8.2 Weaning & Malnutrition

Complementary feeding and malnutrition are high-yield across Arab League primary care and ABHS Part 1 written items. Candidates must distinguish wasting from stunting using WHO z-scores, recognize kwashiorkor by bilateral pitting edema, apply MUAC screening thresholds, and know the phased SAM protocol (F-75 stabilization, then F-100 or RUTF rehabilitation).

Complementary Feeding (Weaning)

Complementary feeding (weaning) is the introduction of foods and liquids other than breast milk or formula. WHO recommends starting complementary foods at 6 months of age, continued alongside breastfeeding - not as a replacement for it - up to 2 years or beyond. Starting complementary foods too early (before 4 months) increases the risk of aspiration, allergy, and displacing breast milk intake; starting too late (after 6-8 months) risks micronutrient deficiency, especially iron, because the iron stores an infant is born with are largely depleted by 6 months.

Developmental readiness signs include good head and neck control, the ability to sit with support, and loss of the tongue-thrust (extrusion) reflex that otherwise pushes solids back out of the mouth.

Principles of Weaning

• Introduce iron-rich foods first - iron-fortified infant cereal or pureed/minced meat - because breast milk alone is low in iron after 6 months
• Progress texture gradually: smooth purees, then mashed/lumpy foods (around 8 months), then soft finger foods and table foods (by 12 months)
• Introduce one new food at a time, several days apart, to identify reactions
• When complementary feeding begins (around 6 months), introduce common allergenic foods (peanut, egg) promptly rather than delaying them — early introduction in developmentally ready infants reduces food-allergy risk, reversing older advice to withhold allergenic foods
• Avoid: cow's milk as the main drink before 12 months, honey before 12 months (infant botulism), added salt and sugar, and choking hazards (whole grapes, nuts, popcorn, hard raw vegetables)
• Continue breastfeeding (or formula) as the primary source of nutrition through the first year, with complementary foods providing an increasing share of calories and micronutrients thereafter

Exam Trap: Delaying peanut and egg introduction to prevent allergy is outdated teaching. Current guidance supports early introduction of allergenic foods around 4-6 months in developmentally ready infants.

Malnutrition Classification (WHO)

WHO classifies childhood malnutrition using three anthropometric indices, each compared to the WHO Child Growth Standards and expressed as a z-score (standard deviations from the median):

• Moderate malnutrition: z-score between -2 and -3 SD below the median
• Severe malnutrition: z-score below -3 SD

Mid-upper arm circumference (MUAC) is a simple, validated community screening tool for children 6-59 months:

• MUAC less than 115 mm = severe acute malnutrition (SAM)
• MUAC 115-125 mm = moderate acute malnutrition (MAM)

Bilateral pitting edema of the feet (and often the legs, hands, or face) defines SAM regardless of anthropometric measurements or MUAC - this is the hallmark of kwashiorkor.

Marasmus vs. Kwashiorkor

Severe Acute Malnutrition (SAM): Management Principles

WHO's protocol for inpatient management of complicated SAM proceeds through stabilization and rehabilitation phases:

1. Stabilization phase - treat and prevent life-threatening problems first: hypoglycemia, hypothermia, dehydration (using ReSoMal, a low-sodium, high-potassium oral rehydration solution designed for malnourished children, not standard oral rehydration solution), and electrolyte imbalance (potassium, magnesium). Empiric broad-spectrum antibiotics are given even without overt fever, since signs of infection are often blunted in severe malnutrition. Feeding starts cautiously with F-75 therapeutic milk (about 75 kcal/100 mL, low protein) to stabilize the child without triggering refeeding syndrome. Iron is deliberately withheld in this phase, because early iron administration can worsen oxidative stress and increase susceptibility to infection.
2. Rehabilitation phase - once appetite returns and acute medical issues resolve, the child transitions to F-100 (about 100 kcal/100 mL, higher protein) or ready-to-use therapeutic food (RUTF), an energy-dense peanut-based paste, to drive catch-up growth. Iron supplementation is added once the child is stable and eating well.
3. Community-based management - uncomplicated SAM (good appetite, no medical complications, no or only mild edema) can be managed at home with RUTF and outpatient follow-up; complicated SAM (poor appetite, significant edema, or a medical complication such as severe infection) requires inpatient stabilization first.

Micronutrient Deficits in Severe Malnutrition

Severely malnourished children are depleted in multiple micronutrients—not only iron. Zinc deficiency contributes to impaired immunity, poor wound healing, dermatitis, and anorexia; therapeutic feeds and RUTF contain supplemental zinc, and zinc is added during rehabilitation. Vitamin A deficiency increases infection severity and mortality in malnourished children; high-dose vitamin A is part of SAM protocols at admission and follow-up in endemic areas. Recognizing that malnutrition is rarely an isolated calorie deficit—but a multisystem depletion of macro- and micronutrients—explains why stabilization prioritizes cautious feeding, broad-spectrum antibiotics, and delayed iron before aggressive catch-up.

Exam Trap: Rapid carbohydrate refeeding in a severely malnourished child can precipitate refeeding syndrome - a fall in phosphate, potassium, and magnesium leading to cardiac arrhythmia and heart failure. This is exactly why cautious, low-calorie F-75 (not full-calorie feeds) is used at the start of treatment.