MALNUTRITION

Malnutrition refers to deficiencies excessive or imbalance in person’s intake of energy and/or

nutrient. Malnutrition affects people in every country. Around 1.9 billion adults worldwide are
overweight, while 462 million are underweight.
Also, an estimated 41million children under the age of 5years are overweight or obese, while some
159millions are stunted and 50millions are wasted.
However, the term malnutrition covers 2broad groups of conditions.
1. Under nutrition, which includes stunting wasting, underweight and micro nutrient
deficiencies or insufficiencies
2. Overweight, this includes obesity and diet related non communicable diseases such as heart
diseases, stroke, diabetes and cancer.

TYPES OF MALNUTRITION
Acute Malnutrition is a devastating epidemic worldwide. Some 55million children under the age of
five suffer from acute malnutrition, 19millions of these suffer from the most serious, type-severe
acute malnutrition. It is also recorded that 3.1million children die of malnutrition.
The human body needs energy and nutrients to function if the food intake is inadequate the body
begins to break down body fat and muscle the metabolism begin slow, thermal regulation is
disrupted, the immune system is weakened and the kidney function is impaired.
1. Acute malnutrition is a form of under nutrition caused by a decrease in food consumption
and/or illness that results in sudden weight loss or oedema (fluid retention). Acute malnutrition
can be moderate or severe, and prolonged malnutrition can cause stunted growth, otherwise
known as stunting.

Severe acute Malnutrition and Moderate acute malnutrition

Severe acute malnutrition and moderate acute malnutrition (severe starvation) is the most extreme
form, which if not treated, lead to death. This affects 16million children globally
(UNICEF/WHO/world Bank 2016)
Moderate acute malnutrition (moderate starvation) is less severe but leads to severe acute
malnutrition. If it goes untreated, it affects approximately 34million children globally (UNICEF/
WHO World Bank 2016).
2. Chronic malnutrition: This is a condition that develops when children do not eat the correct
balance of nutrients in the first 1000 days of life (from conception to the age of two), resulting
in the irreversible stunting of their cognitive and physical development. Thus, maternal nutrition
status before and during pregnancy, as well as during breast feeding.

Also, chronic malnutrition damages the health of over one third of all people in developing
countries, affecting approximately 156million children worldwide at any one time.
Summarily, chronic malnutrition is the most common form of malnutrition and causes stunting
(short individuals) it is also an irreversible condition after 2years of age, while acute malnutrition or
wasting and/or oedema is less common than chronic malnutrition but carries a higher risk of
mortality.
TYPES OF MALNUTRITION
These term malnutrition addresses 3 broad group conditions.
Under nutrition
Under nutrition denotes insufficient intake of energy and nutrients to meet an individual’s needs to
maintain good health.
There are 4 broad sub-forms of under nutrition:
ü Wasting stunting, underweight, and deficiencies in vitamins and minerals. Low weight –for –
height is known as wasting. It usually indicates recent and severe weight loss, because a person
has not had enough food to eat and/or they have, had an infectious disease such diarrhea which
has caused them to lose weight. A young child who is moderately or severely wasted has an
increased risk of death but treatment is possible.
Stunting: low height for-age. It is as a result of chronic or recurrent under nutrition or usually
associated with poor socioeconomic conditions, poor maternal health and nutrition, frequent illness,
and/or in appropriate in fact and young child feeding and care in early life. Stunting holds children
back from reaching their physical and cognitive potentials.
In addition, children with low weight-for-age known as underweight may be stunted, wasted, or
both.
3. Over nutrition: over nutrition is a form of malnutrition (imbalanced nutrition) arising from
excessive intake of nutrients, leading to accumulation of body fats that impairs health (i.e.
overweight/obesity).

Overweight and obesity is when a person is too heavy for his or her weight. In other words, it is
defined as abnormal or excessive fat accumulation in the body.
Body mass index (BMI) is an index of weight – for – height commonly used to classify overweight
and obesity. It is defined as a person’s weight in kilogram divided by the square of his/her heights
in meters (kg/m2). In adults, overweight is defined as a BMI of 25 or more, whereas obesity is BMI
of 30 or more.
Overweight and obesity result from an imbalance between energy consumed (too much) and energy
expended (too little). Consuming foods and drinks that are more energy-dense (high in sugar and
fats) and engaging in less physical activity have contributed to overweight/obesity.
4. Micro nutrient-related Malnutrition

This form of malnutrition also known as hidden hunger is as a result of inadequacies in intake of
vitamins and mineral often referred to as micro-nutrient. Micronutrients enable the body to produce
enzymes, hormones and other substances that are essential for proper growth and development.
Example of the micro-nutrient includes iodine, Vitamin A and iron are the most important in global
public health terms, their deficiencies represent a major threat to the health and development of
populations worldwide, particularly children and pregnant woman in low-income countries.
Signs and symptoms of under nutrition
It is important to understand clinical sign between malnutrition, types of marasmus and
kwashiorkor. In marasmus, the person is thin, is a type of protein energy malnutrition, and is
mainly seen in children.
Symptoms of Marasmus
• Loss of fat muscle mass
• underweight due to mal-nourishment
• dehydration
• Electrolyte imbalance
Infection if marasmus remains untreated for a long time.
• Brittle hair
• Diarrhea
• Lower immunity.
• Stomach infection and lactose intolerance.
• Anaemia due to iron deficiency.

Kwashiorkor occurs in people who have severe protein deficiency. Also, children who develop
kwashiorkor are often older than children who develop marasmus. Eating a diet that’s mainly
carbohydrate can lead to this condition.
ü Edema or puffy swollen appearance to fluid retention
ü Bulging of the abdomen.
ü An inability to gain weight.

Difference between Marasmus symptoms and Kwashiorkor symptoms.

Marasmus symptoms Kwashiorkor symptoms

Weight loss In ability to grow or gain weight
Dehydration Edema or swelling of the hands or feet.
Stomach shrinkage Stomach bulging

General Symptoms of under nutrition

ü Weight loss
ü Loss of fat and muscle mass
ü Hollow cheeks and sunken eyes
ü A swollen stomach
ü Dry Hair and skin
ü Delayed wound Healing.
ü Fatigue
ü Irritability
ü Depression and anxiety
Causes of Malnutrition
ü Food insecurity or lack of access to sufficient and affordable food.
ü Digestive problems and issues with nutrition absorptions.
ü Excessive alcohol consumption.
ü Mental health disorder’s
ü Inability to obtain and prepare foods.

Preventive Measures
The best approach to prevent malnutrition is to eat a healthy balance diet.
It is very important to eat a variety of foods from the main food groups, including.
• Plenty of fruit and vegetables
• Plenty of starchy foods such as bread, rice, potatoes, pasta.
• Some milk and dairy foods or non-diary alternatives.
• Some sources of protein such as meat, fish, egg and beans.

However, childhood malnutrition can be prevented through

• Balanced protein energy supplementation and supplementation during pregnancy.
• Promotion of exclusive breast feeding.
• Appropriate complementary food.
• Preventive strategies for infection.
• Correction of micronutrient, deficiencies.
• Hygienic water and food condition or hygiene practices.

Micronutrients often referred to as vitamins and minerals, are vital to healthy development, diseases
prevention, and wellbeing. With the exception of vitamin D, micronutrients are not produced in the
body and must be derived from the diet.
Micronutrients are only needed in small quantities; its deficiencies can have devastating
consequences.
These are micronutrients of public health concern.
Iron
Iron is essential for motor and cognitive development, children and pregnant women are vulnerable
to consequences of iron deficiencies.
It is also a leading cause of anemia which is known as low haemoglobin concentration. Also, it
should be noted that anemia during pregnancy increased the risk of death for the mother and low
birth weight for infants.
Signs and Symptom of iron deficiency.
• Extreme fatigue
• Weakness
• Pale skin
• Chest pain, fast heartbeat or shortness of breath
 • Dizziness or light headedness
• Brittle nail.
• Swollen or sore tongue.

Vitamin A

Vitamin A supports healthy eyesight and immune system functions, its deficiencies in children
increase risk of blindness and death from infections such as measles and diarrhea.

It is estimated globally that vitamin A deficiency affects an estimated 190 million preschool-age
children.

Clinical Signs and Symptoms of Vitamin A Deficiency

• Dry skin
• Dry Eyes
• Night blindness
• Infertility
• Delayed growth
• Poor wound Healing
• Acne

Iodine

Iodine is also an important micro nutrient required during pregnancy and infancy for the infant’s
healthy growth and cognitive development.

It is also estimated that 1.8million people have insufficient iodine intake. Also, iodine content in
most foods and beverage are low; fortifying salt with iodine is a successful intervention, the amount
of iodine added to salt can be adjusted so that people maintain adequate iodine intake even if they
consume less salt.

Signs Symptoms of Iodine Deficiency

• Swelling in the neck (Goiter)

• Unexpected weight gain (thyroid hormone is made by iodine, thyroid hormone levels are
low, body burns fewer calorie at rest
• Thyroid hormone help to control the speed of metabolism.
• Fatigue weakness
• Hair loss
 • Dry, flaky skin
• Changes in heart rate
• Trouble in learning remembering

FOLATE

Folate, known as vitamin B9, is essential in the earliest days of foetal growth for healthy
development of the brain and the spine. Folic acid is another form of vitamins B9.

Women of reproductive age need 400 microgram of folic acid every day. Ensuring sufficient levels
of folate in women prior to conception can reduce neural tube defects such spine bifida
anencephaly.

The symptoms of folate deficiency are;

• Fatigue
• Grey hair
• Mouth sores
• Tongue swelling
• Growth problems.

ZINC

Zinc is also micro nutrient of public health concern “Zinc” has so many functions such as

- Promoting immune functions

- Resisting infectious diseases including diarrhea, pneumonia and malaria.

Also, zinc supplements have helped to reduce the incidence of premature birth, decreases childhood
diarrhea and respiratory infections.

Symptoms, Signs of Zinc Deficiencies

- Unexpected weight loss

- Delay in wounds healing.
- Lack of alertness
- Diarrhea
- Loss of appetite
- Open sores on the skin
Methods of Detecting Malnutrition

Obviously, nutritional assessment is an important tool used in detecting malnutrition. It can be

defined as the interpretation received from dietary, laboratory (biomedical) anthropometric and
clinical studies.

It is used to determine the nutritional status of individuals or population groups as influenced by the
intake and utilization of nutrients. Information about nutritional status i.e. nutritional assessment is
essential for identification of potential critical nutrients (at population group at risk of deficiency),
formulation of recommendation of nutrients intake; development of effective public health nutrition
(PHN) etc.

Nutritional assessment methods used in determining nutrition are:

- Dietary measurement
- Biochemical
- Anthropometric measurement
- Chemical measurement

This nutritional assessment methods, especially dietary, biochemical and anthropometric

measurement can be applied in four forms of nutritional assessment systems.

- Survey
- Surveillance
- Screening and
- intervention.

Nutritional surveys are usually national cross-sectional studies that are performed to assess
nutritional status of a selected population identify the group at risk of chronic malnutrition; evaluate
existing nutritional problems and inform evidence-based nutrition policies.

Nutritional surveillance is referred to as public health surveillance, a continuous, systematic

collection, analysis and interpretation of health-related data needed for planning, implementation
and evaluation of public health practices.

Nutritional screening is used to identify malnourished children or individuals. It can be carried out
on whole population. During nutritional screening, simple, cheap and rapid measurement are used.
Nutritional interventions are carried out on population subgroups at risk, which are identified during
nutrition surveys or screening. Supplementation and fortification are some example of nutrition
interventions.

METHODS USED IN NUTRITIONAL ASSESSMENT

Anthropometric assessment: it deals with the estimation of nutritional status on the basis of
measurement of physical dimension and gross composition of an individual’s body.

The measurement include:

- Length
- Height,
- Weight
- Head circumference
- Chest circumference
- Waist to Hip ratio.
- Muac
- Skinfold thickness

Biochemical (Laboratory Assessment): estimation of nutritional status on the basis of

measurement of nutrient store, functional forms, excreted forms and / or metabolic functions.

It includes

- Urine test
- PVC (packed cell volume)
- Iron (Serum iron)
- Sodium
- Iodine etc.

Chemical assessment: it is an estimation of nutritional status on the basis of recording a medical

history and conducting a physical examination to detect sign (observation made by a qualified
observer and symptoms manifestation reported by the patient) associated with malnutrition.

These signs include

- Color of the eyes
- Shape of the legs- rickets
- Color of hair
- Bigot spot-eyes
Nutritional assessment is the systematic process of collecting and interpreting information in order
to make decisions about the nature and causes of nutrition related health issues that affect an
individual (British Dietetic Association {BOA}, 2012 (moraine ABCD).

- A – Anthropometric
- B – Biochemical parameters such as serum albumin level and the hemoglobin count
- C – Clinical including assessment of functional, social and marital status, the medical
history and physical examination.
- D – Diet history- adequacy of cell

MALNUTRITION

SCHEMATIC DIAGRAM OF CAUSES OF MALNUTRITION

MALNUTRITION

Immediate Inadequate Diseases

Causes food intake

Underlying Household food Poor Social and Poor Access to Health Care
Causes Insecurity Care and unhealthy Environment
Environment

Formal and informal

Basic
infrastructure Political
Causes
Ideology Resources
Immediate Causes Associated with Malnutrition are Poor Diet and Diseases

Poor diet:

It occurs if a child doesn’t get an adequate diet, they will become malnourished. The poor diet
might be due to enough food or lack of variety of foods in the low concentration of energy in meals,
infrequent meals, insufficient breast milk, and early weaning.

The disease most likely to cause under nutrition are measles, diarrhea, aids, respiratory infection,
malaria, and intestinal worms.

Also, disease, especially infectious disease cause under nutrition because a sick child may not eat or
absorb enough nutrients or may have lost nutrients from the body due to vomiting, diarrhea or
increased nutrient needs which are not met.

Underlying causes:

The two immediate causes of malnutrition inadequate dietary intake and disease are in turn the
result of three major categories of underlying causes.

Dietary intake is affected by availability of food to the household (most people, including
vulnerable group, get their foods by being part of household). Illness depends on access to health
services and a healthy environment (e.g., immunization clean water and sanitation facilities). And
both of these are importantly modified by the household capacity to meet the special care needs of
women and young children.

BASIC CAUSES

The three-underlying cause of mal nutrition are also in turn the result of more basic causes,
examining the formal from household perspective, where many decisions are made that will affect
the individuals. The latter relates to the availability of control of human, economic and organization
resources in the society.

Certain political factors, such as policy decisions and economic situations caused by inflation of
war, can cause under nutrition.

In addition, from the perspective of household, abrupt weaning due to pregnancy. The belief that
food should not be given to a child who is suffering from measles or diarrhea and sharing food from
the same bowl between different children.
EFFECTS OF MALNUTRITION

Malnutrition occurs in stages, the imbalance in nutrients first reflected in blood and tissue followed
by metabolic processes- finally telltale signs symptoms appear.

The effect of malnutrition include:

- Change in body mass.

- Poor wound Healing.
- Severe weight loss (cachexia)
- Organ failure.

Sarcopenia: This is known as the progressive loss of lean body mass, which normally starts after
the age of 40. During natural sarcopenia, men, typically shed 22 pounds of lean body mass, while
women lost half of this amount. When an individual endures under nutrition, an abnormal cause of
sarcopenia may ensue, triggering other effects of malnutrition such as increase in susceptibility to
infections. Those with a cause of over nutrition are not exempted from suffering sarcopenia,
however, this is often camouflaged by an excess of adipose tissue around the internal organs.

Poor wound Healing: Typically, where there by a deficit in the nutrients such as protein,
carbohydrates and vitamins, the body cannot heal. Malnutrition is not only responsible for increased
risk of infections, but also of impairing and delaying healing from common disease or surgery.

In the over nourished, obese patient poor wound healing is due to poor oxygenation of tissues and
the inability to provide necessary nutrients and generate enough white blood cells, as well as, an
increased tension on wound edges.

Cachexia: Another effects of malnutrition, most evident and very dangerous cachexia or wasting
syndrome, encompasses a severe weight loss, along with muscle atrophy, fatigue, weakness and
loss of appetite. A person with cachexia looks like they have shrunk and withered: the skin loses the
elasticity and becomes dry. The hair follicle falls out and theirs is risk of pressure ulcers, bloods
clots and help fractures.

Organ failure:

Kidney: Malfunctioning kidneys can cause failure in the regulation of salt and fluid, which in turn
can trigger over-hydration or dehydration.
Brain: Mental health illness can cause mal nutrition and mal nutrition can be decisive factor in the
development of mental health illness such as apathy, depression, introversion, self- neglect and
deterioration in social interaction.

Reproduction: Reduced fertility and poor sex drive have been associated with malnutrition.
Moreover, malnutrition during pregnancy can make the baby more prone to diseases, strokes and
developing diabetes later in life.

Impaired temperature regulation: Especially seen in people with cachexia, people who endure
severe weight loss due to under nutrition find, themselves unable to store body heat, which can lead
to hypothermia.

MANAGEMENT OF MAL NUTRITION

Management of mal nutrition depends on the underlying cause and how severe or acute
malnourished is the person. The management of mal nutrition in adult is different from the way
infants will be managed.

Advice may be given to follow at home or be supported at home by a dietitian or other health care
professional. In severe cases, treatment in the hospital may be needed.

Obviously, severe malnutrition is birth medical and a social disorder. That is, the medical problems
of the child result, in part, from the social problems of the homes, in which the child lives.

Successful management of the severely malnourished child requires that both medical and social
problems be recognized and corrected. If the illness is viewed as being only a medical disorder, the
child is likely to relapse when he or she returns home.

Management of severe malnutrition in a child is divided into three.

Initial treatment: Life threatening problems are identified and treated in a hospital or a residential
care facility, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is
begun.

Rehabilitation: Intensive feeding is given to recover most of the lost weight, emotional and
physical stimulation are increased, the mother or carrier is trained to continue care at home, and
preparation are made for the discharge of the child.

Follow-up, after discharge, the child and the child’s family are followed to prevent relapse and
assure the continued physical mental and emotional development of the child.
How to Conduct Anthropometric Measurement of Children under 5 years of Age and Women
of Child bearing Age

Children

To assess growth in children (under 5 years), there are several different measurements such as

Ø Length
Ø Height
Ø Weight and head circumference

Length

To carry out the assessment, a wooden measuring board (also called sliding board) is used
measuring the length of children under two years old to the nearest millimeters.

Measuring the child lying down always gives readings greater than the child’s actual length by 1 -
2cm.

Procedures

To measure the length, one need one assistant and sliding board

• The assistant holds the child’s head and ensures that the child’s head touch the base of the
board.
• The assistant hand should be comfortably straight.
• The line of the sight of the child should be perpendicular to the back of the board.
• The child should be flat on the board.
• The measurer should place his/her hand on the child’s knee or chins
• The child’s foot should be flat against the foot piece.
• Then, read the length from the tape attached to the board.
• Record the measurement.

Height

This is measured with the child or adult in a standing position (usually children who are 2 years old
or more). The head should be in the front position (a position where the line pass from the external
ear hole to the lower eye lid is parallel to the floor).

Also, during measurement, the shoulder, buttock and the heels should touch the vertical stand,
either a stadiometer or a portable anthropometer are used. Measurement is recorded in millimeters.
Procedures

• Both the assistant and measurer should be on their knees.

• The right hand of the assistant should be on the chins of the child against the base of the
board.
• The left hand of the assistant should be on the knee of the child to keep them to the board.
• The heel, the calf, buttocks, shoulder and occipital prominence (prominent area on the back
of the head) should be flat against the board.
• The child should be looking straight ahead.
• The hands of the child should be his/her side
• The measurer’s left hand should be on the child chin.
• The child’s shoulders should be leveled.
• The headpiece should be placed firmly on the child’s head.
• Record the measurement.

Weight

A weight sling (spring balance) also called ‘salter scale’ is used for measuring children under two
years old, to the nearest 0.1kg. In adult and children over two years a weighing scale, or a beam
balance is used and the measurement is also the nearest 0.1kg.

Also, in both cases, digital electronic scale can be used for more convenience, do not forget, to
adjust the scale to zero before each weighing.

Procedures Using a Salter Scale

• Adjust the pointer of the scale to zero level.

• Take off the child’s heavy clothes and shoes.

Procedure

ü Adjust the pointer of the scale to zero.

ü Take off the child’s heavy clothes and shoes.
ü Hold the child’s leg through the holes.
ü Hold the child’s feet.
ü Hang the child on the Salter Scale.
ü Read the Scale at eye level to nearest 0.1kg.
ü Remove the child slowly and safely.
Converting Measurement to Indices

Weight-for-Age is an index used in growth monitoring for assessing children who may be
underweight.

Height-for-Age is an index used for assessing Stunting (Chronic malnutrition in Children). Stunted
children have poor physical and intellectual performance and lower work output leading to lower
productivity at individual level.

Therefore, stunting is defined as low height for age of the child compared to the standard child of
the same age, while stunting is defined as low weight for the height of the child compared to the
standard child of the same height. The fact is that while stunted children have decreased mental and
physical productivity, capacity wasted are vulnerable to infection and stand a greater chance of
dying.

Body mass index is the weight of a child or adult in (kg) divided by their height in meter squared =
Weight in (kg)/ (Height in meters) 2

Each Index of children in the community can be calculated as follows.

More than 2500 grams = Normal birth weight.

1500 – 2499 grams – Low birth weight.

Less than 1500 grams = very low birth weight.

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Weight for Age = !"#$%& () &%" -")"-".*" *%#+, () &%" /01" 0$"
× 100

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Weight for Height = !"#$%& () &%" -")"-".*" *%#+, () &%" /01" %"#$%&
× 100

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Weight for Height = !"#$%& () &%" -")"-".*" *%#+, () &%" /01" %"#$%&
×100
Index Cut – off Value based on standard Indicator
deviation (SD)/ Percentage
Weight – for – Less than – 2 and more than -3 Moderate underweight
Age
Weight – for – Less than – 3 Severe underweight
Age
Height – For – Less than – 2 and more than – 3 (1.e 70 – Moderate acute Malnutrition
Age 79.99% of the norm) (MAM)
Height – for – Age Less than – 3 (i.e. Less than 70% of the Severe acute malnutrition
norm and / or bilateral pilting dedema )

Indicators or underweight and Malnutrition survived from the Weight and Height of children
relatives to their age.

Body Mass Index for Women

Body mass index is the weight of a person in kilograms divided by their height in meters squared. A
non-pregnant adult is considered to have a normal BMI when it falls between 18.5 – 25kg/m2

Cut-off values for BMI for assessing adult nutritional status

BMI (Kg/m2) Cut Offs Nutritional status

More than 40.0 Very obese
30.0 - 40.0 Obese
25 – 29.9 Overweight
18.5 – 24.9 Normal
17 – 18.49 Mild chronic energy deficiency
16 – 16.9 Moderate chronic energy deficiency
Less than 16 Severe chronic energy deficiency

MUAC: MUAC (Mild Upper Arm Circumference)

MUAC is food screening tool in determining the risk of mortality among children, and people
living with HIV/AIDS.

MUAC is the only anthropometric measure for assessing nutritional status among pregnant women.
It is also very simple for use in screening a large number of people, especially during community
level screening or community-based nutrition interventions or during emergency situations. The
MUAC is the circumference of the upper arm at the midway between the shoulder tip and elbow tip
on the left arm. The mid-arm point is determined by measuring the distance from the shoulder tip to
the elbow and dividing by two. A low reading indicates a loss of muscle mass.

Measuring the MUAC of Children

A special tape is used for measuring the MUAC of a child. The tape has three colors, with red
indicating severe acute malnutrition, the yellow indicating moderate acute malnutrition and the
green indicating normal nutritional status.

Procedures

ü Remove any clothing that may cover the children’s left arm. If possible, the child should
stand erect and sideways to the measurer.
ü Estimate the midpoint of the left upper arm.
ü Strengthen the child’s arm and wrap the tape around the arm at the midpoint.
Make sure the numbers are right side up
Make sure the tape is flat around the skin.
ü Inspect the tension of the tape on the child arm make sure that the tape has the proper
tension (and that it’s not too tight or too loose). Request any step as necessary.
ü When the tape is in the correct position on the arm with correct tension, read the
measurement to the nearest 0.1cm immediately record the measurement.

Cut-offs points for Screening in the community for SAM and MAM using MUAC

Target Groups MUAC (in cm) Malnutrition

Children under 5years 11 – 11.9 Moderate acute Malnutrition
(MAM)
<11cm Severe acute Malnutrition
(SAM)
Pregnant Women/ adults 17 – 21cm Moderate Malnutrition
18 – 21cm with recent weight Moderate Malnutrition
loss
<17cm Severe Malnutrition
<18cm with recent weight loss Severe Malnutrition
Checking for bilateral Pelting Oedema in a child

In order to determine the presence oedema, one should apply normal thumb pressure on both feet
for three seconds, if a shallow print persist on both feet after three second, then the child has
nutritional oedema.