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PE9.{2,4-7} | Nutritional Assessment Workflow — SDL Guide (Part 3)
Applied Practice: Case-Based Nutritional Assessment
Working through a structured case reinforces the complete assessment-to-plan workflow. Every step of this case can be mapped onto the skills tested in PE9.4, PE9.5, PE9.6, and PE9.7.
Case: Priya, a 2-year-old girl, is brought for a routine well-child visit. Her mother says she eats 'rice and dal but not much.' On examination, she is alert, has no oedema, no pallor. Her weight is 9.2 kg, height 82 cm.
Step 1 — Dietary history and 24-hour recall:
Breakfast: 3-4 spoons of rice with thin dal (estimated 100g cooked rice + 100 mL thin dal = ~130 + 60 = ~190 kcal). Lunch: 50g rice + 50 mL dal + 1 small piece potato = ~80 + 30 + 40 = ~150 kcal. Snack: 2 glucose biscuits = ~40 kcal. Dinner: 80g rice + 80 mL dal = ~140 kcal. Total estimated intake: ≈520 kcal.
Step 2 — Expected requirement:
Holliday-Segar: 9.2 kg = 100 × 9.2 = 920 kcal/day. ICMR-NIN RDA for 1-3 years = 1000 kcal/day.
Caloric gap: 1000 − 520 = 480 kcal/day (deficit of ~48%).
Step 3 — Anthropometric classification:
For age 2 years, median weight ≈ 12 kg; median height ≈ 87 cm. Weight-for-age z-score: 9.2 kg at 24 months ≈ −2.8 SD → severely underweight. Height-for-age: 82 cm at 24 months ≈ −2.0 SD → mildly stunted. Weight-for-height z-score: 9.2 kg at 82 cm ≈ −1.5 SD → not wasted. MUAC: measure required; if, say, 12.0 cm → yellow zone (MAM).
Step 4 — Diet plan prescription:
Target: 1000-1100 kcal/day (current requirement + catch-up allowance).
Increase meal frequency to 5-6 times daily. Add 1 egg daily (~73 kcal + 6g protein). Enrich rice with 5 mL ghee per serving (+45 kcal). Add 100 mL whole milk once daily (~65 kcal, calcium). Replace thin dal with thicker dal (higher energy density). Include amla or lemon with dal to improve iron absorption. Target weight gain: 5-10 g/kg/day during catch-up.
SELF-CHECK
A 30-month-old child has a MUAC of 11.8 cm, weight-for-height z-score of −2.5 SD, no oedema, and passes the appetite test. How should this child be classified and what is the appropriate management setting?
A. SAM — requires inpatient admission to NRC
B. MAM by MUAC, moderate wasting by WHZ — eligible for community-based management with RUTF if appetite test passed
C. Normal nutritional status — reassure and routine follow-up
D. SAM due to WHZ < −3 SD — requires F-75 stabilisation
Reveal Answer
Answer: B. MAM by MUAC, moderate wasting by WHZ — eligible for community-based management with RUTF if appetite test passed
MUAC 11.8 cm falls in the yellow zone (11.5-12.5 cm = MAM). WHZ of −2.5 SD represents moderate wasting (between −2 and −3 SD). The child has no oedema and passes the appetite test (absence of anorexia). This clinical picture is consistent with moderate acute malnutrition — eligible for community-based management with RUTF and close follow-up, not inpatient admission. Inpatient (NRC) is required for SAM with complications (MUAC <11.5 cm OR WHZ <−3 SD OR bilateral oedema) combined with medical complications or failed appetite test.
Self-Assessment
Before this module concludes, perform a brief self-check of your clinical readiness for a nutritional assessment encounter. Can you name the five anthropometric measurements and describe how each is taken correctly? Can you state the MUAC cut-offs for SAM and MAM without looking them up? Can you describe the steps of a 24-hour dietary recall, including how to probe for quantities without leading the caregiver? Can you apply the Holliday-Segar formula to a 14 kg child and calculate the expected caloric requirement? Can you differentiate wasting from stunting by the z-score index used and the clinical implications of each? Can you prescribe a diet for a toddler with moderate acute malnutrition — specifying meal frequency, food types, and energy enrichment? These six questions map directly onto the OSCE stations for PE9.2, PE9.4, PE9.5, PE9.6, and PE9.7.
- MUAC SAM threshold: <11.5 cm (6-59 months)
- MUAC MAM threshold: 11.5-12.5 cm
- Holliday-Segar: 100 kcal/kg for first 10 kg + 50 kcal/kg for next 10 kg + 20 kcal/kg above 20 kg
- Wasting index: weight-for-height z-score (WHZ); Stunting index: height-for-age z-score (HAZ)
- SAM criterion: WHZ < −3 SD OR MUAC <11.5 cm OR bilateral pedal oedema