Learn — Nutrition, malnutrition & diarrhoea

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Gomez classification of malnutrition

The Gomez classification grades protein-energy malnutrition by a single measurement, weight-for-age, expressed as a percentage of the expected weight for that age on the reference standard. It was the first workable field classification and it still appears in every Indian nursing paper, but it is no longer the operational standard because weight-for-age cannot separate a short, chronically stunted child from an acutely wasted one, and it ignores oedema altogether.

The calculation is actual weight divided by the expected weight for that age on the reference standard, multiplied by 100; the median or 50th centile weight for age is the reference.
Normal is above 90 percent of expected weight for age.
Grade I, mild malnutrition, is 75 to 90 percent of expected weight for age.
Grade II, moderate malnutrition, is 60 to 75 percent of expected weight for age.
Grade III, severe malnutrition, is below 60 percent of expected weight for age.
The IAP classification uses the same weight-for-age idea but different bands — Grade I 71 to 80 percent, Grade II 61 to 70, Grade III 51 to 60 and Grade IV 50 percent or less — and adds the suffix K when oedema is present, so read the question stem carefully before choosing a grade.
Waterlow's classification is the one that separates the two processes: weight-for-height identifies wasting, which is acute, and height-for-age identifies stunting, which is chronic.
Welcome classification uses weight-for-age with oedema — 60 to 80 percent with oedema is kwashiorkor and without oedema is undernutrition, while below 60 percent with oedema is marasmic kwashiorkor and without oedema is marasmus.
Current WHO practice classifies acute malnutrition by weight-for-height Z score, mid-upper arm circumference and bilateral pitting oedema, and that is what drives admission and feeding decisions in an NRC — Gomez is history and exam material, not a treatment trigger.

Malnutrition — SAM and MAM

Severe acute malnutrition and moderate acute malnutrition are the WHO classifications of recent, rapid weight loss in children aged 6 to 59 months, defined by weight-for-height, mid-upper arm circumference and the presence of bilateral pitting oedema. The distinction is not academic — a child with severe acute malnutrition carries roughly nine times the risk of death of a well-nourished child, and whether that child is admitted or treated at home is decided at the bedside by three measurements and an appetite test.

Severe acute malnutrition in 6 to 59 months is any one of weight-for-height below minus 3 standard deviations, mid-upper arm circumference under 11.5 cm, or bilateral pitting oedema of nutritional origin.
Moderate acute malnutrition is weight-for-height between minus 3 and minus 2 standard deviations, or mid-upper arm circumference from 11.5 to under 12.5 cm, with no oedema.
Bilateral pitting oedema makes the diagnosis severe on its own whatever the weight shows, and it is graded plus for both feet, plus plus for feet and legs or hands, and plus plus plus when it reaches the face — grade three oedema is always an inpatient.
The appetite test with ready-to-use therapeutic food is the gate: a child who passes it and has no medical complication is managed at home on RUTF, and a child who fails it, has any complication, has grade three oedema or is under 6 months is admitted.
The complications that force admission are hypoglycaemia, hypothermia, severe dehydration or shock, severe anaemia, high fever, lower respiratory infection, persistent diarrhoea, eye signs of vitamin A deficiency, lethargy and convulsions.
Inpatient care follows the WHO ten steps in two phases — stabilisation, which treats hypoglycaemia, hypothermia, dehydration, electrolyte imbalance, infection and micronutrient deficiency and starts cautious feeding, then rehabilitation, which drives catch-up growth, sensory stimulation and preparation for follow-up.
F-75 supplies 75 kcal per 100 mL and is the stabilisation feed, given about 130 mL/kg/day in 8 to 12 small feeds including through the night; F-100 supplies 100 kcal per 100 mL and is the catch-up feed of the rehabilitation phase, increased to 150 to 220 mL/kg/day.
Rehydrate with ReSoMal, not standard ORS, at 5 mL/kg every 30 minutes for the first 2 hours then 5 to 10 mL/kg an hour, because standard ORS carries too much sodium and too little potassium for these children; reserve intravenous fluid for shock.
Give potassium and magnesium from the start but never iron during stabilisation — iron is added only in the rehabilitation phase once appetite has returned, because free iron feeds bacteria and worsens oxidative injury.
Broad-spectrum antibiotics are routine even without visible infection, since the classic signs of sepsis are blunted; oral amoxicillin for uncomplicated cases and injectable ampicillin with gentamicin for complicated ones.
Target weight gain in rehabilitation is 5 to 10 g per kg per day, and discharge from outpatient care needs mid-upper arm circumference of 12.5 cm or more, or weight-for-height at minus 2 standard deviations or better, with oedema gone for at least two weeks.

Indicators of malnutrition

The indicators of malnutrition are the measurable signs that tell whether a child's nutrition is failing, and each one answers a different question — whether the deficit is recent or long-standing, and how severe it is right now. They are grouped as anthropometric, clinical, biochemical and dietary, and the anthropometric group carries most of the exam weight because weight-for-height, height-for-age and mid-upper arm circumference are what trigger admission, referral and supplementary feeding.

Weight-for-height identifies wasting, which is acute or recent malnutrition; below minus 2 standard deviations is moderate wasting and below minus 3 is severe wasting.
Height-for-age identifies stunting, which is chronic or long-standing malnutrition and cannot be reversed quickly; below minus 2 standard deviations is stunted.
Weight-for-age identifies underweight, a composite that cannot tell wasting from stunting — which is exactly why it is no longer the sole indicator for treatment decisions.
Mid-upper arm circumference in 6 to 59 months needs no age and no scale: under 11.5 cm is severe acute malnutrition, 11.5 to under 12.5 cm is moderate, and 12.5 cm or more is normal, colour-coded red, yellow and green on the Shakir tape.
Mid-upper arm circumference is treated as age-independent between 1 and 5 years because it rises only from about 16 to 17 cm across those four years in a well-nourished child, which makes it the ideal community screening tool.
BMI-for-age is the indicator for children and adolescents from 5 to 19 years, with thinness below minus 2 standard deviations, overweight above plus 1 and obesity above plus 2 on the WHO reference.
Head circumference exceeds chest circumference at birth, the two become equal at about 6 to 12 months, and chest overtakes head thereafter; a chest circumference still lagging behind head circumference well beyond the first year suggests undernutrition.
The Kanawati index, mid-upper arm circumference divided by head circumference, is above 0.31 in the well nourished and below 0.25 in severe malnutrition, and the QUAC stick reads arm circumference against height.
Clinical indicators are pallor of anaemia, bilateral pitting oedema, flaky-paint dermatosis, thin sparse depigmented hair, angular stomatitis and glossitis, Bitot spots and corneal xerosis of vitamin A deficiency, and the wide wrists and rachitic rosary of rickets.
Biochemical indicators include haemoglobin, serum albumin, serum retinol and serum zinc, and dietary assessment uses the 24-hour recall and the food frequency questionnaire; growth chart plotting across visits ties them all together, since a flattening or falling line detects trouble before any single value is abnormal.

Calorie intake of 1-year-old

The energy requirement of a 1-year-old is the number of kilocalories a day needed for basal metabolism, activity and the growth that is still adding about 2 to 3 kg and 12 cm in the second year. It is asked constantly because it is the number that turns feeding advice into a plan — how many meals, how much per meal, and how much of the intake should still come from breast milk.

A 1-year-old typically weighs 9 to 10 kg, three times birth weight, and needs roughly 900 to 1000 kcal a day; the ICMR-NIN 2020 requirement for the 1 to 3 year group is about 1100 kcal a day.
ICMR-NIN 2020 energy requirements below that: about 500 kcal a day from 0 to 6 months and about 670 kcal a day from 6 to 12 months.
The weight-based caloric rule for prescribing is 100 kcal/kg for the first 10 kg, 50 kcal/kg for the next 10 kg and 20 kcal/kg for every kilogram beyond 20 — so a 10 kg 1-year-old works out at 1000 kcal a day.
Breast milk supplies about 65 to 70 kcal per 100 mL and still covers roughly a third of energy needs from 12 to 24 months, which is why breastfeeding continues to 2 years and beyond alongside family food.
Complementary food must therefore supply about 550 kcal a day at 12 to 23 months, against about 200 kcal a day at 6 to 8 months and 300 kcal a day at 9 to 11 months.
Feeding frequency at 12 to 23 months is 3 meals plus 1 to 2 nutritious snacks, with about three-quarters to one full 250 mL cup of food at each meal.
Energy density matters more than volume in a small stomach — complementary food should provide at least 1 kcal per gram, so a spoon of ghee or oil is added to the mashed food rather than diluting it with water or thin dal water.
Fat should supply roughly 30 to 45 percent of energy in the 6 to 24 month period, because a low-fat adult-style diet cannot meet a toddler's energy needs in the volume a toddler can eat.
Cow milk is limited to about 500 mL a day after the first birthday; more than that displaces iron-rich food and causes iron deficiency anaemia, and honey is avoided in the first year because of infant botulism.
Growth, not the calculated figure, is the check on adequacy — a child who is gaining weight along the growth chart is getting enough, whatever the arithmetic says.

Nutritional status assessment

Nutritional status assessment is the systematic use of anthropometry, clinical examination, biochemistry and diet history to decide whether a child's nutrition is adequate, and if not, how bad it is and how long it has been going on. No single measurement answers that question, so the methods are used together and remembered as ABCD — anthropometric, biochemical, clinical and dietary — with vital statistics and ecological factors added when a community rather than a child is being assessed.

Anthropometry is the backbone: weight, length or height, mid-upper arm circumference, head and chest circumference and triceps skinfold thickness, each plotted as a Z score against the WHO growth standards.
The three anthropometric verdicts are wasting from weight-for-height (acute), stunting from height-for-age (chronic) and underweight from weight-for-age (mixed), with minus 2 standard deviations as moderate and minus 3 as severe.
Mid-upper arm circumference is the fastest screen in 6 to 59 months — under 11.5 cm severe, 11.5 to under 12.5 cm moderate, 12.5 cm and above normal — and it needs neither the child's age nor a weighing scale.
Clinical examination looks for pallor, bilateral pitting oedema, hair that is sparse, depigmented and easily plucked, flaky-paint dermatosis, angular stomatitis, glossitis, Bitot spots and corneal xerosis, and the bony signs of rickets.
Biochemical tests confirm what the eye suspects: haemoglobin for anaemia, serum albumin, serum retinol, serum zinc, and urinary iodine at the community level.
Dietary assessment uses the 24-hour recall for the individual, the food frequency questionnaire for habitual intake, and weighed food records or the family food-consumption survey for research-grade data.
Indirect or community-level indicators are vital statistics — infant mortality rate, under-five mortality rate, and the prevalence of low birth weight — together with ecological factors such as food availability, sanitation, maternal literacy and household income.
Functional tests round the picture out, such as the dark adaptation test for vitamin A status and grip strength or work capacity in older children.
The single most useful clinical act is plotting serial measurements on the growth chart in the mother and child protection card, because the direction of the line detects deterioration long before any one value crosses a cut-off.

Kwashiorkor

Kwashiorkor is the oedematous form of severe protein-energy malnutrition, in which protein intake fails while energy intake is relatively preserved, so the child retains fat and fluid rather than simply wasting away. It is the classic disease of the toddler displaced from the breast by the next baby onto a starchy, protein-poor diet, and it is dangerous precisely because the oedema and the round face make the child look better nourished than a marasmic child who is at less risk of death.

Bilateral pitting oedema is essential to the diagnosis and begins in the feet, spreading to the legs, hands and finally the face, which gives the moon-face appearance.
Subcutaneous fat is preserved and muscle is wasted, so the limbs are thin while the cheeks and buttocks stay full — the opposite of marasmus, where fat is lost first.
The hair becomes sparse, thin, brittle and depigmented and is easily plucked without pain; alternating pale and dark bands along a hair, the flag sign, record alternating periods of poor and better nutrition.
The skin shows flaky-paint or crazy-pavement dermatosis, with hyperpigmented plaques that peel off and leave raw, hypopigmented, easily infected areas.
The child is apathetic and miserable, cries when disturbed, and above all is anorexic — refusal to eat is the feature that most reliably separates kwashiorkor from marasmus, where appetite is usually good.
Hepatomegaly from fatty infiltration, a distended abdomen, hypoalbuminaemia, anaemia and persistent diarrhoea complete the picture.
Marasmus is the discriminator to state in one line: gross wasting with no oedema, an old-man face from loss of the buccal fat pad, prominent ribs, baggy-pants skin folds over the buttocks, and a child who is alert and hungry.
Marasmic kwashiorkor is the mixed picture, severe wasting together with oedema, and it carries the worst prognosis of the three.
Treatment is the WHO ten-step protocol — F-75 in the stabilisation phase, moving to F-100 for catch-up growth only after oedema begins to resolve and appetite returns, with potassium and magnesium from the start and iron only in the rehabilitation phase.
The oedema is never treated with diuretics and never with albumin infusion; it clears as the child is fed, and a fall in weight in the first days is the oedema going, which is progress rather than deterioration.

Vitamin A prophylaxis — doses

Vitamin A prophylaxis is the biannual high-dose oral supplement given to preschool children under India's national programme, because vitamin A deficiency is a leading preventable cause of childhood blindness and because the supplement also lowers all-cause under-five mortality by reducing deaths from measles and diarrhoea. The nurse is asked for two things — the exact dose at each age and the exact vaccine each dose is linked to — because the schedule is deliberately tied to the immunisation contacts.

The first dose in the Indian schedule is 100,000 IU orally at 9 months of age, given together with the measles-rubella vaccine.
The second dose is 200,000 IU at 16 to 18 months, given with the DPT booster.
Thereafter 200,000 IU is repeated every 6 months up to 5 years of age, making 9 doses in all from 9 months to 5 years.
The WHO schedule quoted alongside it gives 100,000 IU as a single dose at 6 to 11 months and 200,000 IU every 4 to 6 months from 12 to 59 months.
Treatment doses for xerophthalmia, measles or severe acute malnutrition with eye signs are given on day 1, day 2 and again at 2 weeks, at 50,000 IU under 6 months, 100,000 IU at 6 to 11 months and 200,000 IU at 12 months and above.
The Indian preparation is 100,000 IU per mL, so a 200,000 IU dose is 2 mL, measured with the graduated spoon or cup and given by mouth; the dark bottle is kept cool and out of light because vitamin A degrades in heat and sunlight.
Do not repeat a dose within one month of a previous one; a bulging fontanel, vomiting, headache or irritability after dosing is transient acute hypervitaminosis A and needs observation and reassurance rather than treatment.
The deficiency sequence to recognise is night blindness first, then conjunctival xerosis, then Bitot spots as foamy triangular patches on the temporal conjunctiva, then corneal xerosis, then ulceration and keratomalacia, which is a blinding emergency.
High-dose vitamin A is avoided in pregnancy because it is teratogenic, and WHO no longer recommends routine high-dose supplementation of postpartum mothers.
Dietary prevention runs alongside the dose: dark green leafy vegetables, carrot, pumpkin, papaya and mango for beta-carotene, and egg yolk, milk, liver and fish liver oils for preformed retinol, together with breastfeeding, which supplies vitamin A directly.

Rickets

Rickets is defective mineralisation of the growth plate in a growing child, almost always from vitamin D deficiency, so the newly formed osteoid at the metaphysis stays soft and the bone bends and widens under load. It matters because the skeletal deformity is only the visible half — the same deficiency causes hypocalcaemic seizures, tetany and, in infants, cardiomyopathy, and because it is entirely preventable with 400 IU of vitamin D a day.

Nutritional vitamin D deficiency is the usual cause and the peak age is 6 months to 2 years; the risks are exclusive breastfeeding without a vitamin D supplement, dark skin, little sun exposure, covered clothing, prematurity and long-term anticonvulsants.
Craniotabes, a ping-pong-ball softening of the parietal and occipital bones, is the earliest sign in infancy; the anterior fontanel closes late and the forehead bosses.
Chest signs are the rachitic rosary, a row of beads at the costochondral junctions, and Harrison's sulcus, the horizontal groove where the diaphragm pulls on the softened lower ribs.
Limb signs appear once the child bears weight: widened wrists and ankles, bowing of the legs into genu varum or genu valgum, delayed walking, hypotonia with a pot belly, and greenstick fractures.
Biochemistry is the discriminator — serum calcium is normal or low, phosphate is low, alkaline phosphatase is markedly raised and is both the earliest and the most consistent abnormality, 25-hydroxyvitamin D is low and parathyroid hormone is high.
The wrist radiograph shows cupping, fraying and splaying of the metaphysis with a widened growth plate; healing appears as a dense line of provisional calcification within 2 to 4 weeks of starting treatment.
The regimen used widely in India is vitamin D3 60,000 IU orally once a week for 6 to 8 weeks, with 500 mg of elemental calcium a day throughout, followed by lifelong maintenance; adequate calcium must be given with the vitamin D or the bone cannot mineralise.
Prevention is 400 IU of vitamin D a day for every infant under 1 year including the exclusively breastfed, and 600 IU a day thereafter, together with 20 to 30 minutes of sunlight on the face and limbs.
Rickets that does not respond to standard treatment is refractory — think X-linked hypophosphataemic rickets with a low phosphate and normal calcium, vitamin D dependent rickets, renal tubular acidosis or chronic kidney disease, and refer rather than repeating the dose.

Breastfeeding — positions and exclusivity

Exclusive breastfeeding means the infant receives only breast milk for the first 6 months, with no water, no other milk and no other food, allowing only prescribed medicines, vitamins and oral rehydration solution. Almost every breastfeeding failure the nurse is called to — sore nipples, engorgement, a baby who feeds constantly and gains nothing — traces back to position and attachment, so those two skills are the practical core of the topic and the commonest exam material.

The Indian and WHO infant feeding rule is initiation within the first hour of birth, exclusive breastfeeding for 6 months, complementary feeding from the completed sixth month, and continued breastfeeding for 2 years and beyond.
Colostrum, the thick yellow milk of the first 3 to 4 days, is small in volume but rich in protein, vitamin A and secretory IgA; it must be given and never discarded, and it acts as the baby's first immunisation and first laxative for meconium.
The four points of good positioning are that the baby's head and body are in a straight line, the baby faces the breast with the nose opposite the nipple, the baby is held close to the mother's body, and the whole body is supported, not just the head and shoulders.
The four signs of good attachment are more areola visible above the baby's upper lip than below, the mouth wide open, the lower lip turned outward, and the chin touching the breast.
The four usual positions are cradle, cross-cradle, side-lying and the football or underarm hold; the football hold is the one chosen after a caesarean section, for twins and for a small preterm baby, because it keeps weight off the abdominal wound and gives the mother head control.
Effective suckling looks like slow deep sucks with pauses and audible swallowing, with rounded cheeks; quick shallow sucks, drawn-in cheeks, clicking sounds and pain mean the baby is on the nipple rather than the breast, and the answer is to detach with a clean finger and re-attach.
Foremilk at the start of a feed is watery and quenches thirst while hindmilk at the end is fat rich and drives weight gain, so one breast is finished before the second is offered.
Adequacy is judged by output and growth, not by how the breast feels — 6 or more wet nappies in 24 hours, 8 to 12 feeds a day, a settled baby after feeds and appropriate weight gain after the physiological loss of up to 10 percent is regained by day 10 to 14.
The LATCH score assesses Latch, Audible swallowing, Type of nipple, Comfort of the mother and Hold, each scored 0 to 2 for a total of 10, and it gives an objective handover of how a feed is going.
The programme frame is the WHO and UNICEF Ten Steps to Successful Breastfeeding under the Baby Friendly Hospital Initiative, India's MAA programme, and the Infant Milk Substitutes Act of 1992 as amended, which prohibits the promotion of formula, feeding bottles and teats.
Galactosaemia in the infant is the one absolute contraindication; maternal HIV in India is managed with antiretroviral therapy and exclusive breastfeeding rather than avoidance, and a mother on antitubercular treatment continues to feed.

Dehydration — signs of severe

Dehydration in a child with diarrhoea is classified at the bedside by the IMNCI method into severe dehydration, some dehydration and no dehydration, using four signs looked for in a fixed order — general condition, the eyes, the offer of a drink and the skin pinch. The classification is not descriptive but prescriptive: it selects Plan C, Plan B or Plan A, and getting it wrong sends a child who needs intravenous fluid home with a packet of oral rehydration salts.

Severe dehydration is any two of these four signs: lethargic or unconscious, sunken eyes, not able to drink or drinking poorly, and a skin pinch that goes back very slowly, taking longer than 2 seconds.
Some dehydration is any two of: restless and irritable, sunken eyes, drinks eagerly and is thirsty, and a skin pinch that goes back slowly but in under 2 seconds.
No dehydration means there are not enough signs to classify it in either of the other two groups, and the child goes home on Plan A.
The pinch is taken on the abdominal skin midway between the umbilicus and the flank, lifted longitudinally with the thumb and forefinger and held for one second; it is falsely slow in severe malnutrition and falsely fast in an obese or oedematous child.
The fluid deficits behind the classes are roughly under 5 percent of body weight with no dehydration, 5 to 10 percent with some dehydration, and over 10 percent with severe dehydration.
Plan A is home treatment: extra fluids, oral rehydration salts after every loose stool at 50 to 100 mL under 2 years and 100 to 200 mL from 2 years, continued feeding and breastfeeding, zinc for 14 days, and the danger signs that mean come back.
Plan B is 75 mL/kg of low-osmolarity oral rehydration salts over 4 hours at the facility, with breastfeeding continued and the child reassessed and reclassified at 4 hours.
Plan C is 100 mL/kg of Ringer lactate intravenously — for an infant under 12 months, 30 mL/kg in the first hour then 70 mL/kg over the next 5 hours; for a child of 12 months to 5 years, 30 mL/kg in the first 30 minutes then 70 mL/kg over the next 2.5 hours.
Repeat the first rapid instalment once if the radial pulse is still weak or absent, reassess every 15 to 30 minutes, and start oral rehydration salts at about 5 mL/kg an hour as soon as the child can drink.
Zinc is given for 14 days in every diarrhoeal episode — 10 mg a day under 6 months and 20 mg a day from 6 months to 5 years — because it shortens the episode and reduces recurrence over the following months.
Low-osmolarity oral rehydration salts have a total osmolarity of 245 mOsm/L with 75 mmol/L each of sodium and glucose and 20 mmol/L of potassium, and this is the only correct rehydration fluid to give by mouth; home remedies such as plain water, soft drinks or salted lassi do not replace it.
A child with severe acute malnutrition is the exception to all of this — rehydrate with ReSoMal rather than standard oral rehydration salts, and never give a standard Plan C bolus, because the malnourished heart fails.

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