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Severe Acute Malnutrition

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Severe Acute Malnutrition

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Malnutrition is a functional problem and has been defined as a state resulting from lack of uptake or intake of nutrition leading to altered body composition, decreased body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease.

Malnutrition is a functional problem and has been defined as a state resulting from lack of uptake or intake of nutrition leading to altered body composition, decreased body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease.

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Severe Acute Malnutrition

  1. 1. Presented By- BIBHU PRASAD SAHU RUPSY DIYA SAHA HITESH KHATUA ARPIT PATEL PRITHVI SENA JAS
  2. 2. 1. Definition 2. Etiology 3. Pathogenesis/ Pathophysiology 4. Complications 5. Principles of management 6. Summary
  3. 3.  Hunger– Physiological state when food is not able to meet energy needs.  Malnutrition– Malnutrition refers to deficiencies or excesses or imbalances intake of energy and/or nutrients in a person . It could be under-nutrition or over-nutrition(obesity) .  Undernutrition – most common form of malnutrition in developing countries.  Overnutrition(obesity)- common on developed countries
  4. 4. Fig: Undernourished and Obese
  5. 5. WHO and UNICEF defines Severe Acute Malnutrition (SAM) for children aged 6 months to 60 months as : ◆ Weight for height below -3 SD score of the median WHO growth standards. ◆ By visible severe wasting. ◆ Bipedal oedema ; and ◆ Mid upper arm circumference below 115mm.
  6. 6. • Primary - when the otherwise healthy individual's needs for protein, energy, or both are not met by an adequate diet. (most common cause worldwide) • Secondary - result of disease states that may lead to sub-optimal intake, inadequate nutrient absorption or use, and/or increased requirements because of nutrient losses or increased energy expenditure.
  7. 7.  Lack of food (famine, poverty)  Inadequate breast feeding  Wrong concepts about nutrition  Diarrhoea & malabsorption  Infections (worms, measles, T.B)
  8. 8. The “Vicious Cycle”of Undernutrition & Infection Disease: . incidence .severity .duration Appetite loss Nutrient loss Malabsorption Altered metabolism Inadequate dietary intake Weight loss Growth faltering Lowered immunity Mucosal damage F i g u re 2. T h e Synergistic cycle o f infection an d malnutrition
  9. 9. Across all organ systems !! 13
  10. 10. Infection : lung , blood, UT, GIT, skin Metabolic hypoglycemia hypocalcemia hypomagnesemia Hypothermia
  11. 11. • Severe vomiting/ intractable vomiting 4/10/2016 44
  12. 12. Hypothermia: axillary’s temperature < 35°C or rectal < 35.5°C Fever > 39°C 4/10/2016 45
  13. 13. The WHO has developed guidelines have been adapted by the Indian Academy of Pediatrics. *The general treatment involves ten steps in two phases: i. The initial Stabilization phase focuses on restoring homeostasis and treating medical complications and usually takes 2-7 days of inpatient treatment. ii. The Rehabilitation phase focuses on rebuilding wasted tissues and may take several weeks.
  14. 14. Step 1: Treat/Prevent Hypoglycemia *Blood glucose level <54 mg/dl or 3 mmol/l. *If blood glucose cannot be measured, assume hypoglycemia. *Hypoglycemia, hypothermia and infection generally occur as a triad. Treatment *Give 50 ml of 10% glucose or sucrose solution orally or by nasogastric tube followed by first feed. *Feed with starter F-75 every 2 hourly day and night Prevention *Feed 2 hourly starting immediately. *Prevent hypothermia.
  15. 15. Step 2: Treat/Prevent Hypothermia *Rectal temperature less than <35.5°C or 95.5°F or axillary temperature less than 35°C or 95°F. Treatment *Clothe the child with warm clothes. *Provide heat using overhead warmer, skin contact or heat convector. *Avoid rapid rewarming as this may lead to disequilibrium. *Feed the child immediately. Prevention *Place the child's bed in a draught free area. *Always keep the child well covered *Feed the child 2 hourly starting immediately after admission.
  16. 16. Step 3: Treat/Prevent Dehydration with Shock *All severely malnourished children with watery diarrhea have some dehydration. Treatment *Use ORS with potassium supplements. *Initiate feeding within two to three hours of starting rehydration. Prevention *Give ORS at 5-10 ml/kg after each watery stool, to replace stool losses. *If breastfed, continue breastfeeding. *Initiate refeeding with starter F-75 formula.
  17. 17. Step 4: Treat/Prevent Infection *Multiple infections are common. *Majority of bloodstream infections are due to gram- negative bacteria. Treatment *Treat with 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 once daily for 7 days. *If other specific infections are identified, give appropriate antibiotics. Prevention *Follow standard precautions like hand hygiene. *Give proper vaccination if not immunized and is of suitable age
  18. 18. Step 5: Correct Electrolyte Balance *Give supplemental potassium at 3-4 mEq/kg/ day for at least 2 weeks. *On day 1, give 50% magnesium sulphate IM once. Thereafter, give extra magnesium (0.8-1.2 mEq/kg daily) Step 6: Correct Micronutrient Deficiencies *Use up to twice the recommended daily allowance of various vitamins and minerals *On day 1, give....
  19. 19. *Micronutrient supplementation GOI OPERATIONAL GUIDELINES ON MALNUTRITION 2011 36 MICRONUTRIENT DOSING Vitamin A Vitamin A,C, D, E and B12 TWICE RDA Zinc 2 mg/kg/day Iron Start after two days on catch up diet, elemental iron @ 3 mg/kg/day Copper 0.3 mg/kg/day (if separate preparation not available use commercial preparation containing copper) Folate 5 mg on day 1, then 1 mg/day Micronutrient Supplementation
  20. 20. Step 7: Initiate Re-feeding *Start feeding as soon as possible as frequent small feeds. *If unable to take orally, initiate nasogastric feeds. *Total fluid recommended is 130 ml/kg/day. *If breast feeding, then continue breast feeding. *Start with F-75 starter feeds every 2 hourly. *If persistent diarrhea, give a cereal based low lactose F-75 diet as starter diet. Step 8: Achieve Catchup Growth *Once appetite returns in 2-3 days, encourage higher intakes *Increase 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 4gm/kg/day.
  21. 21. Step 9: Provide Sensory Stimulation & Emotional Support *A cheerful, stimulating environment. *Age appropriate structured play therapy for at least 15- 30min/ day. *Tender loving care. Step 10: Prepare for Follow-up *Primary failure to respond is indicated by: *Failure to regain appetite 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 days during the rehabilitation phase.
  22. 22. 39
  23. 23.  Clinical complex, which includes electrolyte changes associated with metabolic abnormalities that can occur as a result of nutritional support ( enteral or parenteral), in severely malnourished patients.  Also called “the hidden syndrome”  History
  24. 24.  Nausea, vomiting, and lethargy  Respiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma, and death
  25. 25. Refeeding a malnourished patient can result in Heart failure due to:  Atrophic myocardium in malnutrition  Muscle depletion of Mg, K, P  Sodium and water overload
  26. 26. Feeding and correction of biochemical abnormalities can occur in tandem without deleterious effects to the patient.(NICE) Early identification of at risk individuals, Monitoring during refeeding , and An appropriate feeding regimen are important.
  27. 27. Sam is major burden in deveoping countries. SAM is a medical emergency Pathophysiology still elusive and incomplete Ten steps are the key to successful management Community based treatment has revolutionised management of SAM Special needs for young infants and follow up issues need to be recognised
  28. 28. *

Editor's Notes

  • ach play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need ach play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need ach play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need ach play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need ach play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need arge play mats and with the mother. each play session should include language and motor activities, and activities with toys. (examples of simple toys for structured play therapy are provided in the annexure 20.) teach the child local songs and games using the figers and toes. encourage the child to laugh, vocalise and describe what he or she is doing. encourage the child to perform the next appropriate motor activity, for example, help the child to sit up; roll toys out of reach to encourage the child to crawl after them; hold the child’s hands and help him or her to walk. Physical activity promotes the development of essential motor skills and may also enhance growth. For immobile children, passive limb movements should be done at regular intervals. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and intensity of physical activities should increase as the child’s condition improves. Mothers and care givers should be involved in all aspects of management of her child. Mothers can be taught to: prepare food; feed children; bathe and change; play with children, supervise play sessions and make toys. Mothers must be educated about the importance of play and expression of her love as part of the emotional, physical and mental stimulation that the children need.
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