Clinical Case Report

Severe Acute Malnutrition

General Data

A case of R.S. 1 year and 5 months old

child from P1, Bagakay, Ozamiz City who
was admitted for the first time due to loose
bowel movement and vomiting.
History of Present Illness

1 month prior to admission, mother noted that patient

started having generalized edema. She did not seek consult
nor gave medications to the patient.

1 day prior to admission, patient had onset of having watery

non-mucoid non-blood streak non-foulsmelling stools about 3
episodes per day. She also had vomiting postprandial about 5
episodes. Patient was given oral rehydration solution (ORS)
with no relief. Persistence of symptoms prompted admission.
Birth and Maternal History

The patient was born to a 37 years old G6P6 (6006)

mother at home via normal spontaneous delivery
assisted by a hilot. Mother denies illnesses during the
course of pregnancy.
Feeding

The patient was breastfed until 3 months old then

shifted to mild feeding using Bearbrand. Weaning and
giving of solid food started at the age of 6 months. Her
mother claims that she usually give the patient lanot
or rice water.
Developmental History

Patient unable to walk without support

Immunization History

The patient received 1 BCG, 3 OPV, 3 DPT and

Measles vaccine
Family History

No seizure, no hypertension, no diabetes mellitus,

no asthma
Environmental and Social
History

Deep well water is not boiled prior to consumption.

Physical Examination

Patient came in drowsy, pale-looking, not in

cardiorespiratory distress with the following vital signs:
HR=112bpm RR=29cpm T=35.5 0C
Wt=6.4kg O2 sat=97%
Anthropometric Measurements=not taken
Skin: warm, good turgor, with crusted lesions all over
the body
HEENT: pale palpebral conjunctivae, anicteric sclerae,
sunken eyeballs, dry lips, moist tongue
Physical Examination

Neck: supple, no lymphadenopathies

Chest/Lungs: symmetrical expansion, no retractions,
clear breath sounds, no rales, no wheeze
Heart: adynamic precordium, tachycardic, regular rate
and rhythm, no murmur
Abdomen: globular, soft, nontender, no organomegaly
Extremeties: pale nailbeds, no cyanosis, full and equal
pulses
MSE/Neuro exam: not done
Admitting Impression

Acute Gastroenteritis with Moderate Dehydration

Allergic Dermatitis with secondary bacterial infection
ER Management

The patient was initially seen and managed at the

emergency room by the pediatric resident on duty.
Intravenous fluid (IVF) was started using Plain LR 500.
Patient was initially given 15 cc/kg IV push and IVF rate
was regulated at maintenance rate plus 50%
maintenance rate.

The following medications were started: Ampicillin

210mg IVTT every 8 hours ANST (98mkD), Zinc Sulfate
syrup 2 ml once a day, ORS volume per volume
replacement. Initial laboratory work ups were the
following: CBC, Stool exam, Na, K.
Course in the Ward

CBC (9/16/2016) Na 133.9 mmol/L

Hemoglobin 8.5 g/Dl K 3.65 mmol/L

Hematocrit 27.7%

WBC 39.48Ul

Segmenters 26.7%

Lymphocytes 39.6%

Platelet count 128 X 10 3/uL

Blood type B+
Course in the Ward

Stool Exam (9/17/2016)

Color- yellow Yeast- few/hpf

Consistency-soft Ova/parasite=none seen

WBC= 0-2/hpf Fat globules=many

Course in the Ward

In the wards, where I have first seen the patient, she

looks weak, stable not dyspneic, dirty looking carried
by her mother. She had 2 episodes of passing watery
non-mucoid, non-blood streak stools. She had no
vomiting. Her lips were dry and pale. Her face and
extremities were edematous. She had several crusted
and dry lesions all over her body. Her mother was
instructed to give oral rehydration solution in small
frequent amount as volume per volume replacement.
Amikacin at 10 mkD was started. The patient was
referred to a Pediatric Specialist for further evaluation
and management.
Course in the Ward

On the second hospital day, patient was awake,

afebrile. She had 3-5 episodes of passing watery stools
per day. There was no vomiting. She was seen by a
Pediatric Specialist who suggested referral to the
medical social worker for assistance regarding possible
child neglect. Cefotaxime was started at 150 mkD and
Metronidazole at 30kmD. The patient was also referred
to the Dietary Department for Nutritional build-up.
Blood culture and sensitivity was ordered.
Course in the Ward

The patient was seen by a nutritionist. Dietary

counseling to the mother and family was done. They
were taught on proper nutrition and proper hygiene.
The patient was given blenderized food that was given
as additional source of food and nutrition to add
calories to the patients daily intake. The blenderized
food was given in a small frequent feeding aside from
the diet that was served to her. A repeat CBC was done
which revealed severe anemia, leukocytosis,
thrombocytopenia. Blood transfusion was ordered.
Serum Albumin was low at 0.9 g/dL.
Course in the Ward

CBC (9/17/2016)

Hemoglobin 6.7g/Dl

Hematocrit 21.5%

WBC 14.24Ul

Segmenters 25.9%

Lymphocytes 51.5%

Platelet count 67X 10 3/uL

Course in the Ward

On the 4th hospital day, patient was weak, afebrile still

with facial edema, crusted lesions all over the body.
Mother said that the patient still with watery stools
about 3-5 episodes per day. She was able to tolerate
the blenderized food provided by the dietary
department.
Course in the Ward

On the 5th hospital day, patient started having fever

with several episodes of passing watery stools. No
vomiting noted. Her mother was instructed to give oral
rehydration solution as volume per volume
replacement. Paracetamol was started at 15mkd every
4 hours round the clock for 24 hours.
Course in the Ward

On the 6th hospital day, patient had no fever but weak-

looking with poor appetite. She was given packed red
blood cells (PRBC) at 10cc/kg. Furosemide was given at
1mg/kg/dose after the blood transfusion.
Course in the Ward

On the 7th hospital day, patient was still weak, poorly

groomed. She had 3-5 watery stools per day. Mother
said that the patient could not consume the
blenderized food given by the dietary section. A repeat
CBC after 1 aliquot of blood revealed severe anemia,
thrombocytopenia.
A second aliquot of PRBC was ordered. Patient was
given 1 vial of Human Albumin.
Course in the Ward

CBC (9/24/2016)

Hemoglobin 6.5 g/Dl

Hematocrit 21%

WBC 10.68Ul

Segmenters 17.1%

Lymphocytes 54.4%

Platelet count 33X 10 3/uL

Course in the Ward

On the 9th hospital day, patient was still weak. Patient

started having cough and fever. Chest and lungs
examination showed equal chest expansion with sternal
and subcoastal retractions, crackles all over the lung
field. A repeat Chest Xray APL was ordered.
Course in the Ward

After several attempts to insert IV line, patient was

referred to surgery department for cutdown. The
following antibiotics were started: Cefixime at 8
mg/kg/Day and Clarithromycin at 15 mg/kg/Day while
patient had no IV line. Surgery department suggested
intra osseous insertion because patient has high risk for
surgical bleeding.
Course in the Ward

On the 10th hospital day, patient started having severe

dyspnea, generalized cyanosis. She had weak pulses.
Course in the Ward

Sepsis; Acute Gastroenteritis with Severe Dehydration

Severe Acute Malnutrition
Discussion
 Causes of
malnutrition
Food: Inadequate household food
security (limited access or availability of
food)
Nutrition: Inadequate access to food
coupled with unsanitary environment,
inadequate health services, and lack of
knowledgeable care to ensure healthy
life.
Health: Limited access to adequate
health services and/or inadequate
environmental health conditions.
Care: Inadequate social and care
environment in the household and
3 local community, especially in regard
0 to women and children.
 Conceptual framework of
malnutrition (UNICEF 1991)

3
1
 Pathophysiology of
Undernutrition
Reductive adaptation
Reductive adaptation is defined as the
physiological response of the body to
under nutrition i.e. Systems slow
down and do less in severe acute
under nutrition in order to allow
survival on limited nutrient resources
especially calories.

3
2
 Pathophysiology of
undernutrition
reduced cellular metabolism
reduction of protein/enzymes synthesis
reduced cardiac output
reduced kidney function - Limited capacity
of excretion,
Electrolyte imbalance - Concentration K+
; Na+
Iron - anaemia
low transferrin
Immune system-Inflammatory responses
absent or severely weakened
Thermoregulation altered; poikilothermia:
hypothermia/pyrexia

33
 PHYSIOLOGICAL BASIS FOR
TREATMENT OF
MALNUTRITION

34
 Cardiovascular
System
Cardiac output and stroke volume
are
reduced
Infusion of saline may cause an
increase in venous pressure
Any increase in blood volume
can easily produce acute heart
failure;
Any decrease will further
35
compromise tissue perfusion
 Cardiovascular
System
Blood pressure is low
Renal perfusion and
circulation time are reduced
Plasma volume is usually
normal and
red cell volume is reduced

36
 LIVER

Synthesis of all proteins is

reduced
Abnormal metabolites of
amino acids are produced c
Capacity of liver to take up,
metabolize and excrete toxins
is severely reduced
Energy production from
37
substrates
 LIVER

Gluconeogenesis is reduced,
which increases the risk of
hypoglycaemia during
infection
Bile secretion is reduced

38
 GENITOURINARY
SYSTEM
Glomerular filtration is
reduced
Capacity of kidney to excrete
excess acid or a water load is
greatly reduced
Urinary phosphate output is
low
Sodium excretion is reduced
Urinary tract infection is
39
 GASTROINTESTINAL
SYSTEM
Production of gastric acid is
reduced
Intestinal motility is reduced
Pancreas is atrophied and
production of digestive
enzymes is reduced
Small intestinal mucosa is
atrophied; secretion of digestive
40
 IMMUNE SYSTEM
All aspects of immunity are
diminished
Lymph glands, tonsils and the
thymus are atrophied
Cell-mediated (T-cell) immunity is
severely depressed
IgA levels in secretions are
reduced
Complement components are low
41
Phagocytes do not kill ingested
 IMMUNE SYSTEM
Tissue damage does not result in
inflammation or migration of white
cells to the affected area
Acute phase immune response is
diminished
Typical signs of infection, such as an
increased white cell count and fever,
are frequently absent
Hypoglycaemia and hypothermia are
both signs of severe infection and are
42
usually associated with septic shock
 ENDOCRINE
SYSTEM
Insulin levels are reduced and the
child has glucose intolerance
Insulin growth factor 1 (IGF-
1) levels are reduced
Growth hormone levels are
increased
Cortisol levels are usually
increased
43
 CIRCULATORY
SYSTEM
Basic metabolic rate is reduced by
about 30%.
Energy expenditure due to activity is
very low
Both heat generation and heat loss
are impaired; the child becomes
hypothermic in a cold environment
and hyperthermic in a hot
environment
44
 CELLULAR
FUNCTION
Sodium pump activity is reduced and
cell membranes are more permeable
than normal,
which leads to an increase in
intracellular sodium and a
decrease in intracellular
potassium and magnesium
Protein synthesis is reduced
45
 SKIN,MUSCLES AND
GLANDS
THE skin and subcutaneous fat are
and glands atrophied, which leads
to loose folds
Many signs of dehydration are unreliable;
eyes may be sunken because of loss of
subcutaneous fat in the orbit
Many glands, including the sweat, tear
and salivary glands, are atrophied; the
child has dryness of the mouth and eyes
and sweat production is reduced
Respiratory muscles are easily fatigued;
the child is lacking in energy
46
 Categories of Under
nutrition
Acute and Chronic Malnutrition.
Children can have a combination of both
acute and chronic Malnutrition.
Acute Malnutrition is categorized into
Moderate and Severe acute Malnutrition,
determined by the clients degree of
wasting (is an indicator of acute
Malnutrition, the result of more recent
food deprivation or illness).
All cases of bi-lateral oedema are
47
categorized as severe acute
 Categories of under nutrition
continued
Chronic under nutrition is determined by a
patients degree of stunting (the result of
prolonged food deprivation and/or disease
or illness), i.e. when a child has not
reached his or her expected height for a
given age.
To treat a patient with chronic under
nutrition requires a long-term focus that
considers household food insecurity in the
long run; home care practices (feeding
48 and hygiene practices); and issues related
 recognition and early
treatment

49
 Definitions of Severe
PEM
WHO
Classification:
+ Oedema No oedema

Severe wasting
(WHZ <-3) Severe wasting
+ oedema*

* If there is severe oedema the weight may

appear reasonable initially.

50
 Definitions of Severe
PEM
WHO Classification:
+ Oedema

No oedema
Severe wasting
WHZ <-3 Severe wasting
+ oedema*

Two simple signs are useful

for classification
51
 Clinical Diagnosis /
Definition
Presence of visible severe wasting
Buttocks, thighs, shoulders
Presence of symmetrical
oedema with supporting
evidence for kwashiorkor:
Skin changes
Hair changes
Weight for age (Road to Health
Card Chart)
52 Should be the minimum form
 Clinical
Diagnosis

Source: KEMRI /Wellcome Trust

But you have to look..it is

often missed
53
 TRIAGEADMISSION
CRITERIA
MEDICAL EXAMINATION AND APPETITE TEST

SAM with SAM without

complications complications Moderate Acute
Nutritional oedema ++,+ malnutrition
++ OR WHZ<-3 without
Marasmic Kwashiorkor complications
OR
(WHZ<-3 OR/MUAC<115mm with
any MUAC<115mm WHZ>-3 and <-2
grade of OR Or
oedema) OR
WHZ<-3(OR Nutritional oedema + MUAC >115mm and
WHM<70%) <125mm
AND
MUAC<115mm
Nutritional Appetite Supplementary
oedema + AND Feeding
Clinically well
No appetite and /or
complications(IMCI danger signs) Alert
Infants
wasted
6months unable to suckle
In Patient
or visibly
Care
104
 APPETITE
TEST (1)
Why to conduct one?
Major medical complications lead to loss of
appetite

It is mainly metabolic malnutrition that causes

death. Often the only sign of severe metabolic
malnutrition is a reduction in appetite

A poor appetite means that the child has a

significant infection or a major metabolic
abnormality such as liver dysfunction, cell
membrane damage, electrolyte imbalance.
55 These children are at immediate risk of death
 APPETITE
TEST (2)

How to conduct one?

In a separate area
Explain to care giver how
Care giver washes hands
Care giver offers RUTF
Child need to be offered plenty
of water

56
 APPETITE
TEST (3)
Result of the appetite Kg Sachets
test
<4 1/8 to
A child who takes the
minimum amount for
4-6.9 to 1/3
their weight as indicated
in the table has passed 7-9.9 1/3 to
A child that does not take at
least the amount of RUTF
10-14.9 to
indicated in the table has
failed 15-29 to 1
>30 >1

57
 Why is detecting
malnutrition
important?
In many hospitals the commonest
reason for death of a child in
hospital is PEM
Case fatality of severe malnutrition
in hospital in Africa is 30-40% (3 or
4 out of 10 die in hospital)
If it is not recognised it is not treated
properly and deaths are not
prevented.
58
 Kwashiorkor where
logic fails
Protein
deficiency

Treatment
with a high
protein diet

Source: KEMRI /Wellcome Trust

59
 Kwashiorkor where
logic fails
Protein
deficiency

Treatment
with a high
protein diet
Source: KEMRI /Wellcome Trust

60
 Severe
malnutrition

Protein
Energy
Malnutrition

61
 Severe
malnutrition

Micronutrient
Protein Electrolyte and and Vitamin
Energy mineral deficiencies
Malnutrition deficiencies

62
 Electrolyte / Mineral
Deficiencies
Potassium:
Potassium supplements help
reduce oedema
Muscle weakness / apathy
Reduced cardiac output.
Magnesium (convulsions /
arrhythmias)
Zinc (diarrhoea / skin disease)
Copper (anaemia)
Selenium (heart failure)
63 Source: KEMRI /Wellcome Trust
 Electrolytes / Minerals What about
Sodium?

Total body sodium is often

increased
Expansion of extracellular fluid
volume
Leakage of sodium into cells
sick cell syndrome
Giving sodium (iv fluids / salty
foods) can be dangerous
64
 What other problems do these
children commonly
have?

65
 10 Step
Approach
Hypoglycaemia
Hypothermia
Dehydration Monitoring
Electrolytes
Infection
Micronutrients
Initiate feeding
Catch-up growth
Sensory stimulation
Discharge
66 preparation
Hypoglycaemia and
Hypothermia
All new admissions with
malnutrition should be kept warm
until there are signs of recovery.
iv or ngt glucose for those who
are unconscious or very
severely ill with no glucose
measurement.
Immediate ngt feeding for
67 conscious children with blood
 Dehydrati
on
Shock is treated with special fluid
plans and Half-Strength Darrows
with 5% dextrose.
Oral rehydration is with ReSoMal.
Feeding must be started by 12
hours.

68
 Oral re-hydration in Severe
Malnutrition.
All concentrations are in Osmolarity
Na+ K+ Osmolarity
mmol/l Glucose

New WHO /
75 20 111
UNICEF ORS
Rehydration Solution ~ 200
for Malnutrition 45 40 Glucose
ReSoMal*. &saccharose

*Add 2 WHO ORS 500ml sachets to 2 litres water rather then 1

litre, then add 50g (5 teaspoons) sugar and 60 mmols
Potassium Chloride (3 10ml iv vials of strong potassium,
20mmols/10mls)
69
Composition
of
RESOMAL

47
 Note
use
of 2
liters
of
wate
r

71
 Oral re-hydration in Severe
Malnutrition
Resomal 5ml/kg every 30 mins for 2
hours.
Use an ngt early.
Then 5 10 mls/kg each hour for a
maximum of 10 hours
Give 10 if the child thirsty / severe
dehydration, 5 if not.
Introduce starter milk (F-75) at 4 hours
and slowly replace Resomal with starter
milk over 12 hours.
72 Continue breast feeding throughout.
 Electrolytes &
Minerals
All severely malnourished
children have potassium
deficiency.
All should receive an extra
4mmol/kg/day of oral potassium
(after stopping ReSoMal).
Ideally should receive Mg, Zn, Cu
and Se as part of mineral mix
added to milk feed.
73
 Infecti
Up to 1/3rd on with malnutrition
children
who die have septicaemia /
bacteraemia
Fever and other signs of infection are
not helpful in identifying these children
when there is severe malnutrition.
ALL children with severe malnutrition
sick enough to be in hospital should be
started on Penicillin (or Ampicillin) and
Gentamicin for at least 5 days.
In addition they receive oral
metronidazole and treatment for
thrush if present.
74
52
Vitamin A
deficiency

Source: KEMRI /Wellcome

 Vitami
ns
Vitamin A:
With Eye signs: 200,000 iu on
admission, on Day 2 and on Day 14
(100,000 iu if aged < 12 months).
Without Eye signs: stat dose appropriate
for age
Multivitamins 1 tablet twice
daily for 14 days.

76
 First
feeding.
Feeds need to be prescribed
they are treatment!

77
 Severe malnutrition

nutritional
treatment

78
 Objectiv
es
Understand the link between
observed pathophysiological
abnormalities and treatment.
Consider the priorities and aims of
immediate nutritional management.
Non-nutritional management is
considered elsewhere.

79
What are the problems
faced in providing acute

Source: KEMRI /Wellcome

nutritional therapy?

Reduced appetite and willingness to

feed
Fatty liver with reduced synthetic
functions
Absorption of nutrients is probably
adequate but may be reduced by
diarrhoea and small bowel bacterial
overgrowth
Reduced renal ability to excrete sodium
80
Impaired cardiac contractility
Gentle nutritional rescue the
process of feeding

Immediate feeding
Small volume / frequent feeding
because of small stomach capacity and
precarious physiology
Vomiting is NOT a contraindication to
feeding
Routine insertion of a naso-gastric tube
should be considered
Feeds are the drug to cure
81 malnutrition, they are a priority (after
60
Contents of F-75. Note that this is
61
 The feed content 1 litre
of F75
Ingredient Amount
Dried skimmed milk 25g
Sugar 100g
Vegetable Oil 27mls
Mineral solution 20mls
Water make up to 1000mls

Mineral solution ideally contains minerals and trace

elements if not available at least add 40mmols
potassium (2x 10mls iv KCl vials) to each 1000mls of
62 feed
 The feeding plan a
prescription
What is the weight?
Marasmus
130 ml/kg/day start-up feed
Kwashiorkor / marasmic
kwashiorkor:
100 mls/kg/day start-up feed
Ideally given in 12 two hourly feeds,
or, if not possible, 8 three hourly
feeds
85
..this means at night too!
 What would this
provide?
Marasmus Kwashiorkor
130 mls/kg/day 100 mls/kg/day

Calories 100 kcal/kg/day 75 kcal/kg/day

0.75 1.3
Protein 1 1.5 g/kg/day
g/kg/day

86
 Why do we not give
more?
The body really cannot tolerate
more
Too vigorous re-feeding has
been associated with
increased mortality.
Too much sugar can cause an
osmotic diarrhoea
Higher protein contents are
87
usually associated with higher
 Standard initial
nutritional
prescriptionage 3
yrs, 10 kg
F-75 165 mls 3 hourly

Potassium chloride 5mmol

2 tabs qds
tabs (crushed in feed)
200,000 iu stat, on day 2
Vitamin A (has eye signs)
and day 14

Multivitamin 1 tab twice daily

88
 When to change
from rescue
feeding?
Return of appetite:
2 to 3 days after admission in those with
no oedema and modest levels of activity
5 to 7 days after admission in those
with severe lethargy / severely ill at
admission
Oedema:
You do not have to wait for resolution of
oedema before changing to recovery
feeding if the child has a good appetite.
89
Feed with cup / cup and spoon
 Weight gain in the first
week
Rescue feeding is usually NOT associated
with weight gain
Weight loss may even occur in
children whose oedema is
improving
Do not panic!
Ensure at least 100 mls/kg/day of starter
feed has been given.
Early recovery involves loss of body water
(reducing weight) and increases in cellular
mass (increasing weight)
Appetite and activity level denote recovery
90 in the first week, not weight change.
71
 F100 : to be mixed with 2litres of water. Note it has vitamin
72
Contains peanut paste, vegetable fat, dry skimmed milk, dry whey, sugar
minerals & vitamin complex
73
74
 The feed content 1 litre
of F100
Ingredient Amount
Dried skimmed milk 80g
Sugar 50g
Vegetable Oil 60mls
Mineral solution 20mls
Water make up to 1000mls

Mineral solution ideally contains minerals and trace

elements if not available at least add 40mmols
potassium (2x 10mls iv KCl vials) to each 1000mls of
75 feed
 What would this
provide?
F75 Starter F100 Catch-up
100mls 100mls

Calories 75 kcal 100 kcal

Protein 0.9 g 3g

96
 A feeding
plan
Admission

130 or 100 ml/kg/day

as 3 hourly feeds, for 2
-7 days

F75

97
 A feeding
plan
Appetite
Admission recovers
130 ml/kg/day as
3 hourly feeds
for 2 3 days

F100, same
volume as
F75
F75

98
 A feeding
plan
Appetite Good appetite,
Admission clinically
stable
recovers

F100, volume
increasing until
F100, same
appetite satisfied
volume as
F75 F75

99
 A feeding
plan Good appetite,
clinically
Increase each feed by stable
10mls until some is not
eaten usually achieve
180 200 ml/kg/day F100, volume
increasing until
appetite satisfied

10
0
 Then
what?

10
1
 Rehabilitati
on
Introduce solid foods and
increase to 5 appropriate
meals a day.
Continue snacks in between
Continue breast feeding
Continue mineral supplements
for 2 weeks
Start oral iron and mebendazole
therapy after 1 week
Monitor progress
10
Provide stimulation / play
2 Educate the family and prepare for
 Monitorin
Rescue
Fever / g 1 Recovery
Hypothermia
Fever /
Glucose Hypothermia
Respiration Respiration

Heart Rate Heart Rate

Weight Weight Rehabilitation

Oedema Oedema Weight

10
3
 Monitorin
g 2should be
Intake of feed
monitored throughout
If there is concern for heart
failure (HR,
RR) in the rescue phase reduce feed
volumes for 24 hours.
Weight gain in recovery /
rehabilitation phases:
Poor, <5g/kg/day, full re-
assessment
Moderate, 5 10g/kg/day, check intake
10 adequate, is there untreated infection
4
 When to

discharge?
Completed antibiotics
Good appetite and gaining weight
Lost any oedema
Appropriate support in the community
or home
Mother / carer:
Available
Understands childs needs
Able to supply needs

10
5
 10 Step
Approach
Hypoglycaemia
Hypothermia
Dehydration Monitoring
Electrolytes
Infection
Micronutrients
Initiate feeding
Catch-up growth
Sensory stimulation
Discharge
10 preparation
6
 Summa
ry
The rescue phase of nutritional
support requires gentle
introduction of calories and small
amounts of protein.
Potassium, vitamins and ideally other
minerals should routinely be given
Recovery feeding starts as the
appetite returns and is gradually
scaled up.
10
7
 Summa
ry.
The risk of death in children
with severe malnutrition is very
high.
The children have many problems
and each needs treating.
The 10 steps approach allows each
problem to be treated
Feeding should not be a high protein
108
diet.