PAEDIATRIC SAM

By
Dr Nadab Musa Yathama
State Specialist Hospital
Gombe

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 INTRODUCTION
• WHO definition of malnutrition: ‘The cellular imbalance
between the supply of nutrients and energy and the body's
demand for them to ensure growth, maintenance, and
specific functions.
• Malnutrition is estimated to contribute to more than one
third of all child deaths, although it is rarely listed as the
direct cause.
• Undernutrition manifests in four broad forms: wasting,
stunting, underweight, and micronutrient deficiencies.
• The vicious cycle of poverty, disease and illness aggravates
this situation.

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 EPIDEMIOLOGY
Protein–energy malnutrition usually manifests early, in children
between 6 months and 2 years of age and is associated with
early weaning, delayed introduction of complementary foods, a
low-protein diet and severe or frequent infections.
Among the four principal causes of mortality in young children
worldwide, undernutrition has been ascribed to be the cause of
death in:
60.7% of children with diarrheal diseases,
52.3% of those with pneumonia,
44.8% of measles cases, and
57.3% of children with malaria.

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 PATHOPHYSIOLOGY

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 PATHOPHYSIOLOGY
The physiological adaptation to starvation.
• The first 24-48 hours there is increased gluconeogenesis
from amino acids and glycerol.
• ketogenesis takes over, and much of the body metabolic
needs are met by ketone bodies and free fatty acids
• This is the consequence of decreasing insulin levels, and
relatively increased influence from catecholamines and
cortisol
• Over prolonged starvation, protein catabolism begins,
resulting in degradation of structurally important
proteins, and organ system dysfunction.

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 PATHOPHYSIOLOGY
The physiological adaptation to starvation.

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 PATHOPHYSIOLOGY
Adaptation to Malnutrition and Starvation.
Theories:
1. Gopalan’s
• Marasmus extreme case of adaptation
• Kwashiorkor stage of adaptation failure
• Continue prolongation of stress
• Sudden precipitation by infections
2. Free radical-Golden’s
• Kwashiorkor from over production of free radicals
and failure of protective mechanisms.
3. Others: e.g., aflatoxins.

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 PATHOPHYSIOLOGY

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 HISTORY
1. Usual diet before current episode of illness
2. Breastfeeding history
3. Food and fluid taken in past few days
4. Recent sinking of eyes
5. Time when urine was last passed
6. Contact with measles or TB
7. Any death of a sibling
8. Birth weight
9. Mile stones reached
10. Immunization
11. Duration and frequency of vomiting or diarrhea their
appearance

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 PHYSICAL EXAMINATION.
1. Weight, edema, length or height.
2. Temperature.
3. Enlarged and tender liver, jaundice
4. Abdominal distention and bowel sound
5. Pallor, Thirst,
6. Eyes corneal lesions
7. Signs of circulatory collapse
8. Ear, mouth and throat for infection
9. Skin, hair --” Flag sign”
10. Respiratory rate and type-pneumonia, heart failure.
Appearance of feces

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 CLINICAL SYNDROMES
Marasmus:
• < 60 % weight for age without oedema is Marasmus
(welcome).
• Their skin is xerotic, wrinkled, and loose because of the loss
of subcutaneous fat, but is not characterized by any specific
dermatosis.
• Grading marasmus:
• Muscle wasting often starts in the axilla and groin (grade
I),
• Then thighs and buttocks (grade II),
• Followed by chest and abdomen (grade III), and
• Finally, the facial muscles (grade IV),
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 CLINICAL SYNDROMES
Kwashiorkor:
• 80-60% weight for age with oedema is Kwashiorkor
(welcome)
• Various skin changes in children with kwashiorkor include
shiny, varnished-looking skin (64%), dark erythematous
pigmented macules (48%), xerotic crazy paving skin (28%),
residual hypopigmentation (18%), and hyperpigmentation
and erythema (11%).
• Grading kwashiorkor:
▪ It usually starts as pedal edema (grade I),
▪ Then facial edema (grade II),
▪ Paraspinal and chest edema (grade III) and (grade IV (ascites))

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 CLINICAL SYNDROMES

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 NUTRITIONAL ASSESSMENT
Nutritional assessment parameters include anthropometric,
biochemical, clinical, and dietary tests.
• for admission to the program the anthropometric and
bilateral pitting pedal oedema parameters are used
exclusively.
• Thoroughly assess the children as follows:
1. Measure Mid upper arm Circumference (MUAC)
2. Measure Weight
3. Measure Height
4. Check for bilateral oedema of the feet and grade the oedema.
5. Determine the weight for height/Length z score using the
weight for height/length reference card.

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 INDICATION FOR ADMISSION

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 INDICATION FOR ADMISSION
Children with one or more IMCI signs should be admitted into
the inpatient facility (IMCI, 2011).
• Anorexia or poor appetite test
• Severe vomiting
• Very pale (Severe anaemia
• Hypothermia ≤ 35 C (axillary), Fever ≥ 39 C (axillary)
• Severe respiratory distress
• >60 breaths/min for under 2 months
• >50 breaths/min from 2 to 12 months
• >40 breaths/min from 1 to 5 years
• >30 breaths/min for > 5years
• Chest in-drawing.
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 INDICATION FOR ADMISSION
Children with one or more IMCI signs should be admitted into
the inpatient facility (IMCI, 2011).
• Not alert (very weak, lethargic, unconscious, fits or
convulsions)
• Shock (lethargic, unconscious; with cold hands, slow
capillary refill (> 3s) or weak (low volume), rapid pulse and
low blood pressure
• Eye signs of Vitamin A deficiency: - Dry conjunctiva or
cornea, bitot spots - Corneal ulceration - Keratomalacia
• Extensive skin lesions
• Conditions requiring IV infusion or NG tube feeding
• Choice of the caretaker.
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 PRINCIPLE'S OF MANAGEMENT
At present, an exclusive inpatient approach to the clinical care
of SAM is recommended.
• The core of accepted WHO management protocols is ten
steps in two phases:
• STABILISATION AND
• REHABILITATION
• The approach requires many trained staff and substantial
inpatient bed capacity.
• Recently admitted children should be kept in a special area
where they can be constantly monitored.
• The child should not be kept near a window or in a draught,
and windows should be closed at night.
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 PRINCIPLE'S OF MANAGEMENT
STABILISATION:
The principal tasks during initial treatment are:
• To treat or prevent hypoglycaemia and hypothermia;
• To treat or prevent dehydration and restore electrolyte
balance;
• To treat incipient or developed septic shock, if present;
• To start to feed the child;
• To treat infection;
• To identify and treat any other problems, including vitamin
deficiency, Severe anaemia and heart failure.

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 PRINCIPLE'S OF MANAGEMENT
REHABILITATION.
The principal tasks during the rehabilitation phase are:
• To encourage the child to eat as much as possible;
• To re-initiate and/or encourage breastfeeding as necessary;
• To stimulate emotional and physical development; and
• To prepare the mother or carer to continue to look after the
child after discharge.
• The child should remain in hospital for the first part of the
rehabilitation phase.

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 IN PATIENT CARE
Lab investigations:
• Blood Glucose assay
• Packed Cell Volume/haematocrit assay
• HIV Screening
• Screening for TB
• Blood film for malaria parasite test
• Chest x-ray
• U/E/Cr estimation
• Blood cultures
• Urine M/C/S
• Stool microscopy assay
• Serum Protein estimation
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 IN PATIENT CARE
TEN STEPS:
1. Prevent/treat hypoglycemia.
2. Prevent/treat dehydration
3. Treat/prevent infection
4. Prevent/treat hypothermia
5. Correct electrolytes imbalance
6. Correct micronutrient deficiency
7. Start cautious feeding
8. Achieve catch-up growth
9. Provide Sensory stimulation and emotional support
10. Prepare for follow-up after recovery.

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 IN PATIENT CARE

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 IN PATIENT CARE
STABILISATION:
Treat/prevent hypoglycemia: (blood glucose < 3 mmol/L or <
54 mg/dl). Signs of hypoglycemia include:
• Low body temperature (< 36.5 °c),
• Lethargy, limpness and loss of consciousness,
• A staring/ frightened expression due to eyelid retraction and
• Sleeping with the eyes open.
• If hypoglycemia is suspected, give treatment immediately
without laboratory confirmation.

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 IN PATIENT CARE
STABILISATION:
Treat/prevent hypoglycemia: (blood glucose < 3 mmol/L or <
54 mg/dl).
• If the patient is unconscious give 10% glucose IV/NGT 5
ml/kg.
• If the patient is conscious or can be roused and is able to
drink, give 50 ml of 10%DW.
• Stay with the child until he or she is fully alert.
• Keep the child warm. Start on appropriate IV or IM
antibiotics.
• To prevent hypoglycemia, sick children should be fed every
3 hours night and day with F75.
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 IN PATIENT CARE
STABILISATION:
Prevent/treat dehydration.
Assume that children with frequent and recent watery diarrhea
may have some dehydration.
• If dehydration is confirmed and there are no signs of shock,
proceed to full assessment and treatment.
• Treatment consists of giving:
• Oral rehydration,
• Starting antibiotic treatment,
• Continuing breastfeeding,
• Initiating therapeutic feeding, and
• Keeping the child warm.
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 IN PATIENT CARE
Prevent/treat dehydration.
• Rehydration without shock:
• Weigh the child to monitor fluid balance and the progress of
rehydration.
• Record the respiratory rate, pulse and liver edge on the
critical care chart.
• Give ReSoMal (45 mmol Na, 40 mmol K and 3 mmol
Mg/L) orally or by nasogastric over a maximum of 12 hours:
• Give ReSoMal 5 ml/kg every 30 minutes for 2 hours (orally
or by nasogastric tube.)
• Re-weigh the child to determine if the child is gaining or
losing weight:
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 IN PATIENT CARE
STABILISATION:
Prevent/treat dehydration.
• Rehydration without shock:
• If the child’s weight is steady (the same), increase the
ReSoMal to 15 ml/kg/h.
• If the child is losing weight, increase the ReSoMal to 20
ml/kg/h
• If the child is gaining weight AND clinically improving,
Then give 5–10 ml/kg in alternate hours for up to 10
hours. (i.e., give ReSoMal and F-75 formula in alternate
hours).
• Loose stool(5ml/kg) and vomiting (2ml/kg).
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 IN PATIENT CARE
Prevent/treat dehydration.
Rehydration without shock:
• During rehydration, monitor continuously for signs of fluid
overload. These include:
• RR ≥ 5 breaths/minute compared to initial RR, or
• HR ≥ 25 beats/minute compared to initial HR
• Plus, any one of the following:
• New or worsening hypoxia (decrease in SpO2 by > 5%)
• New onset of rales and/or fine crackles in lung fields
• New galloping heart rhythm.
• Increased liver size.
• Stop Resomal
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 IN PATIENT CARE
Rehydration with shock:
The common causes of shock in SAM are septicaemia, severe
dehydration, cardiogenic, toxicity from traditional medicines or
therapeutic drugs (e.g., excess metronidazole), hepatic failure
and severe hypernatraemia.
Reliable signs of shock in a child with severe malnutrition
include:
• Weak or absent radial pulse.
• Cold hands and feet.
• Decrease Urine flow.

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Rehydration with shock:
Treatment of hypovolemic shock:
• Ensure ABC
• Give oxygen through nasal prongs or a nasal catheter, with a
flow of 1–2 L/min.
• Prevent/ treat hypoglycemia.
• Keep the child warm to prevent or treat hypothermia. Initiate
and carefully monitor specific IV fluid: give 15 ml/kg over 1
hour.

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 IN PATIENT CARE
STABILISATION:
Rehydration with shock:
Specific iv fluid:
• 5% glucose in ½ DARROWS (50% D10 + 50% FS
Darrow’s)
• 5% glucose in Ringers lacted (add 50 mls 50% dextrose to
450 mls Ringer’s lactate)
• 5% glucose in ½ Normal saline-commercially available.
• Give second line antibiotics.

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Rehydration with septic shock:
• Treat as for hypovolemic shock
• Give maintenance IV fluid, 4 ml/kg per hour (do not exceed
this volume) while waiting for the blood.
• When blood is available:
• Stop all IV fluids and transfuse packed red blood cells
(PRBC), this can be done by giving 5 ml/kg over 3-4
hours, then waiting for about 8 hours and repeating the
infusion of a second 5 ml/kg.
• If there are signs of liver failure (e.g., purpura, jaundice,
enlarged tender liver), give vitamin K1, 5mg IV single
dose.
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 IN PATIENT CARE
Treat/prevent infection.
• Routine first-line antibiotic treatment:
• I.V Amoxycillin (50mg/kg/day) every 12 hours for
72hours then change to
• Oral amoxicillin at 50mg/kg/day every 12 hours to
complete one week OR
• I.V Cefotaxime 50 mg/kg every 12h for 5d
• Add gentamicin I.M (3-5mg/kg/day) once daily for 7
days if the patient is making urine.
• Suppress small bowel overgrowth with I.V metronidazole
10mg/kg/day given 12 hourly for 72hours then change to
oral 10mg/kg/day every 12 hours to complete one week.
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 IN PATIENT CARE
Treat/prevent infection.
• Second line antibiotic:
• If the child fails to improve clinically by 48 hours or
deteriorates after 24hours change to I.V Ciprofloxacin at
the dose of 10mg/kg/dose every 12hours for 72hours and
continue for one week Or
• I.V Ceftriaxone at the dose of 50-100mg/kg/day once a
day for 5 days if meningitis is suspected then give every
12 hours.
• If staphylococcal infection is suspected add cloxacillin
25–50 mg/kg 4 times per day for 14 to 21 days.

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 IN PATIENT CARE
Prevent/treat hypothermia.
The body temperature is below 35.5 °C rectal temperature, or
below 35.0 °C axillary temperature.
It is important to monitor body temperature on admission and
during rewarming.
• To rewarm infants, they must be placed on their mother’s
bare chest. Or
• Rewarm children with a warmed blanket and place a heater
or lamp nearby.
• Monitor temperature 2-hourly until the child’s temperature
remains >36.5oC.
• Early feeding prevents hypothermia.

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Correct electrolytes imbalance.
• Excess body Na Low K and Mg
• Supplement K at 3-4mmol/kg for 2wks.
• 10%KCL (10mls) =13mmol
• If K <2mmol/L or <3mmol/L with ECG changes then
change to:
• 0.3-0.5mmol/Kg/hr of KCL in IVF with monitoring
Arrythmias due to hypo-K- 1mmol/Kg/hr till normal
rhythm.
• On day 1 give IM MgSo4 50% (0.3ml/Kg up to MAX 2ml).
There after 0.4-0.6mmol/Kg Daily
• No added salt in the Diet.
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Correct micronutrient deficiency.
All severely malnourished have severe mineral and vitamin
deficiencies up to twice RDA.
• Give vit a on day 1 ,2 and 14/24.
• Daily:
• Multivitamin (A, C, D, E, B1, B2, B6, B12.)
• FOLIC ACD 5mg on day 1 then 1mg/Kg/day.
• ZINC 2mg/Kg/day
• COPPER 0.2-0.3mg/Kg/day
• IRON 3mg/Kg/day when start gaining weight.
Except those on official F75, F100 or RUTF

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Severe anaemia in malnourished children
• A blood transfusion is required if:
• Hb is less than 4 g/dl or
• If there is respiratory distress and Hb is between 4 and 6 g/dl
Give:
• whole blood 10 ml/kg body weight slowly over 3 hours
• furosemide 1 mg/kg IV at the start of the transfusion
• It is particularly important that the volume of 10 ml/kg is not
exceeded in severely malnourished children.
• Monitor for signs of transfusion reactions.
• DO NOT repeat the transfusion within 4 days.

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Start cautious feeding.
• The diets prescribed for the different phases are all
formulated to meet these specific requirements.
• NO additional nutrients need to be given to children taking
the recommended diets.
• The therapeutic food F75 is used for the initial phase of
treatment of severely malnourished children (75 kcal/ml).
• Give the child at least 80 kcal/kg per day, but no more than
100 kcal/kg per day.
• Use available tables for F75 and F100.
• Feeding bottles should never be used.
• Children should never be left alone to feed.
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Preparation of F-75 and F-100 diets.

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To avoid overloading the intestine, liver and kidneys, it is
essential that food be given frequently and in small amounts.
Children who are unwilling to eat should be fed by NG tube (do
not use IV feeding).
• Children who can eat should be given the diet every 2, 3 or 4
hours, day and night.
• During the initial phase of treatment, maintain the volume of
F-75 feed at 130 ml/kg per day (100ml/kg/day in edematous
SAM), but gradually decrease the frequency of feeding and
increase the volume of each feed until you are giving the
child feeds 4-hourly (6 feeds per day).
• If vomiting occurs, both the amount given at each feed and
the interval between feeds should be reduced.
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Start cautious feeding.
• Always use starting weight to determine feed amounts
• If the child has poor appetite, encourage the mother to coax
and support the child finishing the feed.
• If eating 80% or less of the amount offered for 2 consecutive
feeds, use a nasogastric tube.
• If the child is breastfed, encourage continued breastfeeding
but also give F-75.
• Transfer to F-100 or RUTF as soon as appetite has returned
(usually within 1 week) and oedema has been resolved or is
reduced.

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 IN PATIENT CARE
Start cautious feeding.
The criteria for nasogastric feeding are:
• Anorexia, taking less than 80% of prescribed daily need.
• Being too weak to drink.
• Painful mouth or throat, stomatitis or physical disability.
• Lethargy or unconsciousness.

Days Frequency (hrs.) Volume/kg/feed Volume/kg/day

1-2 2 11 130
3-5 3 16 130
6- 4 22 130

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Start cautious feeding.
Infants <6 months
Type of milk
• For edematous infant: Give F75
• For Non edematous infant: Give Generic Infant formula or
F100 diluted
• If there is a choice, use a formula designed for premature
infants.
Preparation of F100diluted:
• Use 100ml of F100 already prepared and add 35ml of water,
then you will get 135ml of F100diluted. Discard any excess
waste.
• Relactation support.
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Achieve catch-up growth
• Appetite should return by 2-7 days.
• Decrease frequency increase volume
• Each successive feed is increased by 10ml until some is left
uneaten.
• Starter F-75 should be replaced with F-100 in equal amount
in 2 days
• Calorie intake increase to 150-200Kcal/Kg/day
• Protein increased to 4-6gm/Kg/day
• Complementary food should be added as soon as possible.
• Monitor during the transition for signs of heart failure:
o Respiratory Rate, Pulse Rate.

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 IN PATIENT CARE
Achieve catch-up growth
Monitor progress after the transition by assessing the rate of
weight gain:
• Weigh child each morning before feeding.
• Each week calculate and record weight gain as g/kg/day.
• Good weight gain >10g/Kg/day
Continue treatment
5-10g/Kg/day
• Moderate weight gain ▪ Check food intake,
▪ Screen for infection

<5g/Kg/day
• Poor weight gain ▪ Screen for adequate feeding
▪ Especially nutrient deficiencies
▪ Untreated infections e.g., TB,
HIV, psychological problems
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 IN PATIENT CARE
Achieve catch-up growth
Each day the nurse records:
• Weight (and graphs the weight to examine gain or loss)
• Oedema
• Respiratory rate
• Presence or absence of cough
• Pulse rate
• Temperature (a.m. and p.m.)
• Stools passed or Vomit
• Antibiotics and other medication prescribed and given
• Feeding plan.

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Achieve catch-up growth
Improvement during stabilization includes:
• Medical complications start resolving
• Oedema starts reducing
• Appetite returns
• The child is awake and increasingly alert.
• Children should not gain weight in phase 1 and children
with oedema should start losing weight as their oedema
decreases. Weight and weight gain or loss are critical key
signs in the initial treatment and should be closely monitored
and recorded.

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Achieve catch-up growth.
CRITERION TIME AFTER
ADMISSION
Primary failure to respond
Failure to gain consciousness
Failure to start resolving medical complication
Failure to regain appetite Day 4
Failure to start to resolve oedema Day 4
Oedema still present Day 10
Failure to regain appetite Day 10
Secondary failure to respond
Failure to gain at least 5 g/kg of body weight per day During
rehabilitation for 3
successive days
Reappearance of danger signs At any time

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Provide sensory stimulation and emotional support.
Provide:
• Tender loving care
• A cheerful, stimulating environment
• Structured play therapy 15-30 min/d.
• Physical activity as soon as the child is well enough
• Maternal involvement when possible (e.g., Comforting,
feeding, bathing, play).

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Prepare for follow-up after recovery.
• A child who is 90% weight-for-length (equivalent to -1SD)
can be considered to have recovered.
• Good feeding practices and sensory stimulation should be
continued at home.
• Advise parent or carer to:
• Bring child back for regular follow-up checks
• Ensure booster immunizations are given.
• Ensure vitamin A is given every six months.
• Follow-up in 1, week. 2, week. then 1month, 3months,
6months.

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 IN PATIENT CARE
F-75
Type of Milk (g) Eggs (g) Sugar Oil (g) Cereal powder CMV** Water
milk (g) (g)* (red (ml)
scoop=6g)
Dry Skim 25 0 70 27 35 2 UP TO
Milk 1000ml
Dry 35 0 70 20 35 2 UP TO
Whole 1000ml
Milk
Fresh 280 0 65 20 35 2 UP TO
cow milk 1000ml
Fresh 280 0 65 20 40 2 UP TO
goat 1000ml
milk
Whole 0 80 70 20 40 2 UP TO
eggs 1000ml
Egg 0 50 70 15 40 2 UP TO
yolks 1000ml
F-100
Type of Milk (g) Eggs (g) Sugar Oil (g) CMV** Water (ml)
milk (g) (red scoop=6g)
Dry Skim 80 0 50 60 2 UP TO 1000ml
Milk
Dry 110 0 50 30 2 UP TO 1000ml
Whole
Milk
Fresh 900 0 50 25 2 UP TO 1000ml
cow milk
Fresh 900 0 50 30 2 UP TO 1000ml
goat
milk
Whole 0 220 90 35 2 UP TO 1000ml
eggs
Egg 0 170 90 10 2 UP TO 1000ml
yolks
ReSoMal
Ingredient Amount
Standard WHO-ORS one l-litre packet
CMV** (Mineral &Vitamin mix) 1 red scoop (6 gr.)
Sucrose (sugar) 50 g
Water 2000 ml

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Discharge before recovery is complete.
For some children, earlier discharge may be considered if
effective alternative supervision is available.
The child
• Is aged >12 months
• Has completed antibiotic treatment
• Has good appetite and good weight gain
• Has taken potassium/magnesium/mineral/vitamin
supplement for 2 weeks (or continuing supplementation at
home is possible)

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Discharge before recovery is complete.
The mother/carer
• Is not employed outside the home
• Is specifically trained to give appropriate feeding (type,
amount and frequency).
• Lives within easy reach of the hospital for urgent
readmission if the child becomes ill
• Is motivated to follow the advice given
• Has the financial resources to feed the child
• Local health workers are trained to support home care.
• Aim at achieving at least 150 kcal/kg/d and adequate protein
intake (at least 4 g/kg/d).
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Treatment of associated conditions.
Vitamin A deficiency.
If the child shows any eye signs of deficiency, give orally:
vitamin A on days 1, 2 and 14.
• for age >12 months, give 200,000 IU;
• for age 6-12 months, give 100,000 IU;
• for age 0-5 months, give 50,000 IU).
• If first dose has been given in the referring centre, treat on
days 1 and 14 only.

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Treatment of associated conditions.
Vitamin A deficiency.
Corneal clouding or ulceration,
• Instill chloramphenicol or tetracycline eye drops (1%) 2-3
hourly as required for 7-10 days in the affected eye
• Instill atropine eye drops (1%), 1 drop three times daily for
3-5 days cover with eye pads soaked in saline solution and
bandage.
• Children with vitamin A deficiency are likely to be
photophobic and have closed eyes.
• It is important to examine the eyes very gently to prevent
rupture.

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Treatment of associated conditions.
Dermatosis.
• Zinc deficiency is usual in affected children and the skin
quickly improves with zinc supplementation
• Apply barrier cream (zinc and castor oil ointment, or
petroleum jelly or paraffin gauze) to raw areas.
• Omit nappies so that the perineum can dry.
Continuing diarrhoea.
• Mucosal damage and giardiasis
o Metronidazole (7.5 mg/kg 8-hourly for 7 days)
• Osmotic diarrhoea: reduce sugar content.
• Lactose intolerance: rarely.

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Treatment of associated conditions.
Helminthiasis: Worm treatment.
Age (weight) of the Mebendazole Albendazole
Child (single dose (single dose
Before food) Before food)
1 year or below None None
1–2 years (or <10 kg) 500 mg 200 mg
≥ 2 years (or ≥ 10 kg) 500 mg 400 mg
Ascariasis, hookworm and trichuriasis infections are treated
with the standard protocol. If suspected, repeat the standard
doses of albendazole for 3 days instead of giving a single dose.
Usually prior to discharge.
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Failure to respond to treatment.
Indicated by:
High mortality
Case fatality rates vary widely:
• >20% should be considered unacceptable,
• 11-20% poor,
• 5-10% moderate, and
• <5% good.
Low weight gain during the rehabilitation phase.
• Look for Possible causes of poor weight gain.

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 THANK YOU

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