PEM Management: Depending on the severity, PEM may be managed at home, nutritional rehabilitation centers, or hospital.

Hospitalization is indicated in cases with severe PEM, life-threatening complications, severe anorexia and refusal to accept oral feeds, emotionally deprived or neglected child, and failure of domiciliary treatment.

PEM Management aims towards diagnosis & treatment of complications, dietary management for recovery & catch-up growth, and prevention of recurrence.

Accordingly, it may be divided into 3 steps — I) Emergency phase, II) Intensive dietary management, III) Consolidation or rehabilitation phase

Step I – Emergency phase: During first 24-48 hours of presentation, main emphasis is on the diagnosis and PEM Management of early complications as follows —

a) Hypothermia (rectal temperature <35.5°c) is more common in marasmus, due to fat insulation, severe infections and hypoglycemia, which should be treated with gradual warming under radiant warmer or with a blanket, temperature monitoring and frequent feedings.

b) Infections are difficult to recognize in PEM Management, due to poor inflammatory response and absence of constitutional signs e.g. fever. Presence of refractory hypothermia, hypoglycemia, shock and bleeding tendencies e.g. DIC indicates potentially serious underlying infection. Empirical antimicrobial therapy is indicated in these cases. Gram negative sepsis and septic shock is common in PEM Management, which needs intensive fluid and isotropic therapy.

c) Hypoglycemia, though more common in marasmus, is frequently asymptomatic due to low-energy adaptation. Symptomatic hypoglycemia with altered sensorium and seizures may be life-threatening and should be treated immediately with IV dextrose 10% (5-10 mI/kg) as bolus, followed by maintenance infusion of dextrose-containing fluids and frequent feedings.

Hypothermia, hypoglycemia and infections are closely linked complications of PEM Management and presence of any one of them warrants towards search for others.

d) Dehydration following co-existent diarrhea, vomiting, poor oral intake and redistribution of body fluids is common and may be difficult to assess in malnourished children due to edema. Urine output is the most reliable indicator in these cases. Management of dehydration in malnourished cases depends on its severity.

Mild to moderate dehydration is preferably treated with 5-10 ml/kg/hr of WHO-recommended low- sodium ORS or ReSoMal (rehydration solution for severely malnourished children), either orally or via nasogastric tube. ReSoMal can be prepared at home by diluting 1 pack of WHO -ORS in 2 liters of water and adding 50 gm of sucrose and 40 ml of mineral-mix solution.

IV fluids are necessary in severe dehydration or shock, though need a cautious approach due to altered fluid/electrolyte homeostasis and risk of over hydration/CCF. A simple plan is to initiate with 30 mi/kg of Ringer lactate over 2 hours, followed by 10 ml/kg/hr till oral feeding is established. Potassium (30-40 meq/L) should be added in IV fluids, after baby has passed urine.

e) Dyseleetrolytemia is common due to poor intake, CIT losses in diarrhea/vomiting and redistribution of body fluids. Even in absence of clinically obvious signs, a malnourished child generally has relatively more total body water due to loss of adipose tissue, extracellular hypematremia due to renal retention, intracellular hypokalemia due to redistribution of body potassium, hypocalcemia due to decreased albumin-bound fraction, hypophosphatemia due to muscle wasting, and hypomagnesaemia.

Hypokalemia: Intracellular K depletion is common even in asymptomatic PEM, which manifests with muscle weakness, abdominal distension and ECG changes. It should be treated with addition of Potassium into IV fluids (2-3 meq/ kg), after the child has passed urine. It is advisable to continue oral potassium supplements (2-4 meqIkg/d) during recovery phase.

Hyponatremia may develop due to persistent vomiting/diarrhea, though total body sodium is increased in severe PEM. Hence, hypertonic fluids should be avoided even in cases with biochemical hyponatremia.

Hypoealeemia, if symptomatic (tetany, seizures), is treated with slow infusion of IV calcium gluconate 10% (1 mI/kg) with cardiac monitoring. PEM Management