A 12-month-old infant with history of delayed initiation of complementary feeding and few diarrhoeal episodes was found to have length of 72 cm, weight of 5 kg, mid arm circumference of 10 cm and loss of subcutaneous fat.

Assessment of the Case

The provided anthropometric data reveals several concerning findings:

• Length (72 cm): Significantly below the median for a 12-month-old, indicating stunting.
• Weight (5 kg): Well below the expected weight for age, suggesting wasting.
• Mid-Arm Circumference (10 cm): Low, indicative of muscle wasting and malnutrition.
• Loss of Subcutaneous Fat: A clear sign of depleted energy reserves.
• History: Delayed complementary feeding and recurrent diarrhea further support the diagnosis of malnutrition.

Differential Diagnosis

Based on the clinical presentation, the following diagnoses should be considered:

• Marasmus: Characterized by severe wasting, emaciation, and loss of subcutaneous fat. This is the most likely diagnosis given the child’s weight, MAC, and loss of subcutaneous fat.
• Kwashiorkor: Typically presents with edema, particularly in the feet and ankles, along with skin lesions and hair changes. While not explicitly mentioned, it cannot be entirely ruled out without a physical examination.
• Marasmic-Kwashiorkor: A mixed presentation of both marasmus and kwashiorkor.
• Other causes of failure to thrive: Consider underlying infections (e.g., tuberculosis, HIV), congenital anomalies, or malabsorption syndromes, though the history points strongly towards nutritional deficiency.

Diagnosis

Considering the clinical picture, the most probable diagnosis is severe acute malnutrition (SAM), likely Marasmus. The child meets the WHO criteria for SAM based on weight-for-height, mid-upper arm circumference (MUAC), and clinical signs.

Management Plan

Phase 1: Stabilization (Inpatient)

This phase focuses on correcting life-threatening complications:

• Hypoglycemia: Administer 10% dextrose intravenously or orally if the child is conscious.
• Hypothermia: Provide warmth through skin-to-skin contact or radiant warmer.
• Dehydration: Rehydrate cautiously with oral rehydration solution (ORS) or intravenous fluids if severe.
• Infection: Treat any underlying infections with appropriate antibiotics.
• Electrolyte Imbalance: Correct any electrolyte imbalances (e.g., potassium, sodium).
• Dietary Management: Start with F-75 therapeutic milk (low protein, high carbohydrate) in small, frequent feeds, gradually increasing the volume.

Phase 2: Rehabilitation (Inpatient/Outpatient)

Once stabilized, the focus shifts to nutritional rehabilitation:

• F-100 Therapeutic Food: Transition to F-100 therapeutic food (high protein, high energy) to promote weight gain.
• Micronutrient Supplementation: Provide vitamin A, iron, zinc, and folic acid.
• Sensory Stimulation: Encourage interaction and play to promote cognitive development.
• Monitoring: Regularly monitor weight, MUAC, and clinical signs.

Phase 3: Follow-up (Outpatient)

After discharge, continued monitoring and support are crucial:

• Nutritional Counseling: Educate the mother on appropriate complementary feeding practices, hygiene, and infection prevention.
• Growth Monitoring: Regularly monitor the child’s growth at a health facility.
• Food Security: Address any underlying food insecurity issues.

Prognosis

The prognosis depends on the severity of malnutrition, the presence of complications, and the adherence to the management plan. Early diagnosis and prompt intervention significantly improve the chances of a full recovery. However, long-term developmental delays are possible, highlighting the importance of comprehensive follow-up care.