Malnutrition: nutritional rehabilitation and monitoring — formative SAQs

SAQ 1 — The wasted toddler with appetite loss (10 marks, 15 minutes)

A 16-month-old boy is brought in with marked weight loss over six weeks. His weight-for-height z-score is minus 3.4, his MUAC is 108 mm, and he has no oedema. He is afebrile but lethargic, and when offered ready-to-use therapeutic food he takes only a few mouthfuls and then refuses. A bedside glucose is normal. [1]

a) What severity of acute malnutrition does this child have, and what single clinical finding changes his disposition? Justify your answer. (3 marks) [1] [11]

b) Outline your inpatient nutritional rehabilitation, naming the stabilisation formula, its energy content and the aim of the stabilisation phase, and how and when you move to catch-up feeding. (4 marks) [1] [8]

c) Describe how you would prevent, detect and treat refeeding syndrome in this child, including the specific biochemistry you monitor, how often, and one micronutrient you give before feeding. (3 marks) [3] [6]

SAQ 2 — The dehydrated malnourished child (10 marks, 15 minutes)

A 14-month-old girl with marasmus and profuse diarrhoea is found to have sunken eyes, a slow skin pinch, dry mucous membranes and reduced urine output. She is lethargic but not in shock. Her weight-for-height z-score is minus 3.2 and her MUAC is 110 mm. [1]

a) Why must you avoid standard oral rehydration solution and a rapid intravenous bolus in this child, and what would you use instead? Give the rehydration regimen. (4 marks) [1]

b) Explain the pathophysiology of refeeding syndrome and why a normal serum phosphate on admission does not make her safe. (3 marks) [4] [6]

c) Beyond fluids and feeding, outline two other immediate threats in severe acute malnutrition that you would actively prevent or treat on admission. (3 marks) [11] [1]