Malnutrition

Clinical Forms, Assessment, Management & Prevention

Dr. Arun Mitra
Department of Community Medicine

2026-08-27

Recap of Lecture 1

  • Malnutrition is a spectrum: undernutrition, micronutrient deficiency, and overnutrition — the double burden is now the Indian reality
  • NFHS-6 (2023–24): stunting ↓ to 29.3%, severe wasting ↓ to 5.2%, but wasting plateaued (~19%) and exclusive breastfeeding fell to 55.8%
  • Causation is multifactorial — the UNICEF framework’s immediate, underlying, and basic causes — so the response must be multisectoral

The three domains of malnutrition

Learning Objectives

By the end of this session, you should be able to:

  1. Classify differentiate protein-energy malnutrition
  2. Recognise micronutrient deficiencies
  3. Select appropriate tools for nutritional assessment (ABCD)
  4. Outline management of SAM (WHO 2023)

Forms of Undernutrition (PEM)

Protein-Energy Malnutrition (PEM)

A spectrum of clinical conditions resulting from inadequate energy and/or protein intake, presenting as three recognisable syndromes:

  1. Marasmus
  2. Kwashiorkor
  3. Marasmic-kwashiorkor (mixed features)

Marasmus

  • Severe wasting of muscle and subcutaneous fat
  • Characteristic “old man” or wizened facies
  • Marked growth retardation
  • No oedema
  • Child typically alert and irritable, rather than apathetic

Kwashiorkor

  • Bilateral pitting oedema, the clinical hallmark
  • Flaky-paint dermatosis
  • Hair changes (sparse, discoloured, easily pluckable)
  • Moon face; hepatomegaly (fatty liver)
  • Child typically apathetic, rather than irritable

Marasmus vs Kwashiorkor

Feature Marasmus Kwashiorkor
Oedema Absent Present (bilateral, pitting)
Muscle/fat wasting Marked Variable, may be masked by oedema
Mental state Alert, irritable Apathetic
Hair/skin changes Uncommon Common
Liver Normal Enlarged (fatty)

Marasmic-kwashiorkor: severe wasting with oedema, features of both.

Why Do We Classify Malnutrition?

  • Standardises severity: guides referral decisions and the treatment pathway
  • Enables surveillance and comparison across time and between populations
  • Different systems exist because they were developed for different purposes and eras; you need to recognise all of them

Gomez Classification

Based on weight-for-age, expressed as a percentage of the reference median:

Grade % of reference median weight-for-age
Grade I (mild) 75–90%
Grade II (moderate) 60–75%
Grade III (severe) <60%

Limitation: cannot distinguish stunting from wasting; a chronically short but proportionate child may be misclassified.

IAP Classification

  • Also based on weight-for-age
  • Four grades (I–IV), developed by the Indian Academy of Pediatrics
  • Practical and widely used for community-level growth monitoring in India

Wellcome Classification

Combines weight-for-age with the presence or absence of oedema:

Weight-for-age No oedema With oedema
60–80% Underweight Kwashiorkor
<60% Marasmus Marasmic-kwashiorkor

Advantage over Gomez: it incorporates the clinical sign of oedema, so it distinguishes the PEM syndromes, not only severity.

WHO Classification (Z-Scores)

The current international standard, using standard-deviation (z-) scores from the WHO Child Growth Standards:

  • WHZ (weight-for-height z-score): wasting
  • HAZ (height-for-age z-score): stunting
  • WAZ (weight-for-age z-score): underweight

Severity cut-offs (apply to all three indices):

  • Moderate: < -2 SD
  • Severe: < -3 SD

Defining Severe Acute Malnutrition (SAM)

A child (6–59 months) has SAM if any one of the following is present:

  • WHZ < -3 SD, or
  • MUAC < 11.5 cm, or
  • Bilateral pitting oedema

Any single criterion is sufficient; the child does not need to meet all three.

SAM vs MAM

SAM MAM
WHZ < -3 SD -3 to -2 SD
MUAC < 11.5 cm 11.5–12.5 cm
Oedema May be present Absent

Micronutrient Deficiencies

Vitamin A Deficiency

  • The leading cause of preventable childhood blindness worldwide
  • Clinical progression: night blindness → Bitot’s spots → keratomalacia
  • Also increases the severity of infections and childhood mortality, independent of its ocular effects

Iron Deficiency Anaemia

  • The single most common micronutrient deficiency worldwide and in India
  • Presents with fatigue, pallor, reduced work capacity, and impaired cognitive development
  • Disproportionately affects women of reproductive age and young children; recall the NFHS-5 figures (children ~67%, women ~57%)

Iodine Deficiency Disorders (IDD)

  • Spectrum: goitre → hypothyroidism → cretinism (irreversible if it occurs in utero or early infancy)
  • Cretinism causes irreversible impaired cognitive development
  • Entirely preventable through universal salt iodisation

Other Deficiencies & “Hidden Hunger”

  • Zinc: worsens diarrhoea, impairs growth
  • Vitamin D: rickets
  • B-complex: beri-beri (thiamine), pellagra (niacin)

“Hidden hunger” is micronutrient deficiency without overt wasting or visible undernutrition: a child can look adequately nourished by weight and height alone and still be micronutrient-deficient.

Nutritional Assessment

The ABCD Framework

Four complementary approaches to assessing nutritional status:

  • A: Anthropometry
  • B: Biochemical
  • C: Clinical
  • D: Dietary

At the population level, add ecological and vital-statistics indicators.

Anthropometry

  • Measurements: weight, height/length, MUAC, BMI, skinfold thickness
  • Derived indices: WAZ, HAZ, WHZ (as covered in the classification section)
  • Head circumference: used in children under 2 years

Growth Monitoring

  • MCP (Mother & Child Protection) card: India’s standard tool for serial growth recording
  • Plotted against the WHO Child Growth Standards
  • Serial measurements matter more than a single reading: plotting over time detects growth faltering early, before a child crosses into SAM/MAM thresholds

MUAC & Oedema: Field Screening

  • MUAC tape (colour-coded red/yellow/green) allows rapid community-level screening for SAM/MAM without a weighing scale
  • Check for bilateral pitting oedema, graded + (mild), ++ (moderate), +++ (severe)

Biochemical, Clinical & Dietary Assessment

  • Biochemical: haemoglobin, serum proteins, ferritin
  • Clinical: examining for specific signs of deficiency (e.g., Bitot’s spots, goitre, oedema)
  • Dietary: 24-hour dietary recall, food-frequency questionnaire

Management of Malnutrition

Case

A 9-month-old is brought to your PHC. On screening: MUAC 10.5 cm and bilateral pedal oedema. The mother says he has had loose stools for three days.

What now?

  • Does this child have SAM? On which criteria?
  • Complicated or uncomplicated?
  • Facility or community care?

WHO 2023 Guideline — What Changed

WHO Guideline on the prevention and management of wasting and nutritional oedema (launched 20 Nov 2023).

  • Terminology: “wasting and nutritional oedema” now preferred over “acute malnutrition”/“PEM”
  • First guideline to cover both moderate AND severe wasting together
  • Four focus areas: infants <6 months at risk · moderate wasting (6–59 mo) · severe wasting/oedema (6–59 mo) · prevention
  • New emphasis on relapse, caregiver support, and the frontline workforce

WHO 2023 Guideline — What Changed

Triage: Which Pathway?

Two questions set the route: appetite (RUTF test) and complications (no appetite, severe oedema +++, infection, or age <6 months).

flowchart TD
  A[Child with SAM] --> B{Appetite OK and no complications?}
  B -->|Yes| C[Community care: outpatient + RUTF]
  B -->|No| D[Facility care: NRC / inpatient]

Facility-Based Management (NRC)

Nutrition Rehabilitation Centre (NRC)

  • Inpatient care for complicated SAM, failed appetite test, or infants <6 months
  • Located at a First Referral Unit / district hospital; 24×7 care
  • Combines the WHO 10-step protocol with treatment of the precipitating illness

WHO 10 Steps

A standardised inpatient protocol delivered across two phases: stabilisation, then rehabilitation.

Mnemonic order: correct the life-threatening problems first (hypoglycaemia, hypothermia, dehydration, electrolytes, infection), then feed — cautiously at first, then for catch-up.

10 Steps (1–3): Resuscitate

  1. Treat/prevent hypoglycaemia
  2. Treat/prevent hypothermia
  3. Treat/prevent dehydration — use ReSoMal, cautiously (never standard ORS at full strength)

10 Steps (4–6): Correct the Internal Milieu

  1. Correct electrolytes (give K⁺ and Mg²⁺; restrict Na⁺)
  2. Treat infection — broad-spectrum antibiotics, even without obvious signs
  3. Correct micronutrients — no iron during stabilisation

Iron is withheld in the stabilisation phase: free iron promotes oxidative stress and bacterial growth. It is added only once the child is in catch-up.

10 Steps (7–10): Feed & Follow Up

  1. Cautious feeding — F-75 (stabilisation)
  2. Catch-up growth — F-100 / RUTF (rehabilitation)
  3. Sensory stimulation and emotional support
  4. Prepare for follow-up after discharge

The Two Phases

Stabilisation Rehabilitation
Timing ~Days 1–7 From ~week 2
Feed F-75 F-100 / RUTF
Goal Correct complications, restore metabolism Rapid catch-up weight gain
Iron Withheld Added

Therapeutic Foods

  • F-75: 75 kcal per 100 ml → used to stabilise (not for weight gain)
  • F-100: 100 kcal per 100 ml → used for catch-up growth
  • RUTF (Ready-to-Use Therapeutic Food): energy-dense paste, no water needed, enabling home-based treatment of uncomplicated SAM

Community-Based Management (CMAM)

CMAM — Four Components

  1. Community mobilisation and active case-finding
  2. Outpatient therapeutic care for uncomplicated SAM
  3. Inpatient care for complicated SAM
  4. Supplementary feeding for MAM

CMAM shifts most SAM care out of hospitals and into the community; the module is now integrated into POSHAN 2.0.

Outpatient Care with RUTF

  • Home management of uncomplicated SAM in a child who passes the appetite test
  • Weighed weekly/biweekly at the Anganwadi centre, sub-centre, or Health & Wellness Centre
  • Caregiver counselled on RUTF use, hygiene, and danger signs prompting return

Discharge & Follow-Up

  • Discharge criteria (per protocol): sustained weight gain, MUAC ≥ 12.5 cm, and no oedema
  • Continued growth monitoring after discharge to prevent relapse — a WHO 2023 priority
  • Link back to routine ICDS/Anganwadi services

Micronutrient & Lifecycle Programmes

Vitamin A Prophylaxis

  • National Vitamin A Prophylaxis Programme: biannual mega-doses from 9 months to 5 years
  • Therapeutic doses given in measles and xerophthalmia
  • Delivered largely through the Anganwadi/immunisation platform

Anaemia & Iron

  • Anaemia Mukt Bharat — the 6×6×6 strategy (6 interventions, 6 target groups, 6 institutional mechanisms)
  • Age-specific IFA supplementation (National Iron Plus Initiative) plus deworming
  • Diet diversification and food fortification

NFHS-6 did not measure anaemia (haemoglobin testing was dropped); ICMR’s DABS-I with venous sampling is awaited.

Iodine & Zinc

  • Iodine: universal salt iodisation under the National Iodine Deficiency Disorders Control Programme (NIDDCP)
  • Zinc: given with low-osmolarity ORS for 14 days in childhood diarrhoea — reduces duration and recurrence

The First 1000 Days

Conception to age 2 (~1000 days) is the critical window. Damage to growth and cognition here is largely irreversible — so prevention must be front-loaded.

  • Explains why stunting (a chronic, cumulative deficit) is so hard to reverse later
  • Prioritise maternal nutrition, breastfeeding, and complementary feeding in this window

Maternal Nutrition

  • Maternal undernutrition, low BMI, and anaemia → low birth weight (LBW)
  • Antenatal IFA and calcium supplementation; dietary support
  • PMMVY (Pradhan Mantri Matru Vandana Yojana): conditional cash benefit for pregnant/lactating women

The Intergenerational Cycle (DOHaD)

flowchart LR
  A[Undernourished girl] --> B[Small, undernourished mother]
  B --> C[Low-birth-weight baby]
  C --> D[Stunted child]
  D --> A

  • Developmental Origins of Health & Disease (Barker hypothesis): early-life undernutrition programmes later disease risk
  • Breaking the cycle requires investing before pregnancy — in girls and adolescents

IYCF Practices

  • Early initiation of breastfeeding within 1 hour (NFHS-6: 41.8% → 50.1% — improving)
  • Exclusive breastfeeding to 6 months (NFHS-6: 63.7% → 55.8% — a concerning fall)
  • Timely, adequate, safe complementary feeding from 6 months

Adolescent Nutrition

  • Weekly Iron-Folic Acid Supplementation (WIFS) for adolescents
  • Nutrition and anaemia interventions here break the intergenerational cycle before pregnancy
  • Complemented by the erstwhile Scheme for Adolescent Girls (now within POSHAN 2.0)

Back to Our Case

9-month-old · MUAC 10.5 cm · bilateral pedal oedema · 3 days of diarrhoea

  • SAM? Yes: MUAC < 11.5 cm and bilateral oedema (either alone would suffice)
  • Complicated? Yes: oedema with intercurrent illness, plus infant considerations
  • Pathway: complicated SAM, so refer to the NRC
    • Stabilise: F-75 (no iron), treat infection, ReSoMal for dehydration
    • Rehabilitate: F-100 / RUTF for catch-up growth
    • Discharge on MUAC ≥ 12.5 cm, then follow up to prevent relapse

Key Takeaways

  • PEM presents as marasmus, kwashiorkor, or mixed; oedema is the key differentiator, and SAM = WHZ < -3 / MUAC < 11.5 / oedema (any one)
  • ABCD gives a complete assessment; MUAC and oedema enable screening without a scale
  • Management follows WHO 2023: triage on appetite + complications → NRC (10 steps, two phases) or community RUTF
  • Prevention is lifecycle-wide — first 1000 days, maternal and adolescent nutrition — delivered through POSHAN 2.0

Recovery Is Possible

On admission, then after 2 weeks

After 4 weeks, then 5 weeks

Sheema, a girl aged 2, was admitted with severe acute malnutrition: weight 3.875 kg, length 67 cm, weight-for-length below -4 SD. After five weeks of guideline-based inpatient care her weight reached 6.28 kg (weight-for-length about -2 SD), and she was ready to go home.

References

  • WHO (2023) — Guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5; launched 20 Nov 2023.
  • WHO — Management of Severe Malnutrition; the 10 steps of inpatient care; F-75/F-100/RUTF.
  • MoWCD — Mission Saksham Anganwadi & POSHAN 2.0 (2021); Poshan Tracker.
  • MoHFW — Anaemia Mukt Bharat (6×6×6); National Iron Plus Initiative; NIDDCP; NRC/CMAM operational guidelines.
  • NFHS-6 (2023–24) — IYCF indicators (EBF 55.8%, early initiation 50.1%).
  • Park’s Textbook of Preventive and Social Medicine (latest edition).

Thank You