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PE9.1-7,PE10.1-6,PE11.1-4 | Nutrition Assessment and Support — Assignment
CLINICAL SCENARIO
You will conduct and document a complete nutritional assessment for a child presenting with suspected malnutrition (SAM or MAM) in a district hospital or nutrition rehabilitation unit (NRU) setting. This assignment develops your competence in integrating anthropometric measurements, dietary recall, clinical examination, and WHO classification to arrive at a diagnosis and construct a stepwise management plan — the core clinical workflow for any paediatrician managing childhood malnutrition in India.
Instructions
Select a child (6–59 months) admitted to or seen in your paediatric unit with suspected protein-energy malnutrition or referred from an Anganwadi/ICDS centre. If no clinical case is accessible, use the supplied de-identified case vignette provided by your faculty. Complete each section below systematically. Submit your write-up within 7 days. Your write-up will be reviewed by a peer and by your supervising faculty.
Length: 1400–1800 words (excluding growth chart plots and food tables)
What to Submit
Section 1: Clinical Presentation and History
Guidance: Record the age (in months), sex, presenting complaints, duration of illness, and relevant birth history. Document maternal nutritional status and feeding history: exclusive breastfeeding duration, complementary feeding initiation age and foods introduced, any history of recurrent infections, diarrhoea, or hospitalisation. Conduct and record a 24-hour dietary recall: list all foods consumed the previous day, estimated portions, and preparation methods. Comment on the caloric density of the diet relative to age-appropriate RDA.
Section 2: Anthropometric Assessment and Classification
Guidance: Record weight (kg, method used), height/length (cm, supine if <2 years), MUAC (cm), and check for bilateral pitting oedema. Plot weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) on WHO growth charts. Classify nutritional status using WHO/IAP criteria: SAM (WHZ <−3 SD, MUAC <11.5 cm, or bilateral oedema), MAM (WHZ −2 to −3 SD, MUAC 11.5–12.5 cm), stunting (HAZ <−2 SD), underweight (WAZ <−2 SD). State which criterion/criteria are met and whether the child has complicated or uncomplicated SAM.
Section 3: Clinical Examination for Nutritional Deficiency Signs
Guidance: Systematically examine for signs of micronutrient deficiencies: pallor (anaemia/iron), Bitot's spots/night blindness (vitamin A), angular stomatitis/glossitis (riboflavin/B12), goitre (iodine), flaky-paint dermatosis/oedema (kwashiorkor), muscle wasting/prominent ribs (marasmus), and bowing/rachitic rosary (vitamin D). Note the hair (flag sign, dyspigmentation), nails (koilonychia), and skin changes. Summarise findings as a micronutrient deficiency profile.
Section 4: Nutritional Diagnosis and Problem List
Guidance: State the primary nutritional diagnosis (SAM type, MAM, obesity, specific deficiency) and any concurrent nutritional problems. Specify the classification as kwashiorkor, marasmus, or marasmic-kwashiorkor if SAM is present. Calculate the child's actual caloric and protein intake versus the RDA (using the 24-hour dietary recall data from Section 1 and standard Indian food composition tables). Quantify the caloric and protein deficit as a percentage of RDA.
Section 5: Management Plan
Guidance: For SAM: outline the WHO 10-step management plan specific to this child — address each of the first 5 steps (hypoglycaemia, hypothermia, dehydration, electrolytes, infections) with the specific action taken or to be taken. Specify which therapeutic formula (F-75 for stabilisation, F-100 or RUTF for rehabilitation) will be used, volume per feed, feed frequency, and route (oral/NGT). For MAM or mild malnutrition: design a practical diet plan using locally available Indian foods to meet the caloric and protein RDA, including micronutrient supplementation as per IAP/NHM guidelines (iron-folic acid, vitamin A, zinc, vitamin D as applicable). For obesity: outline lifestyle modification targets (dietary modification, physical activity prescription, screen-time limits).
Section 6: Counselling Plan for Parents/Caregivers
Guidance: Write a structured counselling script (key messages in plain language) covering: (a) the diagnosis and its significance; (b) the diet plan with specific food recommendations using local foods and cooking methods; (c) danger signs requiring immediate return (hypothermia, seizures, lethargy, unable to feed); (d) follow-up schedule; (e) hygiene and infection prevention. Include one or two culturally appropriate nutrition-education messages relevant to the family's socioeconomic context.
Section 7: Reflection
Guidance: Write 150–200 words reflecting on: what you found most clinically challenging in this nutritional assessment; how the assessment changed or confirmed your initial impression; and what you would do differently in your next nutritional assessment. Comment on any systemic or social barriers (e.g., food insecurity, family literacy, ICDS access) that you identified and how you addressed or plan to address them.
Grading Rubric — Nutrition Assessment and Management Plan Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Accuracy and completeness of anthropometric assessment and WHO nutritional classification | 20 pts | All four anthropometric indices correctly measured and plotted (WAZ, HAZ, WHZ, MUAC plus oedema check); WHO/IAP classification applied correctly with all three SAM criteria evaluated; type of SAM (kwashiorkor/marasmus/marasmic-kwashiorkor) correctly identified with full justification. |
| Quality of dietary recall and caloric/protein intake analysis | 15 pts | Complete 24-hour dietary recall documented with all meals and portion estimates; caloric and protein intake calculated using Indian food composition tables; deficit quantified as percentage of age-specific RDA; specific food gaps identified (e.g., low caloric density, absent pulse/protein source). |
| Completeness and accuracy of micronutrient deficiency examination | 15 pts | All major micronutrient deficiency signs systematically examined and documented (pallor, Bitot's spots, angular stomatitis, goitre, flag sign/dyspigmentation, bowing/rosary, oedema, dermatosis); findings linked to specific deficiencies with correct pathophysiological reasoning. |
| Clinical accuracy of management plan (WHO 10-step for SAM / therapeutic diet for MAM / lifestyle modification for obesity) | 30 pts | All five immediate steps (hypoglycaemia/hypothermia/dehydration/electrolytes/infection) addressed accurately with correct agents and doses (10% dextrose 5 mL/kg; ReSoMal not standard ORS; amoxicillin ± gentamicin); F-75 volumes and frequency correct for body weight; transition criteria to F-100/RUTF stated correctly (appetite return + oedema resolution); micronutrient supplementation schedule included; follow-up plan with correct post-discharge visits. |
| Caregiver counselling — clarity, completeness, and cultural appropriateness | 20 pts | Counselling script includes all required elements (diagnosis explanation, specific diet plan with local foods, danger signs, follow-up schedule, hygiene messages); language is parent-appropriate (jargon-free); culturally contextualised food recommendations (regional staples, family affordability); reflection demonstrates genuine engagement with social determinants. |
PEER REVIEW
Read your peer's nutritional assessment write-up carefully. Using the rubric criteria as your framework, provide structured written feedback on: (1) Was the anthropometric classification correct? If not, explain the error. (2) Was the management plan clinically safe? Identify any dangerous errors (e.g., F-100 in stabilisation, IV saline for SAM dehydration). (3) Was the counselling culturally realistic and complete? (4) Identify one specific strength and one specific area for improvement. Your feedback must be respectful, specific, and grounded in the rubric criteria — not just 'good job' or 'needs work'. Aim for 200–250 words.