2. SAM & MAM
•Define
•describe the etio-pathogenesis,
•classify including WHO classification,
• clinical features, complication
•management
3. Malnutrition
Malnutrition refers to deficiencies, excesses or imbalances in a person's
intake of energyand/ornutrients (WHO).
malnutrition = undernutrition / overweight and obesity
often the terms malnutrition and protein energy malnutrition (PEM)
are used interchangeably with undernutrition
4. WHO Classification
The assessment of nutritional status is done according
to weight-for-height (or length), height (or
length)-for-age and presence of edema.
The WHO recommends the use of Z scores or
standard deviation scores for evaluating
anthropometric data, so as to accurately classify
individuals with indices
5. Growth Charts
Growth Standards
Growth standards represent norms of growth and can be
presented in tabular or graphical manner. These are obtained by either
cross-sectional or longitudinal studies in large populations.
Growth Charts
If the growth measurements are recorded in a child over a period of time
and are plotted on a graph, the deviation in the growth profile of the child
from the normal pattern of growth for that age can be easily interpreted.
This is asatisfactory tool to diagnose deviation of growth from normal.
6. Growth Charts
USA - Based on data obtained from US children, the National Center
for Health Statistics (NCHS) developed growth charts in 1977. In the
year 2000, revised growth charts provided by CDC
WHO - WHO conducted the 'Multicentre Growth Reference Study'
(MGRS) and published new growth charts for infants and children up to
5 yr of age in 2006. The MGRS was a community-based, multi-country
project conducted in Brazil, Ghana, India, Norway, Oman and the
United States.
7. Percentiles
normal range of variation= between 3rd and 97th percentile
curves.
Percentile curves represent frequency distributioncurves.
For example, 25th percentile for height in a population would mean
that height of 75% of individuals is above and 24% are below this value.
One standard deviation (SD) above the mean coincides with 84th percentile
curve.
Likewise 16th percentile curve represents one SD below the mean.
Values between third and 97th percentile curve correspond to mean ±2 SD
8. WHO Z scores (standard deviation scores)
The WHO recommends the use of Z scores or standard
deviation scores (SOS) for evaluating anthropometric data,
so as to accurately classifyindividuals with indices below the extreme
percentiles
The SD score is defined as the deviation of the value for an individual
from the median value of the reference population, divided by the
standard deviation of the reference population.
10. Z-scores
Population~ a typical Gaussian (normal) distribution,
Individual value expressed ~ how many SDs it lies above or below
the mean. This is the Z-score for that observation.
weight is at 2 SD below the mean = -2 Z. If the value lies above the
mean, Z-score is positive, lies below the mean, Z-score is negative.
Z score allows comparison of different observations between
individuals. For example, one can compare the height and weight of
two individuals by obtaining the respective Z scores.
11. Standard Deviation
A standard deviation (or σ) is a measure of how dispersed the data
is in relation to the mean.
Low standard deviation means data are clustered around the
mean, and high standard deviation indicates data are more spread
out.
A standard deviation close to zero indicates that data points are
close to the mean, whereas a high or low standard deviation
indicates data points are respectively above or below the mean.
13. SD vs Z score
• Standard deviation defines the
line along which a particular
data point lies.
• Standard deviation is essentially
a reflection of the amount of
variability within a given data set
• Z-score indicates how much a
given value differs from the
standard deviation.
• The Z-score, or standard score, is
the number of standard
deviations a given data point lies
above or below mean.
• z = (x – μ) / σ
18. Midupper arm circumference
It increases rapidly in the first
year (11-16 cm). found to be
relatively stable between the ages
1 and 5 yr at a value of between
16 and 17 cm.
Any value below 13.5 cm is
abnormal and suggestive of
malnutrition
WHO recommends age reference
data where possible.
19. Define SAM (WHO and UNICEF)
Severe acute malnutrition 6-59 months of age
any of the following three criteria:
i. weight for height below -3z scores of the median WHO
growth standards or
ii. Presence of nutritional edema; or
iii. Mid upper arm circumference (MUAC) below 11.5 cm.
Ina child below 6 months of age, the MUAC is not used as a criterion
20. Define Moderate acute malnutrition
Weight-for-height
< −2 but > −3 z scores of the median WHO growth
standards
or
Mid-upper-arm circumference
11.5 cm to 12.5 cm
22. malnutrition etiology
inadequate food supply caused by socioeconomic, political, and
environmental factors, and it is most commonly seen in low- and middle-
income countries
Responsible factors include
household food insecurity,
poverty,
poor nutrition of pregnant women,
intrauterine growth restriction, low birth weight, poor breastfeedingand
inadequate complementary feeding,
frequent infectious illnesses, poor quality of water, hygiene,
24. Three immediate causes of undernutrition
Low dietary intake: Delayed complementary feeding and
inadequate intake of food means less nutrients available
for growth
Low birthweight: Infants born small, often remain small
Infection: Diarrhea, pneumonia and other infections
consume energy and hamper growth. Diarrhea causes
nutrition loss in stool
25. Pathophysiology - physiologic adaptations
Inadequate energy intake physiologic adaptations
physiologic adaptations
growth restriction,
loss of fat, muscle, and visceral mass,
reduced basal metabolic rate,
reduced total energy expenditure
26. Pathophysiology biochemical changes
metabolic, hormonal,and glucoregulatory mechanisms.
The main hormones- Reduced tri-iodothyroxine (T3), insulin, insulin-like growth
factor-1 (IGF-1) and raised levels of GH and cortisol
Glucose levels are often initially low, with depletion of glycogen stores. In the
early phase there is rapid gluconeogenesis with resultant loss of skeletal muscle
caused by use of amino acids, pyruvate and lactate. Later there is the protein
conservation phase, with fat mobilization leading to lipolysis and ketogenesis .
Major electrolyte changes including sodium retention and intracellular potassium
depletion can beexplained by decreased activity of the glycoside-sensitive energy-
dependent sodium pump to increased permeability of cell membranes in
kwashiorkor
27. Pathophysiology - immune system
Cellular immunity is affected because of atrophy of the thymus,
lymph nodes, and tonsils. There are reduced cluster of
differentiation(CD) 4 with normal CD8-T lymphocytes, loss of
delayed hypersensitivity, impaired phagocytosis, and reduced
secretory immunoglobulin A.
Consequently, the susceptibility to invasive infection (urinary,
gastrointestinal infections, septicemia, etc. is increased
28. C/f -Marasmus- characterized marked
wasting of fat and muscle
The main sign is severe wasting (skin and bones)
The loss fat in body Axillary pad, buccal pad of fat creates the
aged or wrinkled appearance
Baggy pants appearance refers to loose skin of the buttocks
hanging down
alert , no edema
29. C/f Kwashiorkor main sign pitting edema
starting in feet - legs advanced hands face
Edema 5-20% of the body weight
Muscle wasting - weak, hypotonic and unable to stand or walk
Skin changes. increased pigmentation, desquamation confluent
resembling flaky paint and dyspigmentation.
Pigmentation typically on buttocks, perineum and upper thigh.
Petechiae may be seen over abdomen.
Outer layers of skin may peel off and ulceration may occur. The
lesions may sometimes resemble burns
30. C/f Kwashiorkor
Hair dyspigmentation, loss of curls and sparseness . Hairs also lose
easily pluckable. A flag sign which is the alternate bands of
hypopigmented and normally pigmented hair pattern
Mental changes.apathy no signs of hunger and it is difficult to feed
them
Gastrointestinal system. Anorexia vomiting is the rule.
Anemia mild greater severity
Mucous membrane lesions. Smooth tongue, cheilosis and angular
stomatitis are common.
31. MANAGEMENT OF SAM
Assessment
History -
breastfeeding, diarrhea (duration, watery/bloody), vomiting,
loss of appetite, tuberculosis, HIV
Examination prognostic significance
i. Signs of dehydration ii. Shock (cold hands, slow capillary
refill, weak and rapid pulse) iii. Severe palmar pallor iv. Eye
signs of vitamin A deficiency
32. The general treatment
• The initial stabilization phase
focuses on restoring homeostasis and treating medical
complications and usually takes 2-7 days of inpatient
treatment.
• The rehabilitation phase
focuses on rebuilding wasted tissues and may take
several weeks
34. Step 1 Hypoglycemia
Blood glucose level <54 mg/dl or 3 mmol/1
If blood glucose cannot be measured, assume hypoglycemia
Treatment
Asymptomatic hypoglycemia Give 50 ml of 10% glucose or sucrose
solution orally or by nasogastric tube followed by first feed
Symptomatic hypoglycemia Give 10% dextrose IV 5 ml/kg
Prevention Feed with starter F-75 every 2 hourly day and night Feed 2
hourly
starting immediately Prevent hypothermia, managed infection
35. Step 2 Hypothermia
Rectal <35.5C or 95.5F/axillary< 35C or 95F
Treatment
Clothe the child with warm clothes; ensure that the head is also
covered with a scarf or cap Provide heat using overhead warmer, skin
contact or heat convector as this may lead to
disequilibrium
Prevention
Place the child's bed in Always keep the child
; ensure that head is also covered well May place the child in
contact with the mother's bare chest or abdomen (skin-to-skin)
36. Step 3 Dehydration -Difficult to assess
dehydration status accurately
Assume that all severely malnourished children with
have some dehydration can coexist
with edema
Treatment - Use reduced osmolarity ORS with potassium supplements
for rehydration and maintenance Amount depends upon how much
the child wants, volume of stool loss, and whether the child is vomiting
Initiate feeding within two to three hours; use F-75 formula on
alternate hours along with reduced osmolarity ORS Be alert for signs of
overhydration Prevention Give reduced osmolarity ORS at 5-10 ml/kg
after each watery stool, to replace stool lossescontinue breastfeeding,
Initiate refeeding with starter F-75 formula
37. ReSoMal
World Health Organization (WHO) guidelines for the management of
dehydration recommend the use of oral rehydration with ReSoMal (an
oral rehydration solution (ORS) for SAM), which has lower sodium
(45mmols/l) and higher potassium (40mmols/l) content than old WHO
ORS.
ReSoMal PO/NG – 5ml/kg for first 2 hours
Then 5–10ml/kg/hr, alternating F75 and ReSoMal for 4–10 hours
39. Step 4 Electrolytes
Give supplemental potassium at 3-4 mEq/kg/day for at least 2
weeks
On day l, give 50% magnesium sulphate (equivalent to 4
mEq/ml) IM once (0.3 ml/kg; maximum of 2ml). Thereafter,
give extra magnesium (0.8-1.2 mEq/kg daily)
Excess body sodium exists even though the plasma sodium
may be low; decrease salt in diet
40. Step 5 Infection- assume serious
bloodstream by gram-negative bacteria
Treatment- parenteral ampicillin 50 mg/kg/dose 6 hourly for at least 2
days followed by oral amoxicillin 15 mg/kg 8 hourly for 5 days and
gentamicin 7.5 mg/kg or arnikacin 15-20 mg/kg IM or IV once daily for
7 days .If no improvement occurs within 48 hr, change to IV cefotaxime
(100-150 mg/kg/day 6-8 hourly) or ceftriaxone (50-75 mg/kg/day 12
hourly)
If other specific infections are identified, give appropriate antibiotics
Prevention Follow standard hand hygiene
Give measles vaccine if the child is >6 mo and not immunized, or if the
child is >9 mo and had been vaccinated before the age of 9 months
41. Step 6 Micronutrients
On day 1, give immediately vitamin A orally (if age >1
yr give 2 lakh IU; age 6-12 mo give 1 lakh IU; age 0-5
mo give 50,000 IU)
Folic acid 1 mg/day (give 5 mg on day 1)
Zinc 2 mg/kg/day
Copper 0.2-0.3 mg/kg/day
Iron 3 mg/kg/day, once gaining weight
42. Emergency treatment of severe anemia
If a severely
malnourished child has severe anemia with a hemoglobin
less than 4 g/dl or between 4 and 6 g/dl but with
respiratory distress, a blood transfusion should be given
with whole blood 10 ml/kg bodyweight slowly over 3 hr.
Furosemide should be given at the start of the transfusion
43. Step 7 Initiate feeding Start as soon as
possible as frequent small feeds- oral /NG
One should begin with 80 kcal/kg/day and gradually increase to
100 kcal/kg/day. To fulfill this, start with 2 hourly feeds of
11 ml/kg/feed. Night feeds.Total fluid recommended is 130
ml/kg/day; reduce to 100 ml/kg/day if there is severe
edema. Start with F-75 starter feeds every 2 hourly. The volumeand
calorie increased gradually decreasing the frequency . If persistent
diarrhea, give a cereal based low lactose F-75 diet as starter diet If
diarrhea continues on low lactose diets give, F
44. F-75
The suggested starter formulae are usually milk based,
such as starter F-75 (with 75 kcal/100 ml and 0.9
g of protein/100 ml),
; lactose not more than 2-3 g/kg/day;
appropriate renal solute load (urinary osmolarity <600
mOsm/1)
adequate bioavailability ofmicronutrients and low viscosity
46. Step 8 Catch-up growth
Once appetite returns in 2-3 days, encourage higher intakesIncrease
volume offered at each feed and decrease the frequency of feeds to 6
feeds per day Make a gradual transition from F-75 to F-100 diet
Increase calories to 150-200 kcal/kg/day, and
proteins to 4-6 g/kg/day
a higher calorie density (100 kcal/100 ml) and
have at least 2.5-3.0 g protein/100 ml.
Add complementary foods as soon as possible to prepare the child for
home foods at discharge
48. Monitoring progress during treatment
good weight gain of>10 g/kg/day, the same treatment should
becontinued tillrecovery.
moderate weightgain of 5-10 g/kg/day; food intake should be checked
and screened for systemic infection.
poor weight gain of <5 g/kg/day possible causes like
inadequate feeding,
untreated infection,
psychological problems and
coexisting infections like tuberculosis and HIV
49. Step 9: Sensory Stimulation and
Emotional Support
A cheerful, stimulating environment
Age appropriate structured play therapyfor at least 15-
30 min/day
Age appropriate physical activity as soon as the child is well enough
Tender loving care
50. Step10 Prepare for followup
Primary failure to respond is indicated by:
Failure to regain appetite by day 4
Failure to start losing edema by day 4
Presence of edema on day 10
Failure to gain at least 5 g/kg/day-by-day 10
Secondary failure to respond is indicated by:
Failure to gain at least 5 g/kg/day for consecutive 3 days during the
rehabilitation phase
51. Criteria for discharge and failure of response
Criteria for discharge and failure of response Ideally
6-8 weeks of hospitalization is required for complete
recovery. recovered when his has 15% weight gain,
and he has no edema.
The child may be discharged earlier if it is certain that
the final stages of recovery will not be jeopardized by
early discharge.
52. ready for discharge
• Is alert and active, eating at least 120-130 kcal/kg/day
with a consistent weight gain (of at least 5 g/kg/day
for 3 consecutive days) on exclusive oral feeding
• Is receiving adequate micronutrients
• Is free from infection
• Has completed immunization appropriate for age
• The caretaker has been sensitized to home care.
53. Criteria for discharge before recovery
Domiciliarycare should only be considered if the child:
• Is aged >12 months
• Has a good appetite with satisfactory weight gain
• Has completed antibiotic treatment
• Has taken 2 weeks of potassium/magnesium/mineral/
vitamin supplement (or continuing supplementation
at home is possible).
54. Care at home
For children being rehabilitated at home,
One should aim at achieving at least
150 kcal/kg/day and adequate protein (at least 4 g/kg/
day). This would require feeding the child at least 5 times
per day with foods that contain approximately 100 kcal and
2-3 g protein per 100 g of food. A practical approach should
be taken using simple modifications of usual staple home
55. Complication
Pseudotumor cerebri Overenthusiastic nutritional correction transient
rise of intracranial tension. The phenomenon is benign and self limiting
Nutritional recovery syndrome high quantity of proteins during the
course of rehabilitation an increase in the estrogen level and by a
variety of trophic hormones produced by the recovering pituitary
glandgynecomastia, hepatomegaly,splenomegaly ascites, prominent
thoracoabdominal venous network parotid swelling,
Encephalitis like syndromes kwashiorkor, within 3-4 day, self limiting.
Occasionally, fatal outcome- parkinsonian and myoclonus may appear
several days after starting the dietary rehabilitation. much protein diet.
56. Treatment of MAM in some country
In the province where there is OPD or community center receive
Ready to use therapeutic food (RUTF) as supplementary food until
they reach discharge criteria.
Weekly or by weekly they attend and receive RUTF
The daily amount of RUTF to be consumed varies according to body
weight as follows: 3-4.9 kg: 105-130 g; 5-6.9 kg: 200-260 g; 7-9.9 kg:
260-400 g and 10-14.9 kg: 400-460 g. This amount is to be
given along with plenty of water in 2-3 hourly feeds
children aged 6-59 months
