Over half remain emotionally -disturbed, have school problems. Small number die suspiciously.

haemoglobin electrophoresis, sweat chlorides, tests of endocrine function. PROGNOSIS. Non-organic ones eventually attain normalcy. Over half remain emotionally -disturbed, have school problems. Small number die suspiciously. In case of organic cause prognosis depends on underlying disease. Treatment and Prevention: 1 Temporary change of environment-hospitalization may ease tension and cause dramatic improvement in weight gain and social interactions. 2. Treatment of organic disease. 3. Parental education, birth spacing, family planning, marital counseling. 4. Early recognition of 'at risk' families -immature parents, drug addiction, anti-social behaviour, child dislike, economic and emotional instability, single parent, family tragedy. 5. Support- from physician, social worker. family welfare agency, temporary foster care. 1. Insufficiency of diet-(i) Early cessation of breast feeding, diluted feeds. unsutabe feeding habits, disturbed mother-child relationship, poverty. (ii) Inability to take food property - (a) Local lesions of mouth and jaw -cleft palate, hare lip, micrognathia,thrush,chronic nasal obstruction (b) Upper gastrointestinal tract disease - pyloric stenosis, oesophageal stricture, hiatus hernia (c) Neurological - muscular weakness due to anterior spinal muscular atrophy, congenital hypotonia, facial palsy, brain damage due to birth injury or kemicterus, congenital developmental anomalies, 2. Lack of digestion - (a) Achlorhydria due to chronic infection. (b) Diminished pancreatic juce - cystic fibrosis (c) Absence of bile - obstructive jaundice, infective hepatitis, biliary atresia (d) Any other infection causing diminished secretion of all intestinal juices. (e) Malnutrition itself suppresses some enzymes especially pancreatic and lactase 3. Impaired absorption - Low grade bowel infection including giardiasis, milk allergy, lactose intolerance, coeliac disease, cystic librosis, congenital dilatation of colon, biliary fistula and any disease that causes prolonged diarrhoea and/or vomiting. 4. Absorbed but cannot be metabolized satisfactorily - Localised infection, hepatitis. urinary infection. Generalised disease such as tuberculosis, chronic infection. Metabolic disorder - diabetes, hypothyroidism. galactosemia. 5. Metabilized but not properly utilized - Children of low birth weight borrn at term brain lumour. mental retardation, chronic renal disease chromosomal abnormalities. Clinical picture: 1. Progressive loss of subcutaneous fat - Grade I - buttocks. Grade II -axilla and groins. Grade III - abdomen, chest, spine. Grade IV - buccal pad. When fat is put on again, it is in the reverse order. 2. Child is irritable and cries excessively, initially very hungry. 3. Sharp features with typical appearance of withered old man (monkey facies) 4. Sunken and lustreless eyes and sunken anterior fontanalie. 5. Cold, pale face and lips and extremities with low body temperature. 6. Muscles flabby and poor muscular tons. Bony prominences marked. 7. Lack of playful movements and persistent crying or anxiety. 8. Delay in sitting, standing, walking. 9. Poor resistance to disease, intercurrent infections common especially TB, gastroenteritis, viruses. fungal skin infections. Vicious cycle of PEM and infection. Modarate to severe PEM depresses cell - mediated immunity, secretory IgA production, and causes defective bactericidal killing capacity of neutrophils. Infection aggravates PEM by causing anorexia and catabolic state. Gastroenteritis and giardiasis cause malabsorption and bacterial overgrowth in small bowel. 14. Failure to gain weight and growth retardation when long-standing 11. Oedema absent, purpura occasional. 12. Evidence of specific deficiencies like rickets. scurvy, pellagra uncommon. 13. Abdomen may be distended or sunken and reveal the outlines of the intestines beneath. 14. Constipation usual, sometimes starvation diarrhoea with mucus in stools. Managemenl: 1 Diet - Adequate intaks of calories. carbohydrates, proteine and fats, minerals and vitamins. The ammount may be calculated based on actual weight. Start low, build upto 200cals/kg/day and 4 gm /kg/day of protein. Feeds small. every, 2-21/2 hours by tube it needed. Milk with 2 teaspoons sugar/100 ml, milk forms basis of leeding unless lactose intolerance is documeted (Stool pH<6>2- reaction) Banana, rice and dal, vegetable oil safely given for calories. Egg as flip with milk and water good source of first class protein. Dal and rice and buttermilk can be given in lactose intolerance. Multi-vitamins particularly vitamin A in full therapeutic doses should be given daily by mouth. Once the appetite returns, gradually widen articles of diet and increase solid content of food. "Catch-up" growth adequate if rate is about 15
gm/kg/day. 2. Prevention and treatment of hypothemia and hypogtycemia -Wrapping blankets. use of 'hot box', or radiant warmers, rectal temparature maintained above 37 oC. Glucose 25% IV 4 ml/kg bolus if hypoglycemia documented. 3. Treatment of cause - (a) Correct education of parents (b) Removal of infections and infestations such as worms. (c) Surgical correction of defects such as cleft palate. (d) Treatment of electrolyte imbalance. Supplementation of potassium with potassium chloride (4-5 mEq/kg/da/). and zinc (1 mg/kg elemental zinc) to heat skin lesions and improve immunity. Iron 6 mg/kg/day supptemented only