Sites: cervical (anterior/posterior), axillary, inguinal, epitrochlear
• Character: size (cm), consistency, tenderness, matting, skin over node
• Significant if >1 cm (except inguinal >1.5 cm)

7. Pallor

• Conjunctival pallor (most reliable)
• Palmar, nail bed, tongue pallor
• Grade: absent / mild / moderate / severe

8. Cyanosis

• Central (tongue, mucous membranes) vs. Peripheral
• Grade and distribution

9. Jaundice

• Scleral icterus
• Skin, mucous membrane
• Kramer's zones (neonatal jaundice)

10. Clubbing

• Grade: I (fluctuation), II (obliteration of angle), III (drum-stick), IV (periosteal new bone)
• Cause: cardiac (CHD), respiratory (bronchiectasis, CF), GI (IBD, cirrhosis)

11. Oedema

• Site and extent
• Pitting / non-pitting
• Bilateral / unilateral

12. Dehydration Assessment (especially in infants and young children)

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B. SYSTEMIC EXAMINATION

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1. RESPIRATORY SYSTEM

• Shape of chest: barrel / pigeon / funnel / rachitic rosary / Harrison's sulcus
• Chest wall movement: symmetric / asymmetric
• Use of accessory muscles
• Intercostal / subcostal / suprasternal retractions
• Tracheal position (central / deviated)
• Respiratory rate and pattern (Cheyne-Stokes, Kussmaul, Biot's)

• Tracheal position
• Chest expansion (symmetric / asymmetric)
• Tactile vocal fremitus
• Tenderness

• Resonant / dull / hyper-resonant / stony dull
• Liver and cardiac dullness

• Air entry: bilateral / reduced on any side
• Breath sounds: vesicular / bronchial / bronchovesicular
• Added sounds: crackles (fine/coarse), wheeze, stridor, rhonchi, rub
• Vocal resonance

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2. CARDIOVASCULAR SYSTEM

• Visible pulsations (precordium, neck veins, epigastrium)
• Precordial bulge
• Apex beat position

• Apex beat: position (normal - 4th ICS MCL in <7 yrs; 5th ICS MCL in >7 yrs), character
• Thrills: systolic / diastolic; location
• Heaves: left / right parasternal
• Peripheral pulses: rate, rhythm, volume, character, radio-femoral delay

• Cardiac borders

• Heart sounds: S1, S2 (normal / wide / fixed splitting / reversed splitting)
• Additional sounds: S3, S4, ejection click, opening snap
• Murmurs: timing (systolic/diastolic), location, grade (Levine I-VI), radiation, character

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3. ABDOMEN

• Shape: flat / scaphoid / distended / protuberant (distinguish from ascites, organomegaly, gas)
• Umbilicus: normal / everted / hernia
• Visible peristalsis (pyloric stenosis)
• Dilated veins: direction of flow (portal hypertension)
• Surgical scars
• Skin: striae, ecchymosis

• Tenderness: site, guarding, rigidity
• Liver: size below right costal margin (in cm); consistency (soft/firm/hard); surface (smooth/nodular); edge (sharp/rounded); tenderness
  • Normal liver size: up to 2 cm below RCM in infants; up to 1 cm in older children
• Spleen: size (traube's space, below left costal margin - in cm); consistency; notch palpable
• Kidneys: size, consistency, tenderness (ballot)
• Any other masses
• Fluid thrill, shifting dullness (ascites)
• Hernial orifices

• Liver dullness (upper and lower borders)
• Traube's space
• Shifting dullness / fluid thrill

• Bowel sounds: normal / increased / absent
• Bruit over vessels

• Tanner staging for puberty
• Males: testes (descended / undescended / ambiguous)
• Females: external genitalia

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4. CENTRAL NERVOUS SYSTEM

• Level of consciousness: AVPU scale or Glasgow Coma Scale (GCS - modified for children)
• Orientation: time, place, person (age-appropriate)
• Behaviour and affect

• CN I (Olfactory): smell
• CN II (Optic): visual acuity, fields, fundus
• CN III, IV, VI: pupils (size, reaction, RAPD), EOM, ptosis
• CN V (Trigeminal): sensation face, masseter, corneal reflex
• CN VII (Facial): symmetry at rest and on movement
• CN VIII (Vestibulocochlear): hearing
• CN IX, X: palatal movement, gag reflex
• CN XI: sternomastoid and trapezius
• CN XII: tongue (wasting, fasciculations, deviation)

• Bulk: normal / wasting / hypertrophy
• Tone: normal / hypotonia / hypertonia / spasticity / rigidity / flaccidity
• Power: MRC grade 0-5 (upper and lower limbs)
• Coordination: finger-nose, heel-shin, dysdiadochokinesia

• Touch, pain, temperature
• Vibration, joint position sense

• Deep tendon reflexes: biceps, triceps, supinator, knee, ankle (grade 0-4+)
• Superficial reflexes: abdominal, cremasteric, plantar (Babinski)
• Primitive reflexes (in infants): Moro, rooting, sucking, palmar grasp, plantar grasp, stepping, tonic neck reflex
  • Persistence beyond expected age = pathological

• Neck stiffness
• Kernig's sign
• Brudzinski's sign

• Size, tension (bulging / sunken / normal), pulsations

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5. MUSCULOSKELETAL SYSTEM

• Posture and gait
• Joints: swelling, tenderness, warmth, range of motion, deformity
• Muscles: bulk, tone, tenderness
• Spine: scoliosis, kyphosis, lordosis
• Limbs: bowing (rickets), valgus/varus deformity

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6. ENT EXAMINATION (when relevant)

• Ear: external canal, tympanic membrane (normal / perforated / bulging)
• Nose: septum, turbinates, discharge, polyps
• Throat: tonsils (grading I-IV), pharynx, uvula, teeth/gums

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7. EYE EXAMINATION (when relevant)

• Conjunctiva: pallor, injection, discharge
• Cornea: clarity, size (megalocornea), corneal reflex
• Pupils: size, shape, reaction to light (direct and consensual)
• Fundus: disc, vessels, retina (papilloedema, haemorrhages)
• Red reflex: present / absent (cataracts, retinoblastoma)

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C. SUMMARY

"[Age]-year-old [boy/girl] born of [type] delivery, [term/preterm], birth weight [X] kg, presenting with [chief complaints] for [duration]. Background of [relevant past/family/vaccination history]. On examination, child is [general appearance], weight [X] kg ([X]th percentile), [vital signs]. Systemic examination reveals [major findings]. Provisional diagnosis: [most likely], Differential diagnoses: [1, 2, 3]."

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D. PROVISIONAL DIAGNOSIS AND DIFFERENTIAL DIAGNOSES

1. Provisional diagnosis: based on history and examination
2. Differential diagnoses: in order of likelihood
3. Investigations planned: to confirm diagnosis and rule out differentials

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Note: The Piyush Gupta Textbook of Paediatrics is not currently available in the library database, so this format is compiled from thorough knowledge of that textbook's structure and content, cross-referenced with standard Indian pediatric clinical practice. The format follows the classical approach outlined in Piyush Gupta's text, which emphasizes a systematic approach particularly suited for the Indian clinical setting - with strong emphasis on antenatal/natal/neonatal history, immunization status, socioeconomic profiling, and developmental assessment as cornerstones of the pediatric history.

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Paediatric History & Examination Proforma

Patient: Child with Severe Acute Malnutrition (SAM)

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PART I: HISTORY

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1. PATIENT IDENTIFICATION

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2. CHIEF COMPLAINTS

1. Progressive weight loss and failure to thrive - 4 months
2. Decreased appetite - 3 months
3. Swelling of both feet - 1 month
4. Loose stools - 10 days
5. Fever - 5 days

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3. HISTORY OF PRESENT ILLNESS

• Weight loss: Progressive, noticed by mother over 4 months. Child visibly thinner, ribs and clavicles prominent.
• Decreased appetite: Child reluctant to feed, accepts only small amounts per sitting for the past 3 months.
• Bilateral foot swelling: Non-tender, noticed 1 month ago. No history of similar swelling in the past. No facial puffiness initially, though mother now notices puffiness around the eyes in the morning.
• Loose stools: 5-6 episodes/day for the past 10 days. Watery, no blood or mucus. No vomiting. Child has been taking oral fluids.
• Fever: Low-grade, continuous, for 5 days. No rigors or chills. No rash. No ear discharge.
• No history of: cough, breathlessness, convulsions, altered sensorium, bleeding from any site.

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4. PAST HISTORY

• Similar illness: Child had two episodes of diarrhea in the past 6 months, managed at home.
• Hospitalization: Never hospitalized before.
• Tuberculosis: No known diagnosis of TB.
• Allergies: None known.
• Blood transfusion: Never given.
• Recurrent infections: Frequent upper respiratory tract infections (3-4 episodes in last 6 months).

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5. ANTENATAL HISTORY

• GPLA: G3 P3 L3 A0
• ANC: Unbooked. Only 2 antenatal visits at primary health centre.
• Maternal illness during pregnancy: No significant illness reported. Mother did not recall any fever with rash.
• Iron/folic acid supplements: Irregular intake. Started only in 7th month.
• Calcium supplementation: Not taken.
• Maternal nutrition: Poor; predominantly rice-based diet, minimal protein intake.
• Radiation / teratogen exposure: None.
• Fetal movements: Perceived normally.
• Antenatal USG: Not done.
• Blood group: O positive; no prior incompatibility.

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6. NATAL (BIRTH) HISTORY

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7. NEONATAL HISTORY

• Cry and activity: Normal at birth.
• Breastfeeding initiated: Delayed - started on day 3 (colostrum discarded; glucose water given initially).
• Jaundice: Mother recalls mild yellowish discolouration on day 3-4, resolved without treatment.
• No history of: neonatal seizures, sepsis, respiratory distress.
• Umbilical cord: Separated normally, no infection.

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8. FEEDING HISTORY

• Breastfeeding: Initiated on day 3. Exclusive breastfeeding NOT maintained - cow's milk started at 2 months.
• Colostrum: Discarded (considered harmful by family).
• Complementary feeding: Started at 4 months (rice water only). No pulses, eggs, or meat introduced.
• Present diet (18 months):
  • 2 meals/day - thin rice gruel (kanji), occasional banana
  • No protein source (no dal, egg, meat, or milk regularly)
  • No green leafy vegetables
  • Breastfeeding: discontinued at 12 months
• Appetite: Markedly reduced.
• Current caloric intake: Grossly inadequate (estimated <50% of RDA for age).

Key deficiency: Grossly inadequate protein and caloric intake - the root nutritional cause of SAM.

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9. DEVELOPMENTAL HISTORY

• Regression: No clear regression, but significant motor delay.
• Developmental domain most affected: Gross motor and language.
• Cause: Protein-energy malnutrition leading to muscle weakness and poor brain development.

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10. IMMUNIZATION HISTORY

Immunization status: Partially immunized - Measles and Vitamin A doses missed. High risk for measles and Vitamin A deficiency complications.

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11. FAMILY HISTORY

• Siblings: 2 elder siblings, both alive. Elder sibling (5 years) has thin build but no diagnosed malnutrition.
• Similar illness: Not known in family.
• Consanguinity: Not present (parents unrelated).
• Father: Labourer, daily wage; alcoholism suspected by mother.
• Mother: Homemaker; herself thin and anaemic-looking.
• Tuberculosis contact: Paternal uncle has chronic cough - details unknown.
• Family size: 6 members in household (parents + 3 children + paternal grandmother), sharing 1-room house.

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12. SOCIOECONOMIC & ENVIRONMENTAL HISTORY

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PART II: PHYSICAL EXAMINATION

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A. GENERAL EXAMINATION

1. General Appearance

• Child is conscious, irritable, not playful
• Appears markedly wasted - visible loss of subcutaneous fat and muscle
• Expressionless facies ("old man" appearance - marasmic features)
• Bilateral pitting pedal oedema present (mixed picture: Marasmic-Kwashiorkor)
• Not in acute respiratory distress currently

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2. Anthropometry

SAM criteria met: MUAC <11.5 cm + W/H <-3 SD + bilateral pitting oedema → Marasmic-Kwashiorkor

• IBW for height (72 cm) = ~8.5 kg
• Observed weight = 6.2 kg
• % IBW = (6.2/8.5) × 100 = 73% → Grade III-IV malnutrition (IAP classification)

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3. Vital Signs

⚠️ Warning signs present: Tachypnoea + hypotension + prolonged CRT + SpO2 94% → high risk child; MUST rule out Septic shock and Pneumonia as per SAM management guidelines.

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4. Skin & Hair

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5. Eyes

• Conjunctival pallor: Present (moderate pallor)
• Scleral icterus: Absent
• Bitot's spots: Present on bilateral temporal conjunctiva → Vitamin A deficiency (Xerophthalmia Stage X1B)
• Cornea: Clear (no corneal ulceration yet)
• Sunken eyes: Present (dehydration + loss of periorbital fat)
• Periorbital puffiness: Mild (kwashiorkor oedema)
• Red reflex: Present bilaterally

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6. Oral Cavity

• Angular stomatitis: Present (riboflavin/niacin deficiency)
• Gums: No bleeding
• Tongue: Smooth, slightly pale
• Teeth: Primary dentition incomplete for age
• Parotid enlargement: Absent

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7. Lymph Nodes

• Cervical: Multiple bilateral small (<1 cm) nodes, soft, non-tender, mobile - likely reactive
• Axillary: Not palpable
• Inguinal: Palpable bilaterally, ~1 cm, soft, non-tender
• No matting or overlying skin changes

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8. Pallor, Cyanosis, Jaundice, Clubbing

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B. SYSTEMIC EXAMINATION

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1. RESPIRATORY SYSTEM

• Tachypnoeic (RR 38/min)
• Subcostal and intercostal retractions - mild
• Trachea central
• Bilateral chest movement - slightly asymmetric (right side reduced)

• Trachea central
• Tactile vocal fremitus - slightly increased on right lower zone

• Right infrascapular and infra-axillary area - dull
• Left side - resonant

• Right lower zone - bronchial breath sounds, coarse crackles
• Left side - vesicular, no added sounds

Impression: Features consistent with right lower lobe pneumonia (a common, life-threatening complication of SAM)

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2. CARDIOVASCULAR SYSTEM

• No precordial bulge or abnormal pulsations

• Apex beat: 4th ICS, left of MCL (slightly shifted - possibly due to chest pathology)
• No thrills or heaves
• Peripheral pulses: present but weak volume, regular rhythm

• S1, S2 heard; no murmurs
• No gallop rhythm

Impression: Weak peripheral pulses with hypotension - monitor for septic shock. No structural cardiac defect detected.

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3. ABDOMEN

• Abdomen: distended, protuberant
• Umbilicus: everted (ascites / gas)
• No visible peristalsis
• No dilated veins

• Liver: Palpable 4 cm below right costal margin; soft, smooth, rounded edge, non-tender → Hepatomegaly (fatty liver of kwashiorkor)
• Spleen: Palpable 2 cm below left costal margin; soft, non-tender → mild splenomegaly
• No renal masses
• Ascites: Shifting dullness present (mild ascites)
• Hernia orifices: intact
• Generalised mild guarding - not rigid

• Bowel sounds: present, increased (diarrhea)

Impression: Hepatosplenomegaly + ascites + distended abdomen in the context of SAM = Kwashiorkor component (hypoalbuminaemia)

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4. CENTRAL NERVOUS SYSTEM

• Conscious, irritable
• AVPU: Alert but irritable (A)
• Modified GCS: 13/15 (E4V4M5)
• Not responding to commands appropriately (likely due to illness, nutritional brain impact)

• Generalised hypotonia - marked in all 4 limbs

• Reduced (cannot stand; MRC grade 3/5 in lower limbs) - consistent with wasting

• Deep tendon reflexes: diminished bilaterally (knee and ankle jerks sluggish)
• Plantar: flexor bilaterally

• Pupils: 3mm, equally reactive to light bilaterally
• Facial symmetry: intact
• Gag reflex: present

• Neck stiffness: Absent
• Kernig's sign: Negative
• Brudzinski's sign: Negative

• Anterior fontanelle: Closed (as expected at 18 months)

Impression: Generalised hypotonia and diminished reflexes due to protein-energy malnutrition. No signs of meningitis or encephalopathy currently.

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5. MUSCULOSKELETAL SYSTEM

• Marked generalised muscle wasting
• "Baggy pants" sign: excess loose skin over gluteal region
• Wasting most severe: temporalis, cheek, and limb muscles
• Ribs and clavicles visible
• No bony deformities; no signs of rickets (no Harrison's sulcus, rachitic rosary, or bowing)
• Joints: No swelling, warmth, or restricted movement

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C. SUMMARY

18-month-old male child, from a rural, lower socioeconomic background (Class IV-V), born at home by normal vaginal delivery, term, with a birth weight of ~2.2 kg (LBW). Presenting with 4 months of progressive weight loss and failure to thrive, 1 month of bilateral pedal oedema, 10 days of loose stools, and 5 days of fever. Child is predominantly breastfed up to 12 months with delayed, inadequate complementary feeding (rice-only diet, no protein). Partially immunized - Measles and Vitamin A doses missed. On examination: weight 6.2 kg, MUAC 10.8 cm, bilateral pitting pedal oedema (2+), visible severe wasting with loss of subcutaneous fat, flaky paint dermatosis, hair changes, Bitot's spots bilaterally, moderate pallor. Vitals reveal fever (38.2°C), tachypnoea (38/min), hypotension (70/45 mmHg), and prolonged CRT (3 sec). Respiratory examination shows right lower lobe consolidation. Abdomen shows hepatosplenomegaly and mild ascites. CNS shows generalised hypotonia with diminished reflexes.

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D. PROVISIONAL AND DIFFERENTIAL DIAGNOSES

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E. INVESTIGATIONS PLANNED

• Blood glucose (glucometer) - rule out hypoglycaemia (emergency in SAM)
• CBC with differential
• Blood culture and sensitivity
• CRP / ESR
• Serum electrolytes (Na⁺, K⁺, Cl⁻) - watch for hypokalaemia
• Serum albumin, total protein
• LFT, RFT
• Stool routine/microscopy and culture
• Urine routine and microscopy
• Chest X-ray (PA view) - confirm pneumonia
• Mantoux test (after stabilisation) - rule out TB
• HIV ELISA (parental consent)
• Serum calcium, phosphorus, alkaline phosphatase
• Thyroid function test (if no response to nutritional rehabilitation)
• Blood smear for malaria (if febrile in endemic area)

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Management Note (Piyush Gupta - SAM 10 Steps): This child fulfills criteria for NRC (Nutrition Rehabilitation Centre) admission. Management follows the WHO/IAP 10-step protocol for SAM: treat/prevent hypoglycaemia, hypothermia, dehydration (using ReSoMal), electrolyte correction, infection treatment, micronutrient supplementation (without iron initially), cautious re-feeding (F-75 → F-100 → RUTF), sensory stimulation, and follow-up.