This document discusses the assessment and management of severe acute malnutrition in children. It defines different types of severe malnutrition including marasmus, kwashiorkor, and marasmus-kwashiorkor. Common complications are described such as hypoglycemia, hypothermia, dehydration, shock, anemia, eye complications, abdominal distension, and dermatosis. The management of a child with severe acute malnutrition involves treating any complications, feeding the child formulated foods to gradually rehabilitate them, and providing routine medicines and supplements.

1. Sever Acute Malnutrition
Ayichew Alemu (PCHN)
1

2. Learning objectives
Discuss assessment of child with severely acute malnutrition
State management options of child with sever acute malnutrition
Identify complications of sever acute malnutrition and
management
Discuss how to discharge child with sever acute malnutrition
Explain prevention methods sever acute malnutrition
2

3. Severe acute malnutrition(PEM)
One of most common causes of morbidity and mortality among
children under the age of 5 years worldwide.
Needs case management in hospitals and follow-up care
Both medical and social problems be recognized and corrected.
3

4. Severe acute malnutrition(PEM)
Marasmus (non-edematous) believed to result primarily from
inadequate energy intake .
 Kwashiorkor (edematous ) was believed to result primarily from
inadequate protein intake.
Marasmic –kwashiorkor: has features of both disorders
(wasting(upper body) and edema(lower
4

5. Marasmus(non Edematous )
Wasting of muscle mass and
the depletion of body fat
stores.
 Low weight-for-
height/length
 Small MUAC,
wearing “baggy pants”.
5

6. Kwashiorkor(edematous )
Pitting edema in the lower extremities and peri orbitally
Hepatomegaly
Distended abdomen
Loss of hair color and easily plucked
Marasmus –kwashiorkor
Both edema on lower extremity and wasting upper on
extremity
6

7. Edema
Seen in the lower legs ,feet and arms.
 In severe cases it may also be seen in the upper limbs
and face.
Grasp both feet so that they rest in your hand with
your thumbs on top of the feet.
Edema if a pit (dent) remains in both feet when you
lift your thumbs.
Sign of severe malnutrition, edema must appear in
both feet.
7

8. Hypoalbuminemia(kwashiorkor)
Movement and distribution of water between the
plasma and tissue spaces of all tissues is physically
regulated by the balance of hydrostatic and oncotic
pressures across capillary blood vessel walls.
8

9. Edema…
Grade +
 Bilateral pitting
oedema in both
feet.(mild)
9
Grade ++
Both feet plus the
lower legs, hands
lower arms are
swollen.
(moderate).
 Grade +++
Generalized,
including both
feet, legs, arms,
hands
and face.(sever)

10. Admission criteria age 6 to 59 months for complicated
severe acute malnutrition (SAM)
10
1. Generalized bilateral pitting edema grade (+++)
2. Any grade of bilateral pitting edema combined with
sever wasting(muac<11.5cm or wfh<-3z score, less than 70
% of median )
3. Bilateral pitting edema grade(+,++) or sever
wasting(muac<11.5cm or wfh<-3z score, less than
70 % of median ) and any one of the medical
complications

11. Uncomplicated SAM treated in OTP
Bilateral pitting edema grade(+ or ++) or MUAC <11.5cm or
WFH <-3z score and appetite test passed ,clinically well and alert.
Moderate acute malnutrition
MUAC >=11.5cm to <12.5cm or WFH>= -3z score to < -2z score
And clinically well and alert ,no bilateral pitting edema.
No acute malnutrition
MUAC >=12.5cm or WFH >= -2z score and no bilateral pitting
edema so counsel on appropriate feeding practice
11

12. Pathophysiology of severe acute malnutrition
Systems of the body begin to “shut down” with severe malnutrition.
Systems slow down and do less in order to allow survival on
limited calories.
Slowing down is known as reductive adaptation.
12

13. Pathophysiology of severe acute malnutrition
Reductive adaptation affects treatment of the child in a
number of ways.
Presume and treat infection
Nearly all children with severe malnutrition have bacterial
infections.
13

14. Pathophysiology of severe acute malnutrition
However, as a result of reductive adaptation, the usual signs of
infection may not be apparent, because the body does not use its
limited energy to respond in the usual ways, such as inflammation
or fever.
Assume that infection is present and treat all severe malnutrition
admissions with broad spectrum antibiotics.
14

15. Pathophysiology of severe acute malnutrition
Provide potassium and restrict sodium
Normally the body uses a lot of energy maintaining the appropriate
balance of potassium inside the cells and sodium outside the cells.
This balance is critical to maintaining the correct distribution of
water inside the cells, around the cells and in the blood.
In reductive adaptation, the “pump” that usually controls the
balance of potassium and sodium runs slower.
15

16. Pathophysiology of severe acute malnutrition
As a result, the level of sodium in the cells rises and the
potassium leak out of the cells and is lost ( in urine or
stools).
Commercially prepared F-75 and F -100 have enough
potassium and magnesium and there is no need to
supplement.
16

17. Pathophysiology of severe acute malnutrition
If a child has diarrhea, a special rehydration solution called
Resomal should be used instead of regular WHO ORS.
 RESOMAL has less sodium and more potassium than regular
WHO ORS.
Resomal = rehydration solution for malnutrition special prepared
for malnourished child
17

18. Important things not to do during management of child
with SAM in inpatient
Do not give diuretics to treat edema.
Proper feeding of formulas only
Do not give IV fluids routinely.
Only give iv fluids to children with signs of shock(SAM
with shock).
.
18

19. Management of children with SAM in
stabilization center (in-patient care)
Treatment Approach
Treatment of complications
Routine medicines
Dietary Treatment
o Phase I (1 – 2 days)
o Transition phase (3- 7 days)
o Phase II (2 – 6 weeks)
19

20. Management of children with SAM in
stabilization center (in-patient care)
Child with severe acute malnutrition should be separated from
infectious children(phase 1,transition ,phase2)
Initial treatment(stabilization phase, phase 1)
Life-threatening medical complications identified & treated
Formula feeding F-75
Folic acid and vitamin A give
20

21. Complications management
Hypoglycemia
Blood glucose level less than <54 mg/dl (< 3 mmol/L).
Lethargy
loss of consciousness.
Eye-lid retraction (due to overactive sympathetic
nervous system, thus a child sleep with eyes slightly
open).
21

22. Treatment of hypoglycemia
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Preparation of 50 ml of D10%,P/O or NG

23. Treatment of hypoglycemia
 D10% is not available on its own so we prepare from
Higher concentration glucose and lower concentration glucose
by mixing
85% (0.85*50ml )D5% and 15% (0.15*50ml) D40% or
75% distilled water or sterile water and 25% D40%
20% D50% and 80% distilled water
12% D50% and 88% D5%
23

24. Treatment of hypoglycemia
If the child is lethargic, unconscious, or convulsing or no response
give 5 ml/kg body weight of sterile 10% glucose by IV, followed by
50 ml of 10% glucose or sucrose by NG tube.
After 2 hours and check the child’s blood glucose again.
 If blood glucose is now 54 mg/dl (3mmol/l) or higher, change to 2-
hourly feeds (12 feeds per day) of F-75.
If still low, make sure antibiotics and feed F-75 . 24

25. Hypothermia
Highly susceptible to hypothermia.
If axillary temperature is below 35oc.
Skin to skin contact (technique kangaroo)
child’s head covered
Give warm fluid to the mother.
Use a heater or incandescent lamp with caution.
Monitor temperature every 30 minutes
Do not use hot water bottles due to danger of burning fragile skin.
All hypothermic children are more likely to have hypoglycemia and
infection as well. 25

26. 26

27. Dehydration
Hx of recent fluid loss (watery diarrhea)
Clear history of a recent change in the child’s appearance
Sunken eye then the mother must say that the eyes have
changed to become sunken since the diarrhea or vomiting
started
If the child with edema has definite watery diarrhea and is
deteriorating clinically (excessive weight loss), the child is
27

28. Dehydration
History of recent fluid loss (watery diarrhea)
Clear history of a recent change in the child’s appearance.
Sunken eye then the mother must say that the eyes have changed to
become sunken since the diarrhea or vomiting started.
If the child with edema has definite watery diarrhea and is
deteriorating clinically (excessive weight loss), the child is
dehydrated.
28

29. General Signs of Dehydration in SAM
Lethargy
Restless, irritable
Sunken eyes
Thirsty
Dry mouth and tong
Skin pinch goes back slowly
29

30. Dehydration…
Give RESOMAL po/ng tube as rehydration solution for
malnutrition.
Resomal contains less sodium, more sugar, and more
potassium
Resomal is available commercially in some places, but it
may also be prepared from standard ORS and some
additional ingredients.
30

31. Preparation of Resomal
Both are oral rehydration solutions
One sachet of 42g of Resomal itself need to be diluted by 1 litter of
water.
We can prepare Resomal from ORS by mixing 1 packet of ORS
with 2 litter of water plus 50g sugar plus 3 tab kcl or 600mg.
Normally 1 sachet of ORS is diluted by 1 litter of water.
Any resomal or who ors diluted should be wait for , only 24 hrs ,
discard after that time

32. Preparation of Resomal…

33. Resomal dose and duration
Prevention of dehydration
• Child under 2 years: 50 to 100 ml after each loose stool as long as
diarrhea persists
• Child over 2 years: 100 to 200 ml after each loose stool as long as
diarrhea persists
Treatment of dehydration(with out signs of shock)
• 5 ml/kg every 30 minutes over the first 2 hours, then 5 to 10
ml/kg/hour for the next 4 to 10 hours, until dehydration is
corrected.

34. For a child who has dehydration with sign of shock, give IV
fluids(SAM with shock)
Signs of shock
34

35. Signs of improving hydration status
Less thirsty
Less lethargic
Slowing of rapid respiratory and pulse rates
Passing urine
 Gaining weight with clinical improvement
If a child has three or more of the above signs of
improving hydration status, stop giving resomal.
35

36. Signs of overhydration
Stop Resomal if any of the following signs appear:
Child’s weight exceeds the target weight(add 5% weight loss to
current weight to get target rehydration weight)
Increased respiratory rate by 5 breaths and pulse rate by 25 beats per
minute. (Both must increase to consider it a problem)
Jugular veins engorged
Sudden increase in liver size and tenderness
Increasing edema (e.g., Puffy eyelids).
 Increasing weight with clinical deterioration
36

37. Rehydration
37

38. Shock
Hypoperfusion
Cold hands plus either:
Slow capillary refill* (longer than 3 seconds), or
weak, fast** or absent radial or femoral pulses
Press the nail of the thumb or big toe for 2 seconds to produce
blanching of the nail bed.
Count the seconds from release until return of the pink color.
If it takes longer than 3 seconds, capillary
refill is slow.
38

39. Shock treatment
Give oxygen (for infants 0.5 to 1 lit per minutes and for older
children 1 to 2 lit per minute).
Give sterile 10% glucose 5 ml/kg by IV
 keep the child warm.
Infuse iv fluid at 15ml/kg over 1 hour.
Ringer’s lactate solution with 5% glucose
0.45 % normal saline with 5% glucose
39

40. Shock treatment
If no improvement with IV fluids, give blood transfusion
Transfuse whole fresh blood at 10 ml/kg slowly over 3
hours.
If there are signs of heart failure, give packed
cells(remove plasma ) instead of whole blood as these
have a smaller volume
40

41. Severe anemia
Hgb< 4 g/dl (or hematocrit <12%).
If it is not possible to test hemoglobin , anemia based on
paleness of gums, lips, palm and inner eyelids.
Mild or moderate anemia is very common in severely
malnourished children and should be treated later with iron
41

42. Anemia..
Give blood transfusion in the frst 48 hours if:
Hgb is < 4 g/dl, (hct is < 12 %), or
Hgb 4 to 6 g/dl (hct 12 to 18%) and respiratory distress
If there are no signs of congestive heart failure, transfuse whole
fresh blood at 10 ml/kg slowly over 3 hours.
If there are signs of heart failure, give 5-7 ml/kg packed
cells(plasma removed) over 3 hours instead of whole blood.
42

43. Anemia..
43

44. Eye complications
Bitots’ spots – superficial foamy white spots on the
sclera(white part of the eye) associated with vitamin A
deficiency.
Corneal clouding, ulceration
44

45. Eye care
Give vitamin A and atropine eye drops immediately for corneal
ulceration and clouding
Vitamin A.
45

46. Infection
46

47. Abdominal distension
 Occur because of reduced gastrointestinal motility due to
electrolyte disturbance (hypokalemia).
Give a single IM injection of magnesium sulphate (2ml of 50%
solution).
Pass an ng-tube and introducing 50ml of isotonic solution clear
fluid (5% dextrose or 10% sucrose into the stomach and then gently
aspirating all the fluid back again.
47

48. Dermatosis
 Common in children who have edema than in wasted
children.
Extent of dermatosis can be
+ (mild): discoloration or a few rough patches of skin
 + + (Moderate): multiple patches on arms and/or legs
+ + + (Severe): flaking skin, raw skin, fissures (openings in
the skin)
48

49. Dermatosis
Rx
• Use regular soap for bathing if the child does have mild or moderate
dermatosis.
Child with severe (+++) dermatosis
• Bathe for 10-15 min/day in 1% potassium permanganate solution.
• Sponge the solution onto affected areas lesions, helps to prevent
loss of serum and inhibits infection.
• If potassium permanganate solution is not available, affected areas
may be dabbed with gentian violet.
49

50. Routine medicines
Vitamin A
On admission (day 1), give vitamin A for all children except those
with oedema(can not be absorbed because of fluid accumulation, it is
fat soluble) or those who received vitamin A in the past 6 months.
Give vitamin A to every patient on the day of discharge care.
Folic Acid
On the day of admission, one single dose of folic acid (5mg for 6
moths to 5 years and 2.5mg stat for infants) can be given to children
with clinical signs of anemia.
Antibiotics
Should be given to every patient with SAM 50

51. Feeding
Feeding formulas
F-75, F-100 formulas and RUTF
F-75 is the “starter” formula used during stabilization phase(phase
1), and continuing for 2-7 days until the child is stabilized.
Low protein and calorie
F-75 contains 75 kcal and 0.9 g protein per 100 ml.
F-100 contains more calories and protein: 100 kcal and 2.9 g
protein per 100 ml
51

52. Formula milk

53. Formula milk…
53

54. 54

55. Feeding children 6– 59 months
Phase 1(stabilization phase)
Feed the child with F-75
 F-75 every 2 hours (12 feeds in 24 hours, including through the
night).
Offered a total of 130 ml/kg/day give the child 100 kcal/kg/day and
1 - 1.5 g protein/kg/day.
If the child has severe (+++) edema, his/her weight will not be a true
weight; the child’s weight may be 30% higher due to excess fluid.
55

56. Feeding…
To compensate, the child with severe edema should be
given only 100 ml/kg/day of F-75.
F-75 can be given by orally or ng tube
56

57. Feeding…
Nasogastric (NG) feeding
Child is very weak,
Mouth ulcers
Cleft lip/palate
Pneumonia
Unconscious
Minimum acceptable amount for the child to take is 80 % of the
amount offered.
Do not plunge f-75 through the ng tube; let it drip in, or use gentle
pressure.
If the child develops a hard-distended abdomen with very little
bowel sound, give 2 ml of a 50% solution of magnesium sulphate
IM.
57

58. Feeding…
Transition phase
Feeding the child in transition with F-100
Return of appetite (easily finishes the F-75 feeds)
Reduced edema or minimal edema (++ or less)
No ng tube
No iv line
Smile at this stage
Transitioned from F-75 to F-100 or RUTF .
58

59. Feeding…
Rehabilitation(phase 2)
Feed freely with F-100 or RUTF
Give iron and deworming's
Good appetite: takes all the F-100 prescribed for the
transition phase .
Edema reduced to moderate (++) or mild (+).
Medical complications are resolved
Clinically well and alert.
59

60. IRON
Giving iron in phase I can lead to “free iron” in the body.
Free iron is highly reactive and promotes the formation of
free radicals, which may engage in uncontrolled chemical
reactions with damaging effects.
Free iron promotes bacterial growth and can make some
infections worse.
 Iron should be given at phase 2
60

61.  Iron supplement 3 mg/kg/day into two divided doses until
discharge (if in tablet form, crush the tablet and dilute it in
the milk) at phase two or rehabilitation phase
61

62.  Deworming tablets albendazole or mebendazole is given
at the start of rehabilitation phase(phase2) for children
greater than 2 year that will remain as inpatient
62

63. Admission criteria below 6 months of age for
severe acute malnutrition (SAM)
63
 Any grade of Bilateral pitting(+,++,+++)
edema
or
 WFL < -3SD( less than 70% of median ,Visible Severe Wasting if
it is difficult to determine W/L )
 With or with out Medical complications

64. Possible cause of acute malnutrition in age below 6
months
1.Lack of breast feeding.
2. Partial breast feeding
3. Inadequate and unsafe artificial breast feeding
4. Mother dead or absent
5. Mother is malnourished , traumatized, ill , and or unable to
respond normally to her infant’s needs.
6. Infant has a disability which affect his ability to suckle or swallow
and/or a developmental problems which affect the infant’s feeding.
64

65. Feeding infants less than 6 months
Malnourished infants less than 6 months should always
be treated in inpatient facilities.
Management of complication is the same as children 6-
59
RUTF is not suitable for them
65

66. Children younger than 6
months with SAM
Children 6-59 months with
SAM
Should be treated only in the
inpatient care
Can be treated in the
inpatient care or outpatient
care
Receiving usually F100 Diluted
or if edema present F75
until edema resolution ,
NEVER shall be given RUTF
Can be given F75,F100 or
RUTF
MUAC is not considered in
admission
MUAC criteria for admission
Breast feeding is integral part
of therapeutic care for SAM
infants
Breast feeding is
complementary to
therapeutic care
66

67. Feeding infants less than 6 months…
With potential care giver able to breast feed the infants, the objective
is to gradually withdraw the F100 diluted and depend more on the
care giver breast milk.
With no care giver or no prospect of being breast fed ,the objective
is to gradually increase the F100 diluted until the child reach an age
when we can introduce the complementary food or available ,safe
,affordable alternative feeding.
With potential
care giver able to 67

68. Feeding infants less than 6 months
Infants without edema should be supplemented with expressed
breast milk, or, if this is not possible give diluted F-100.
Infants with edema should be supplemented with expressed breast
milk or, if this not possible, F-75 until the edema has resolved.
68

69. Feeding infants less than 6 months…
F-100-diluted is prepared by adding 30% of the water which was
added to prepare the full strength F-100
Mother holds a cup with the F-100 diluted.
 End of a ng tube (size nº8) is put in the cup, and the tip of the tube
on the breast, at the nipple.
Infant is offered the breast in the usual way.
 Cup is placed 5 – 10 cm below the level of the nipple for easy
suckling.
69

70. Feeding infants less than 6 months…
Transition
Decrease supplementary milk feeds by half when the child has
gained at least 20g per day for 3 consecutive days and completely
stop the milk when the child maintains a 10g per day weight gain and
continue on breast milk alone
70

71. Rehabilitation
Child does not receive any more milk supplement and is gaining
weight by being exclusively breastfed.
Breastfeeding must be at least 20 minutes.
Continue to encourage the mother.
71

72. Care for the mothers
Assess the mother’s nutritional status using MUAC, if < 23.0 cm,
admit in the Targeted Supplementary Feeding Program .
Explain the treatment and discourage self-criticism for the lack of
breast milk.
Mother should be counseled strongly on exclusive breast feeding.
72

73. Discharge in less than 6 months
Gaining weight on exclusive breastfeeding (i.e., more than 5
g/kg/day for at least 3 successive days).
No bilateral pitting oedema.
Clinically well and alert.
 Infant has been checked for immunization
Mothers or caregivers have been linked with community-based
follow-up and support.
73

74. Discharge criteria
Children age 6-59 months
No bilateral pitting edema for 2 weeks
 And MUAC ≥ 12.5 cm or WFH/WFL ≥ -2 z-score
And clinically well and alert
74

75. Play, emotional well being, stimulation
 Reduce the risk of permanent mental and emotional
damage.
Create a friendly supportive atmosphere.
Mother should be encouraged to feed, hold, comfort and
play with her child as much as possible.
Safe and cheap toys should be available in the child’s
room, as well as the play area.
75

76. Prevention of malnutrition
Growth monitoring
Exclusive breastfeeding and appropriate weaning
Immunization and treatment of diseases
Education or awareness creation about childhood nutrition
Family spacing/planing
Food supplementation
76

77. References
Nelson text book of pediatrics 21th edition
Up to date 21
Ethiopian guideline for SAM, 3rd edition
,2019.
Pediatrics and child health lecture note for
health science students, jimma university,
2006.
77

78. Thank you !
78