PE9.1-7,PE10.1-6,PE11.1-4 | Nutrition Assessment and Support — Practice Quiz

Weight-for-height between −2 SD and −3 SD with MUAC ≥11.5 cm and no oedema classifies as MAM. SAM requires WHZ <−3 SD or MUAC <11.5 cm or bilateral pitting oedema.

SAM criteria are WHZ <−3 SD, MUAC <11.5 cm (6–59 months), OR bilateral pitting oedema — any single criterion suffices. MAM is WHZ −2 to −3 SD or MUAC 11.5–12.5 cm without oedema.

Review WHO/IAP SAM and MAM classification criteria. SAM is defined by WHZ <−3 SD AND/OR MUAC <11.5 cm AND/OR bilateral pedal oedema. This child's WHZ is −2.5 (between −2 and −3) and MUAC is 12.2 cm (≥11.5), so SAM thresholds are not met.

WHO 10-step SAM protocol mandates IV 10% dextrose 5 mL/kg for symptomatic hypoglycaemia, followed by 2-hourly F-75 feeds to maintain blood glucose. 25% dextrose is too concentrated and risks osmotic injury.

WHO SAM step 3 (treat hypoglycaemia): symptomatic — IV 10% dextrose 5 mL/kg stat; conscious — 50 mL of 10% glucose orally. F-75 is continued 2-hourly thereafter. Never use F-100 in the stabilisation phase.

Symptomatic hypoglycaemia in SAM requires IV 10% dextrose 5 mL/kg as per WHO protocol. A high-concentration bolus (25%) risks intracellular osmotic injury. F-100 is reserved for the rehabilitation phase, not stabilisation, and switching prematurely risks refeeding syndrome.

Holliday-Segar: first 10 kg = 100 mL/kg/day. For a 9 kg child: 9 × 100 = 900 mL/day.

Holliday-Segar maintenance fluids: 100/50/20 mL/kg/day for first 10 kg / next 10 kg / each additional kg. Caloric requirement approximation: 100/50/20 kcal/kg/day by the same brackets.

Apply the Holliday-Segar formula: 100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the next 10 kg, 20 mL/kg/day for each additional kg beyond 20 kg. For 9 kg: 9 × 100 = 900 mL/day.

RUTF (e.g., Plumpy'Nut) is a peanut-butter-based, lipid-based, energy-dense therapeutic food (~500 kcal/92 g sachet) recommended by WHO/UNICEF/WFP for community-based management of SAM without complications. It does not require mixing with water, reducing contamination risk.

RUTF (ready-to-use therapeutic food) is lipid-based, peanut-butter core, ~500 kcal/92 g sachet, no water required — the WHO standard for community-based management of uncomplicated SAM. Locally produced RUTF variants (e.g., chickpea-based in India) are also recognised.

RUTF such as Plumpy'Nut is the WHO-recommended standard for community-based SAM rehabilitation. F-75 and F-100 are facility-based therapeutic milks. Cow's milk alone lacks the micronutrient density needed for rehabilitation. Khichdi may be culturally appropriate supplementation but is not a standardised therapeutic diet for SAM.

BMI-for-age ≥95th percentile in children/adolescents defines obesity. This boy is at the 97th percentile, confirming obesity. Overweight is 85th–94th percentile. The metabolic markers (acanthosis nigricans, striae, pseudogynaecomastia) are external markers of obesity-related complications.

Paediatric obesity is BMI-for-age ≥95th percentile; overweight is 85th–94th. External markers of obesity include acanthosis nigricans (insulin resistance), striae, pseudogynaecomastia, and flat-footedness. Always use BMI-for-age charts, not adult BMI cut-offs, for children.

IAP/WHO criteria for children: overweight = BMI-for-age 85th–94th percentile; obese = ≥95th percentile; severely obese (class 2) typically ≥99th percentile or ≥120% of 95th. The 97th percentile falls in the obese category.

WHO 10-step SAM protocol: transition to F-100 (rehabilitation phase) when the child has a good appetite (passes appetite test) and oedema has resolved or is resolving. This typically occurs after 1–2 weeks in the stabilisation phase. Forced rapid weight gain in stabilisation risks refeeding syndrome and cardiac failure.

F-75 (stabilisation) → F-100 (rehabilitation) transition requires: (1) return of appetite (passes appetite test) and (2) oedema resolved or resolving. Do NOT rush this transition — premature F-100 before oedema resolution increases risk of fluid overload and cardiac failure.

The criteria for transitioning from stabilisation (F-75) to rehabilitation (F-100) are: return of appetite (appetite test — able to finish 1 sachet of RUTF) + resolution of oedema. Blood glucose normalisation is an early goal of stabilisation, not a transition marker. Rapid weight gain in stabilisation is a warning sign of overfeeding.

ReSoMal (Rehydration Solution for Malnutrition) has sodium 45 mmol/L (vs standard ORS 75 mmol/L), higher potassium (40 mmol/L), and added magnesium — addressing the altered electrolyte physiology of SAM where high sodium load risks fluid overload and cardiac failure.

ReSoMal (Rehydration Solution for Malnutrition): Na 45 mmol/L, K 40 mmol/L — lower sodium than standard ORS to avoid fluid overload in SAM. Use 5–10 mL/kg/hour for 30–60 min, then re-assess. Standard ORS is contraindicated in SAM dehydration.

Children with SAM have abnormal cell membrane sodium-potassium pump function, making standard ORS (high sodium) dangerous (risk of cardiac overload/oedema exacerbation). ReSoMal addresses this with low Na, high K, and Mg supplementation. Reduced-osmolarity ORS is used for well-nourished children's diarrhoea but is NOT the same as ReSoMal.

For a school-age child (6–10 years), the approximate caloric requirement is ~70–80 kcal/kg/day (ICMR/IAP RDA). For 22 kg: 22 × ~75 ≈ 1650–1700 kcal/day. The ICMR 2020 RDA for sedentary 7–9-year girls is approximately 1690–1750 kcal/day.

ICMR/IAP RDA for caloric intake by age: 0–1 yr ~100 kcal/kg; 1–3 yr ~100 kcal/kg (~1000 kcal/day); 4–6 yr ~1350 kcal; 7–9 yr ~1700 kcal; 10–12 yr ~2000 kcal; adolescents 13–18 yr ~2200–2500 kcal (sex-dependent).

Age-based RDA for caloric intake: infants 6–12 months ~80–100 kcal/kg; toddlers 1–3 years ~100 kcal/kg; school-age 6–10 years ~70–80 kcal/kg; adolescents 11–18 years vary by sex. At 22 kg with ~75 kcal/kg, the estimate is ~1650 kcal/day. 2200 kcal is closer to an adult woman's requirement.

Adolescent girls are highly vulnerable to iron-deficiency anaemia due to (a) rapid growth increasing iron demand, (b) menstrual blood loss, and (c) often poor dietary iron intake. Pale conjunctivae, fatigue, and heavy menstrual cycles are the classic triad pointing to iron deficiency as the primary nutritional problem.

Adolescent girls are the highest-risk group for iron-deficiency anaemia in India due to menstrual losses, growth demands, and often cereal-dominant diets. The Weekly Iron Folic Acid Supplementation (WIFS) programme under RBSK/NHM targets this group. Screen with haemoglobin and treat with therapeutic iron (3–6 mg/kg/day elemental iron).

Iron deficiency is the most common nutritional deficiency in adolescent girls globally and in India. Heavy menstrual cycles compound the growth-related demand for iron. Vitamin A deficiency presents with night blindness/Bitot's spots; iodine deficiency with goitre; zinc deficiency with growth retardation, hypogonadism, and poor wound healing.

Comprehensive nutritional assessment in children uses: (1) Anthropometry — weight-for-age (WAZ), height-for-age (HAZ), weight-for-height (WHZ), BMI-for-age, and MUAC plotted on WHO growth charts; (2) Dietary recall (24-hour or 3-day) to identify intake gaps; (3) Clinical examination for deficiency signs (pallor, oedema, angular stomatitis, Bitot's spots etc.).

Nutritional status assessment = anthropometry (WAZ/HAZ/WHZ/BMI-for-age + MUAC plotted on WHO growth charts) + dietary recall (24-h recall or food frequency) + clinical signs examination. Each dimension catches different aspects: anthropometry — chronic vs acute malnutrition; dietary recall — intake gaps; clinical examination — specific deficiency signs.

Adult reference curves and BMI alone are insufficient for growing children — age and sex-specific WHO charts are mandatory. Biochemical markers (albumin, prealbumin) are supplementary, not primary. MUAC alone is the best single rapid-screening tool for emergency settings but is not comprehensive assessment.