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Malnutrition - SAM & PEM

MBBS Final Year Paediatrics Examination Guide

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1. DEFINITIONS & TERMINOLOGY

• Weight-for-height >3 SD below the median WHO child growth standards (WHZ score < -3), OR
• Mid-upper arm circumference (MUAC) < 115 mm, OR
• Presence of nutritional oedema

SAM affects ~50 million children worldwide. ~45% of deaths in children under 5 in low-resource countries are attributable to undernutrition. Severely wasted children are 9 times more likely to die than well-nourished children.

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2. THE SPECTRUM OF SAM - TWO ENDS

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3. CLINICAL FEATURES IN DETAIL

MARASMUS ("Dry" PEM)

• Severe growth retardation and arrested development
• Extreme muscle wasting and depletion of subcutaneous fat (emaciation)
• "Wizened old man" / "Monkey facies" - head appears too large for the emaciated body
• Skin hangs in folds ("baggy pants" sign)
• No oedema
• Weakness and anemia
• Cortisol and glucagon elevated (adaptive response); low insulin
• Leptin production is low, stimulating the HPA axis contributing to lipolysis
• Immunity impaired (T cell mediated): concurrent infections common

KWASHIORKOR ("Wet" PEM)

1. Bilateral pitting oedema (starts in feet, ascends) - due to hypoalbuminaemia
2. Protuberant abdomen - due to weakened abdominal muscles + intestinal distension + hepatomegaly (ascites is RARE; if present, think liver disease)
3. Fatty liver (hepatomegaly) - due to reduced synthesis of apolipoprotein, impairing VLDL export; fat accumulates
4. Skin changes: "Flaky paint dermatosis" / "Crazy pavement dermatosis" - alternating zones of hyperpigmentation, desquamation, and hypopigmentation
5. Hair changes: Depigmentation ("flag sign" - alternating bands of pale and dark colour), straightening, fine texture, easy pluckability (Pluck sign positive), loss of attachment to scalp
6. Moon face (from oedema)
7. Hypoalbuminaemia - albumin typically < 3 g/dL
8. Apathy, listlessness, loss of appetite
9. Anorexia and misery

• Hypoalbuminaemia → reduced oncotic pressure → fluid moves to extravascular space
• Leaky cell membranes → K+ and other intracellular ions leak out → osmotic water movement
• Often triggered by physiologic stress (infection) superimposed on a malnourished child

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4. CLASSIFICATIONS - EXAM TABLES

Waterlow Classification of PEM in Children

• Wasting = low weight-for-height (acute malnutrition)
• Stunting = low height-for-age (chronic malnutrition)
• Underweight = low weight-for-age (used by ICDS/growth charts)

WHO Z-score Classification

IAP (Indian Academy of Pediatrics) / ICMR Grades (Gomez classification - weight-for-age)

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5. CLINICAL ASSESSMENT - MUAC

• Used in children 1-5 years (arm circumference is relatively stable in this age range)
• Cannot be used before 1 year of age

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6. PATHOPHYSIOLOGY

Body Compartments Affected

• Somatic compartment (skeletal muscle proteins) - depleted in marasmus
• Visceral compartment (liver and organ proteins) - depleted in kwashiorkor

In Marasmus (Calorie deprivation):

• Low insulin → lipolysis and proteolysis (adaptive response)
• Cortisol elevated → muscle catabolism
• Amino acids released from muscle → gluconeogenesis (energy)
• Visceral proteins relatively preserved → albumin near-normal
• This is "adapted starvation" (adaptive malnutrition)

In Kwashiorkor (Protein deprivation, calories relatively adequate):

• Carbohydrate intake adequate → insulin secretion maintained → suppresses lipolysis and proteolysis
• Visceral protein synthesis drops severely
• Reduced apolipoprotein synthesis → fat accumulates in liver (fatty liver)
• Hypoalbuminaemia → oedema
• This is "non-adapted malnutrition" (insulin keeps fat stores intact but visceral protein fails)

Effects on Organ Systems (PEM):

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7. MORPHOLOGY (Pathology - Robbins)

1. Growth failure (universal)
2. Peripheral oedema (kwashiorkor)
3. Muscle atrophy and loss of body fat (more in marasmus)
4. Fatty liver (kwashiorkor, not marasmus)
5. Small bowel: decreased mitotic index in mucosal cells, villous shortening; superimposed infections common
6. Immune organs: thymus, lymph nodes, spleen may show atrophy

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8. INVESTIGATION / DIAGNOSIS

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9. WHO 10-STEP MANAGEMENT OF SAM (MBBS Exam Favourite)

• F-75: Stabilisation phase (75 kcal/100 mL; 0.9 g protein/100 mL)
• F-100: Rehabilitation phase (100 kcal/100 mL; 2.9 g protein/100 mL)
• RUTF: Ready-to-Use Therapeutic Food (Plumpy'nut - peanut paste); 500 kcal/sachet; for community-based management

Why ReSoMal and NOT standard ORS? SAM children have high intracellular Na and low K. Standard ORS has too much Na and can cause fluid overload. ReSoMal has lower Na (45 mEq/L vs. 75 mEq/L) and higher K and Mg.

Why no iron in Phase 1? Free iron promotes bacterial growth and oxidative stress (iron creates free radicals via Fenton reaction). It is given only in Phase 2 (rehabilitation) once infection is controlled.

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10. COMMUNITY MANAGEMENT (CMAM)

• RUTF (Ready-to-Use Therapeutic Food): used for community-based management of uncomplicated SAM
• MUAC taping: community workers use MUAC tapes (red/yellow/green zones) for screening
• Indicators for inpatient care: presence of oedema, complications (hypoglycaemia, dehydration, infections), or failure of appetite

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11. EARLY DETECTION OF PEM

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12. PREVENTION (Park's Preventive Paediatrics)

1. Nutritional support for pregnant and lactating mothers
2. Promotion of exclusive breastfeeding (first 6 months)
3. Development of low-cost weaning foods (complementary feeding from 6 months)
4. Improve family diet and food security
5. Nutrition education and correct feeding practices
6. Family planning and birth spacing
7. Home economics and sanitation

1. Periodic vitamin A supplementation
2. ICDS (Integrated Child Development Services) - India specific
3. Mid-day meal programmes
4. Prevention and treatment of infections (immunisation, ORS)

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13. COMPLICATIONS OF SAM

• Hypoglycaemia (blood glucose < 54 mg/dL)
• Hypothermia (rectal temp < 35.5°C)
• Severe dehydration
• Electrolyte imbalance (hypokalaemia is most dangerous)
• Septicaemia / infections (due to immune impairment)
• Anaemia
• Vitamin A deficiency → xerophthalmia, blindness
• Refeeding syndrome (hypophosphataemia, hypokalaemia on rapid refeeding)
• Long-term: cognitive impairment, growth stunting, developmental delay

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14. MUST-KNOW MNEMONICS & ONE-LINERS

• "KWA-shiorkor" = K for Kwashiorkor, K for pottassium loss, K for Kids post-weaning
• "EDIT" - Kwashiorkor = Oedema, Depigmented hair, Irritable, Thin albumin
• Marasmus = "Mad hunger" - Marked wasting, Alert child, Depleted fat, No oedema
• RUTF = "Ready peanut": 500 kcal per sachet, used at HOME
• ReSoMal = Low Na (45), High K, for SAM rehydration
• Flag sign of hair = kwashiorkor (alternating light-dark bands)
• Flaky paint / crazy pavement = skin in kwashiorkor
• Fatty liver = kwashiorkor (NOT marasmus)
• WHO SAM criteria = WHZ < -3 SD, OR MUAC < 115 mm, OR nutritional oedema

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15. HIGH-YIELD EXAM ONE-LINERS

1. The term "kwashiorkor" means "disease of the displaced child" (Ga language, Ghana)
2. In kwashiorkor, insulin is relatively preserved (carbs available) - this is non-adapted malnutrition
3. In marasmus, low insulin allows lipolysis + proteolysis - this is adapted malnutrition
4. Somatic protein depleted in marasmus; visceral protein depleted in kwashiorkor
5. The role of gut microbiome in SAM pathogenesis is an emerging area (Robbins 2024)
6. SAM children are 9x more likely to die than well-nourished children
7. MUAC is NOT used before 1 year of age
8. Iron is NOT given in Phase 1 of SAM management
9. Standard ORS is NOT used in SAM - use ReSoMal
10. F-75 in stabilization, F-100 in rehabilitation

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