This is not always practicable.
ANAEMIA due to folate, iron and copper deficiency is often present, but the haematocrit may be high owing to dehydration.
BLOOD should be examined for malarial parasites and the stools for pathogens.
CHEST X-RAY. Tuberculosis is common and is easily missed if a chest X-ray is not performed.


Treatment must involve the provISIon of protein and energy supplements and the control of infection. Resuscitation The severely ill child will require correction of fluid and electrolyte abnormalities, but intravenous therapy should be avoided if possible because of the danger of fluid overload.


This needs to be carefully planned and during the initial treatment of the acute case only enough energy and protein should be given to maintain a steady state. Large increases in energy lead to heart failure, circulatory collapse and death. A child requires approximately 100 kcal kg-I (450 k] kg:”) daily, which is provided by 0.6 g kg:” of protein. This is often given as milk with additional water, flour, maize or whatever is available locally. Sugar mixed with dried skimmed milk and small amounts of cottonseed oil (DISCO) is frequently used. Attempts should be made to give the feeds as slowly and as often as possible, although anorexia is often a problem and can be exacerbated by excess feeding. If necessary, fluids and food should be given by nasogastric tube. The child is then gradually weaned to liquids and then solids by mouth.
Hypothermia and hypoglycaemia occur in severely ill children, often with an accompanying infection, and need to be treated urgently. Because of the cold temperatures at night, blankets and sometimes additional heat are necessary.


Gradually, as the child improves, more energy can be given and during rehabilitation maximum weight gain is achieved in the shortest time by extra calories (‘catch-up weight gain’). Children who have been severely ill need constant attention right through the convalescent period, as often home conditions are poor and feeds are refused. Supplements of vitamins (A, D, Band C) should always be given, together with folic acid and iron. Many children are deficient in minerals such as zinc, copper and selenium, and supplements should be given if deficiency is suspected.
Diarrhoea can lead to potassium deficiency, and glucose electrolyte mixtures (such as the WHO formulation,) are sometimes necessary. Diarrhoea is often due to bacterial or protozoal overgrowth and metronidazole is very effective and is often given routinely. Parasites are also common and, as facilities for stool examination are usually not available, mebendazole 100 mg twice daily for 3 days should be given. In high-risk areas, antimalarial therapy is given. Adults do not usually suffer such severe malnutrition, but the same principles of treatment should be followed.


Children with extreme malnutrition have a mortality of over 50%. By careful management this can be significandy reduced to 1-2%. This largely depends on the availability of facilities. Brain development takes place in the first years of life, a time when severe PEM frequently occurs. There is evidence that intellectual impairment and behavioural abnormalities occur in severely affected children. Physical growth is also impaired. Probably both of these effects can be alleviated if it is possible to maintain a high standard of living with a good diet and freedom from infection over a long period.


Prevention of PEM depends not only on adequate nutrients being available but also on education of both governments and individuals of the importance of good nutrition (Information box 3.2). Short-term programmes are useful for acute shortages of food, but long-term programmes involving improved agriculture are equally important. Bad feeding practices and infections are more important than actual shortage of food in many areas of the world. However, good surveillance is necessary to avoid periods of famine. Food supplements (and additional vitamins) should be given to ‘at-risk’ groups by adding high-energy food, e.g. milk powder, meat concentrates, to the diet. Pregnancy and lactation are times of high energy requirement and supplements have been shown to be beneficial.

Prevention of protein-enerqy malnutrition (a WHO priority programme).
Prevention of protein-enerqy
malnutrition (a WHO priority programme).

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