Management of SAM.pdf

PAEDIATRICS AND CHILD HEALTH
• Paediatrics and Child Health
• Management of Severe Acute Malnutrition (SAM):
- Kwashiorkor
- Marasmus
- Marasmus-Kwashiorkor
Dr. Chongo Shapi (Bsc. HB, MBChB)
Medical Doctor.
3/20/2022 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ 1

Investigations for SAM
Septic screen in fear of missed infection:
• FBC/DC (check including Hb) + ESR
• Blood/urine/stool (including ova for parasites) for MCS
• Urinalysis
• RDT/MPS
• Gastric lavage for AAFB + culture and sensitivity
• CXR
• RVT
• LP if indicated
• Reducing substances in loose stool (Clinitest)
NB: urgent Xmatch if pt very pale

Treatment of SAM
• Admit patient
• Resuscitate patient: CABs and monitor vitals
• Manage the complications including shock
• Follow the WHO 10 essential steps (next slide)
3/20/2022 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ. 4

There are ten essential steps: THE 10 STEPS
1. Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte imbalance
5. Treat/prevent infection
6. Correct micronutrient deficiencies
7. Start cautious feeding
8. Achieve catch-up growth
9. Provide sensory stimulation and emotional
support
10.Prepare for follow-up after recovery

Feeding
• Stabilisation phase
Target is:
100 kcal/kg/day 1-1.5g protein/kg/day
Give F75 (75 kcal and 0.9g protein/100ml)
130 ml/kg/d of fluid (100 ml/kg/d if the child has severe
oedema)
• Rehabilitation phase (catch-up growth)
Target is:
150-220 kcal/kg/day
4-6 g protein/kg/day
Give F100 (100 kcal and 2.9g protein/100ml)
or RUTF (ready-to-use therapeutic food)
or modified family foods

• These steps are accomplished in 3 phases:
1. Stabilisation phase: where the acute medical
conditions are managed. Days 1-7. Minimum of
2 days and maximum of 7 days
2. Rehabilitation phase: lasts for the next 2-6 wks
3. Follow up (Consolidation) Phase: Next 7-26 wks
Note that treatment procedures are similar for
marasmus and kwashiorkor

Step 1. Treat/prevent hypoglycaemia
• Hypoglycaemia and hypothermia usually occur
together and are signs of infection
• Check for hypoglycaemia whenever hypothermia
(axillary <35 ⁰C; rectal <35.5 ⁰C) is found
• Frequent feeding is important in preventing both
conditions

Treatment:
• If child conscious and dextrostix shows <3mmol/l give:
a. 50 mL bolus of 10% glucose or sucrose solution (1 rounded
teaspoon of sugar in 3.5 tablespoons water), orally or by NGT.
Then feed starter F-75 every 30 min for 2 hours (giving one
quarter of the two-hourly feed each time)
b. Antibiotics
c. Two-hourly feeds, day and night
• If child unconscious, lethargic or convulsing give:
a. IV sterile 10% glucose (5mL/kg), followed by 50mL bolus of 10%
glucose or sucrose by NGT. Then give starter F-75 as above
b. Antibiotics
c. Two-hourly feeds, day and night

Monitor:
1. Blood glucose: if it was low, repeat RBS after 2 hrs. If falls
to <3 mmol/l give a further 50ml bolus of 10% glucose or
sucrose solution, and continue feeding every 30 min
until stable
2. Rectal temperature: if this falls to <35.5 ⁰C, repeat RBS
3. Level of consciousness: if this deteriorates, repeat RBS
Prevention:
a. Feed two-hourly, start straight away or if necessary,
rehydrate first
b. Always give feeds throughout the night
NB: If you are unable to test the blood glucose level, assume
all severely malnourished children are hypoglycaemic and
treat accordingly

Step 2. Treat/prevent hypothermia
Treatment:
• Axillary temp <35 ⁰C, take the rectal temp using a
low reading thermometer
• If the rectal temp is <35.5 ⁰C:
a. Feed straight away (or start rehydration if needed)
b. Rewarm the child: either cloth the child (including
head), cover with a warmed blanket and place a
heater or lamp nearby, or put the child on the
mother’s bare chest (the Kangaroo Mother Care)
and cover them
c. Give antibiotics

Monitor:
a. Body temp: during rewarming take rectal temp
2 hourly until it rises to >36.5 ⁰C (take half-
hourly if heater is used)
b. Ensure the child is covered at all times,
especially at night
c. Feel for warmth
d. Blood glucose level: check for hypoglycaemia
whenever hypothermia is found

Prevention:
a. Feed two-hourly, start straightaway
b. Always give feeds throughout the day and night
c. Keep covered and away from draughts
d. Keep the child dry, change wet nappies, clothes and
bedding
e. Avoid exposure (e.g. bathing, prolonged medical
examinations)
f. Let child sleep with mother/carer at night for warmth
Note: If a low reading thermometer is unavailable and the
child’s temperature is too low to register on an ordinary
thermometer, assume the child has hypothermia

Step 3. Treat/prevent dehydration
Note: Low blood volume can coexist with oedema
- Do not use the IV route for rehydration except in
cases of shock and then do so with care
- In shock, infuse slowly to avoid flooding the
circulation and overloading the heart
- Dehydration in malnutrition is usually secondary
to diarrhoea. Treat with ReSoMal

Treatment:
• Standard ORS (90 mmol/L of Na+) or Reduced
Osmolarity ORS (75 mmol/L of Na+) contains too
much Na+ and too little K+ for severely malnourished
children. The Na+ can kill the patient
• Instead give special Rehydration Solution for
Malnutrition (ReSoMal)
• Contents of ReSoMal:
1. Water (Boiled and cooled) = 2L
2. WHO ORS = 1L sachet
3. Sugar = 50g
4. CMV = 1 scoop (1 scoop = 1.64 g)

Average Concentration/L of ReSoMal
• Glucose: 55 mmol
• Saccharose: 73 mmol
• K+ : 40 mmol
• Na+ : 45 mmol
• Mg2+ : 3mmol
• Cl- : 70 mmol
• Citrate: 7 mmol
• Zn2+ : 300umol
• Cu2+ : 45 umol
• NB:
- ReSoMal has reduced
sodium, and high
potassium than standard
WHO ORS
- Malnourished children have
increased total body Na+
and reduced total body
potassium
- Na+ plasma levels might
show hyponatremia due to
oedema in malnutrition

WHO ORS
a. 13.5 g of CHO = 75 mmol/L
b. 20 g of CHO = 111 mmol/L
c. Base = 2.5 g of NaHCO3 (30 mmol/L of HCO3-) or 2.5 g of
Trisodium citrate (10 mmol/L of citrate)
d. The formula containing citrate is much more stable

• It is difficult to estimate dehydration status in a
severely malnourished child using clinical signs alone
• Signs of dehydration used in malnutrition:
1. Lethargy or unconsciousness
2. Delayed CRT > 3 sec
3. Weak feeble and fast pulse
4. Reduced urinary output (< 0.5-1 mL/Kg/hr)
5. Cold peripheries
NB: These signs indicate shock, hence treat first as
shock

• NB: This is dehydration minus shock
• So assume all children with watery diarrhoea may
have dehydration and give:
a. ReSoMal 5 ml/kg every 30 min for 2 hrs, orally or
by NGT, then
b. 5-10 ml/kg/h for next 4-10 hrs alternating with F-
75 (4, 6, 8 and 10 hrs):
- The exact amount to be given should be determined
by how much the child wants, and stool loss and
vomiting, then
- ReSoMal to be given for maximum of 10 hrs
c. Continue feeding starter F-75

• During treatment, rapid RR and PR should slow
down and the child should begin to pass urine
• Monitor progress of rehydration
• Observe half-hourly for two hours, then hourly for
the next 6-12 hours, recording:
a. PR
b. RR
c. Urine output/urine frequency
d. Stool/vomit frequency
e. Hydration signs (Return of tears, Moist mouth, Eyes
and fontanelle appearing less sunken and
Improved skin turgor)

• Note that many severely malnourished children will
not show these changes even when fully rehydrated
• Continuing rapid RR and PR during rehydration
suggest coexisting infection or over-hydration
• Signs of excess fluid (over-hydration) are:
a. Increasing RR and PR
b. Increasing oedema
c. Puffy eyelids
• If these signs occur, stop fluids immediately and
reassess after one hour

Prevention:
• To prevent dehydration when a child has
continuing watery diarrhoea:
a. Keep feeding with starter F-75
b. Replace approximate volume of stool losses
with ReSoMal. As a guide give 50-100 ml after
each watery stool
c. If child still breastfed, encourage to continue

Step 4: Correct Electrolyte Imbalances
• All severely malnourished children have excess body
Na+ even though plasma Na+ may be low
• Thus, giving high sodium loads will kill the patient
• Deficiencies of K+ and Mg2+ are also present and may
take at least two weeks to correct
• Oedema is partly due to these imbalances
• Do NOT treat oedema with a diuretic
• Give:
a. Extra K+: 3-4 mmol/kg/d
b. Extra Mg2+: 0.4-0.6 mmol/kg/d
c. When rehydrating, give low sodium rehydration
fluid (e.g. ReSoMal)
d. Prepare food without salt

Step 5: Treat/Prevent Infection
• In SAM, the usual signs of infection, such as fever, are
often absent, and infections are often hidden
• Therefore give routinely on admission:
a. BSAs
b. Metronidazole (7.5 mg/kg 8-hourly for 7 days):
- Hastens repair of the intestinal mucosa
- Reduces risk of oxidative damage and systemic
infection arising from the overgrowth of anaerobic
bacteria in the small intestine
c. Measles vaccine if child is > 6mo and not immunised
(delay if the child is in shock)

Step 5: Treat/Prevent Infection
• Choice of BSAs follows
the hospital protocol
• UTH (A07) Protocol as of
2014:
1st line: X-pen + Gentamycin
2nd line: Ciprofloxacin +
Cloxacillin
3rd line: Vancomycin
Infections seen in PEM in
developing countries:
1. Diarrhoea (Bacteria,
Protozoa, Helminths)
2. Malaria
3. Tuberculosis (TB)
4. HIV infection
5. Pneumonia
6. Measles

WHO Antibiotics for Severely Malnourished Children

Step 6. Correct micronutrient deficiencies
• All children with SAM, have vitamin and mineral
deficiencies
• Although anaemia is common, do NOT give iron
initially in the stabilization phase but wait until the
child has a good appetite and starts gaining weight
• Give iron in the rehabilitation phase
• Iron is usually given by the second week because it
can make infections worse
• Give Vitamin A orally on Day 1, 2 and 8:
a. >12 mo, give 200,000 IU
b. 6-12 mo, give 100,000 IU
c. 0-5 mo, give 50,000 IU

Step 6. Correct micronutrient deficiencies
• Give daily for at least 2 weeks:
a. Multivitamin supplement
b. Folic acid 1 mg/d (give 5 mg on Day 1)
c. Zinc 2 mg/kg/d
d. Copper 0.3 mg/kg/d
e. Iron 3 mg/kg/d but only when gaining weight

Step 7: Start Cautious Feeding
• In the stabilisation phase a cautious approach is required
• This is because of the child’s fragile physiological state and
reduced homeostatic capacity
• Feeding should be started as soon as possible after
admission
• The feeding should be designed to provide just sufficient
energy and protein to maintain basic physiological
processes
• Milk-based formulas such as starter F-75 containing 75
kcal/100 ml and 0.9 g protein/100 ml will be satisfactory for
most children
• Give from a cup
• Very weak children may be fed by spoon, dropper or syringe

Re-feeding syndrome
- The hallmark is the development of severe
hypophosphatemia after the cellular uptake of
phosphate during the 1st week of starting to refeed
- Remember, phosphates are needed to make ATP in
the cells
- May complicate the acute nutritional rehabilitation of
children who are undernourished from any cause
- Phosphate levels should be monitored during refeeding
- If low, phosphate should be administered during
refeeding to treat severe hypophosphatemia

Re-feeding syndrome
- Serum phosphate levels of ≤ 0.5 mmol/L can produce:
1. Weakness
2. Rhabdomyolysis
3. Neutrophil dysfunction
4. Cardiorespiratory failure
5. Cardiac arrhythmias
6. Seizures
7. Altered level of consciousness
8. Sudden death

• The essential features of feeding in the stabilisation
phase are:
a. Small, frequent feeds of low osmolarity and low
lactose
b. Oral or NGT feeds (never parenteral preparations)
c. 100 kcal/kg/d
d. 1-1.5 g protein/kg/d
e. 130 ml/kg/d of fluid (100 ml/kg/d if the child has
severe oedema)
f. If the child is breastfed, encourage to continue
breastfeeding but give the prescribed amounts of
starter formula to make sure the child’s needs are
met

• If intake does not reach 80 kcal/kg/d, give the
remaining feed by NGT for intake volumes below
which NG feeding should be given
• Do not exceed 100 kcal/kg/d in this phase
Monitor and note:
1. Amounts offered and left over
2. Frequency of vomiting
3. Frequency of watery stool
4. Daily body weight
• During the stabilisation phase, diarrhoea should
gradually diminish and oedematous children should
lose weight

Step 8: Achieve Catch-Up Growth
• In the rehabilitation phase a vigorous approach to
feeding is required to achieve very high intakes
and rapid weight gain of >10 g gain/kg/d
• The recommended milk-based F-100 contains 100
kcal and 2.9 g protein/100 ml
• RUTF is also recommended as an alternative to
F100
• Modified porridges or modified family foods can be
used provided they have comparable energy and
protein concentrations

• Note that breast milk does not have sufficient
energy and protein to support rapid catch-up
growth
• Readiness to enter the rehabilitation phase is
signalled by a return of appetite, usually about
one week after admission
• A gradual transition is recommended to avoid the
risk of heart failure which can occur if children
suddenly consume huge amounts

• Transition from starter F75 to catch-up formula
F100:
1. Replace starter F-75 with the same amount of
catch-up formula F-100 for 48 hours then,
2. Increase each successive feed by 10 ml until
some feed remains uneaten. The point when
some remains unconsumed is likely to occur
when intakes reach about 30 ml/kg/feed (200
ml/kg/d)

Monitor during the transition for signs of CCF:
1. RR
2. PR
• If RR increase by ≥ 5/min and PR by ≥ 25/min for two
successive 4-hourly readings, reduce the volume per
feed
After the transition give:
1. Frequent feeds (at least 4-hourly) of unlimited
amounts of a catch-up formula
2. 150-220 kcal/kg/d
3. 4-6 g protein/kg/d
4. If the child is breastfed, encourage to continue

Monitor progress after the transition by assessing the
rate of weight gain:
1. Weigh child each morning before feeding and plot
weight
2. Each week calculate and record weight gain as g/kg/d
• If weight gain is:
a. Poor (<5 g/kg/d), child requires full reassessment
b. Moderate (5-10 g/kg/d), check whether intake
targets are being met, or if infection has been
overlooked
c. Good (>10 g/kg/d), continue to praise staff and
mothers

Calculating weight gain :
• The example is for weight gain over 7 days, but the
same procedure can be applied to any interval:
* substract from today’s weight (in g) the child’s
weight 7 days earlier ;
* divide by 7 to determine the average daily weight
gain (g/day) ;
* divide by the child’s average weight in kg to
calculate the weight gain as g/kg/day

Step 9: Provide Sensory Stimulation and Emotional Support
• In SAM, there is delayed mental and behavioural
development
• Provide:
1. Tender loving care (TLC)
2. A cheerful, stimulating environment
3. Structured play therapy, 15-30 min/d
4. Physical activity as soon as the child is well
enough
5. Maternal involvement when possible (e.g.
comforting, feeding, bathing, play)

Step 10: Prepare For Follow-Up After Recovery
• A child who is 90% weight-for-length (equivalent
to -1SD) can be considered to have recovered
• The child is still likely to have a low weight-for-age
because of stunting
• Good feeding practices and sensory stimulation
should be continued at home

Step 10: Prepare For Follow-Up After Recovery
• Show parent or carer how to:
1. Feed frequently with energy- and nutrient-
dense foods
2. Give structured play therapy
• Advise parent or carer to:
a. Bring child back for regular follow-up checks
b. Ensure booster immunizations are given
c. Ensure vitamin A is given every six months

Summary of the Steps
• Hypothermia: Warm patient up; maintain and
monitor body temperature
• Hypoglycemia: Monitor blood glucose; provide oral
(or intravenous) glucose
• Dehydration: Rehydrate carefully with oral solution
containing less sodium and more potassium than
standard mix
• Micronutrients: Provide copper, zinc, iron, folate,
multivitamins
• Infections: Administer antibiotic and antimalarial
therapy, even in the absence of typical symptoms

Summary of the Steps
• Electrolytes: Supply plenty of potassium and
magnesium
• Starter nutrition: Keep protein and volume load
low
• Tissue-building nutrition: Furnish a rich diet dense
in energy, protein, and all essential nutrients that is
easy to swallow and digest
• Stimulation: Prevent permanent psychosocial
effects of starvation with psychomotor stimulation
• Prevention of relapse: Start early to identify causes
of protein-energy malnutrition in each case; involve
the family and the community in prevention

Treatment of Severe Anaemia in SAM
• A BT is required if:
1. Hb is less than 4 g/dl
2. or if there is respiratory distress and Hb is 4-6 g/dl
• Give:
a. Whole blood 10 ml/kg body weight slowly over 3
hours
b. Furosemide 1 mg/kg IV, stat
• It is particularly important that the volume of 10
ml/kg is not exceeded in SAM
• If the severely anaemic child has signs of CCF,
transfuse parked RBCs (5-7 ml/kg) rather than whole
blood

• Monitor for signs of transfusion reactions and
vitals (PR, RR, T, urine output)
• If any of the following signs develop during the
transfusion, stop the BT:
a. Fever
b. Itchy rash
c. Dark red urine
d. Confusion
e. Anaphylactic shock (give adrenaline as
prophylaxis in case of a reaction)

• If RR or PR rises, transfuse more slowly
• Following the BT, if the Hb remains less than 4 g/dl
or between 4 and 6 g/dl in a child with continuing
respiratory distress, DO NOT repeat the BT within
4 days
• In mild or moderate anaemia, oral iron should be
given for 2 months to replenish iron stores BUT
this should not be started until the child has
begun to gain weight

Treatment of Associated Conditions
Vitamin A deficiency
• Any eye signs of vitamin A deficiency, give orally:
vitamin A on days 1, 2 and 8:
a. >12 months = 200,000 IU
b. 6-12 months = 100,000 IU
c. 0-5 months = 50,000 IU
• If first dose has been given in the referring centre,
treat on days 1 and 8 only

Vitamin A deficiency
• If there is corneal clouding or ulceration, give
additional eye care to prevent extrusion of the
lens:
a. Instil chloramphenicol or tetracycline eye drops
(1%) 2-3 hourly as required for 7-10 days in the
affected eyes
b. instil atropine eye drops (1%), 1 drop three
times daily for 3-5 days
c. Cover with eye pads soaked in saline solution
and bandage
Note: children with vitamin A deficiency are likely
to be photophobic and have closed eyes

Dermatosis
Signs:
1. Hypo-or hyperpigmentation
2. Desquamation
3. Ulceration (spreading over limbs, thighs,
genitalia, groin, and behind the ears)
4. Exudative lesions (resembling severe burns)
often with secondary infection, including
Candida

Dermatosis
• Zinc deficiency is usual in affected children and the skin
quickly improves with zinc supplementation
• The dermatosis of zinc deficiency is called
acrodermatitis enteropathica
• In addition:
a. Apply barrier cream (zinc and castor oil ointment, or
petroleum jelly or paraffin gauze) to raw areas
b. Omit nappies so that the perineum can dry
Parasitic worms
Give mebendazole 100 mg orally, twice daily for 3 days

Continuing Diarrhoea
• Diarrhoea is a common feature of malnutrition but
it should subside during the first week of
treatment with cautious feeding
• In the rehabilitation phase, loose, poorly formed
stools are no cause for concern provided weight
gain is satisfactory
• Mucosal damage and giardiasis are common
causes of continuing diarrhoea
• Where possible examine the stools by microscopy
• Give metronidazole (7.5 mg/kg 8-hourly for 7
days) if not already given

• Lactose intolerance
- Only rarely is diarrhoea due to lactose intolerance
- Treat only if continuing diarrhoea is preventing
general improvement
- Starter F-75 is a low-lactose feed
- In exceptional cases:
a. Substitute milk feeds with yoghurt or a lactose-
free infant formula
b. Reintroduce milk feeds gradually in the
rehabilitation phase

• Osmotic diarrhoea
- May be suspected if diarrhoea worsens
substantially with hyperosmolar starter F-75 and
ceases when the sugar content is reduced and
osmolarity is <300 mOsmol/l
- In these cases:
a. Use isotonic F-75 or low osmolar cereal-based
F-75
b. Introduce F-100 gradually

Possible Causes of Low Weight Gain During Treatment
• Inadequate feeding
• Specific nutrient deficiencies
• Untreated infection
• HIV/AIDS
• Psychological problems

At Discharge
1. Give instructions for feeding at home:
a. What feed?
b. How much?
c. How often?
2. Medications and Supplements
a. Multivitamins
b. Folic acid
c. Take the child for Vitamin A every 6 months
d. Others: HEPS, oil
3. Pre-HAART results: come with father. If already on
HAART, counsel on adherence

At Discharge
4. Danger signs means bring the child for immediate care:
a. Not able to drink or breastfeed
b. Stops feeding
c. Diarrhoea of more than 1 day
d. Blood stool
e. Swelling in feet, hands, legs, or arms
f. Fever
g. Convulsions (fits)
h. Fast breathing
5. Come for scheduled follow-up
6. Tick immunizations given and emphasize that the child
should be given the remaining ones
7. Give recommendations for feeding during sickness and
healthy

Thanks!

Management of SAM.pdf

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