Early Detection and Referral of Children with Malnutrition
Detection and Referral of Children with Acute Malnutrition
Screening for Acute Malnutrition
Acute malnutrition is a result of recent (short-term) deficiency of protein, energy together with minerals and vitamins leading to
loss of body fats and muscle tissues. Acute malnutrition presents with wasting (low weight-for-height) and /or presence of pitting oedema of both feet.
Screening for Acute Malnutrition should be done at any contact points; children wards, immunization points, community out-reaches,
ART sites, young child clinics, counselling units and psycho social groups. Community-based service providers can also perform
malnutrition screening provided that they are adequately trained and equipped.
Screening for acute malnutrition includes
- Use and interpretation of Mid-Upper Arm Circumference (MUAC) Tape
- Checking for bilateral pitting oedema
NOTE: Children with confirmed bilateral oedema are directly identified to be severely malnourished and are recorded has having nutritional oedema.
Recognizing Visible clinical Signs
Marasmus signs
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- Prominent bones (ribs)
- Skinny limbs
- Loose skin (on lifting)
- Loose skin around the buttocks (buggy pants)
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Kwashiorkor
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- Presence of bilateral pitting oedema
- Hair changes (brownish, scanty, straight)
- Skin changes (dermatosis)
- A large, protuberant belly
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Nutritional Oedema
(source: ENCU/EWD/MOARD Guidelines for Emergency Nutrition Surveys in
Ethiopia, Interim new version, September 2008)
Oedema is the retention of water in the tissues of the body. Bilateral
oedema is a sign of kwashiorkor, a form of severe acute malnutrition.
Children presenting oedema must be referred to the closest health centre.
To diagnose oedema, normal thumb pressure is applied to the tops of the feet
for about three seconds (if you count “one thousand and one, one thousand
and two, one thousand and three” in English, pronouncing the words
carefully, this takes about three seconds). If there is oedema, an
impression remains for some time (at least a few seconds) where the oedema
fluid has been pressed out of the tissue (see below).
The child should only be recorded as oedematous if both feet present pitting
oedema. These children are at
high risk of mortality and need to be treated in a therapeutic feeding program urgently.
Nutritional oedema always starts from the feet and extends upwards to other parts of the body.
Checking for Oedema
In order to determine the presence of oedema, normal thumb pressure is
applied to both feet for three seconds.
Indication of edema – a symptom of malnutrition
For this simple but important test to detect abnormal swelling, the nurse
checks for edema by using only her hands and vision. The nurse applies
pressure with her thumbs on the feet, the lower legs, and the face of the
child to view the severity of the child's edema.
Photo: Geno Teofilo/Oxfam
If a shallow print or pit persists on both feet when the thumbs are lifted, then the child presents
oedema. This is the only way to confirm nutritional oedema. You cannot tell by just looking.
Indication of edema – a symptom of malnutrition
When the nurse removes her thumbs, it leaves a pair of depressions on the
skin of the child's feet. These depressions indicate a positive test for
edema, a symptom of malnutrition.
Photo: Geno Teofilo/Oxfam
How to classify oedema
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- No oedema: 0
- Oedema below the ankles: +
- Odema in both feet and legs, below the knees: ++
- Odema on both feet, legs, arms and sacral pad and eye lids:+++
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Mid-upper Arm Circumference (MUAC) for children 12-59 months
MUAC Resources
MUAC is a quick and simple way to determine whether or not a child is malnourished using a simple colored plastic strip. MUAC is
suitable to use on children from the age of 12 months up to the age of 59 months. However, it can also be used for children over six months with length above 65 cm.
Steps for taking the MUAC measurement of a child
- Determine the mid-point between the elbow and the shoulder (acromion and olecranon) as shown on the picture below.
- Place the tape measure around the LEFT arm (the arm should be relaxed and hang down the side of the body).
- Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose.
- Read the measurement from the window of the tape or from the tape.
- Record the MUAC to the nearest 0.1 cm or 1mm.
- If using a 3-colour tape:
a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of malnutrition;
a measurement in the red zone means that the child is acutely malnourished.
If using a 4-colour tape:
a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of malnutrition;
a measurement in the orange zone means that the child is moderately malnourished;
a measurement in the red zone means that the child is severely malnourished.
- Repeat the measurement two times to ensure an accurate interpretation.
4-colour Mid-Upper Arm Circumference (MUAC) tape
click here for a larger image
03 October, 2011
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