Malnutrition: nutritional rehabilitation and monitoring — branching viva

Branching viva from a wasted 16-month-old with severe acute malnutrition, through the anthropometric criteria and the complicated-versus-uncomplicated disposition decision, the WHO phased rehabilitation from F-75 stabilisation to F-100 catch-up, the mechanism and prevention of refeeding syndrome through phosphate and potassium monitoring and thiamine, the choice of ReSoMal over standard oral rehydration solution for the dehydrated malnourished child, and a pivot to a high-resource adolescent with anorexia nervosa to test the general refeeding-syndrome safeguard.

branching clinical structured oral3 min readVerification in progress

Prompt

You are the paediatric registrar on the ward. The examiner asks you to work through a 16-month-old with marked wasting and a mid-upper arm circumference in the red zone who refuses to eat, and later a 15-year-old with anorexia nervosa being refed. Information is released in stages.

Opening — recognising and grading the malnutrition

The examiner begins: a 16-month-old has lost weight over six weeks, his weight-for-height z-score is minus 3.4 and his MUAC is 108 mm, with no oedema. He is lethargic and refuses food. Talk me through your assessment. [1]

I would recognise this as severe acute malnutrition, because his z-score is below minus three and his MUAC is below 115 mm, either of which defines SAM. The decisive finding is that he refuses food, which means he has lost his appetite and therefore has complicated SAM, so he needs inpatient stabilisation rather than outpatient ready-to-use therapeutic food. I would check a bedside glucose, look for hypothermia and infection, and begin the WHO stabilisation pathway. [1] [3]

Paediatrics Fellowship Pro

You have read the opening of this viva. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References6Show ledger

[1]Lenters LM; Wazny K; Webb P; et al Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health, 2013.PMID 24564235
[3]Mogase T; Van Onselen A; Rodriguez-Sanchez N; et al The Identification and Management of Refeeding Syndrome in Inpatient Severely Acutely Malnourished Children Aged 6 to 59 Months in Sub-Saharan African Countries: A Systematic Review and Meta-Analysis. Children (Basel), 2025.PMID 41007088
[6]Namusoke H; Hother AL; Rytter MJ; et al Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda. Am J Clin Nutr, 2016.PMID 26739034
[4]Corsello A; Trovato CM; Dipasquale V; et al Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review. J Pediatr Gastroenterol Nutr, 2023.PMID 37705405
[5]da Silva JSV; Seres DS; Sabino K; et al ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract, 2020.PMID 32115791
[8]Muzeyi W; Ochieng Andra T; Oriokot L; et al High Incidence of Refeeding Syndrome during the Transition from F75 to Ready-to-Use Therapeutic Feeds among Children 6 to 59 Months with Severe Acute Malnutrition at the Pediatric Nutritional Unit of Mulago Hospital. J Nutr Metab, 2024.PMID 39372094