This presentation focuses on the all important topic of childhood malnutrition. It addresses the different components, both acute and chronic, but focuses more on the severe acute malnutrition which is the most important killer, particularly for the under-5s. terms like kwashiokor and marasmus are no longer in use.

1. CHILDHOOD
MALNUTRITION
BY
DR KEMI DELE
DEPARTMENT OF FAMILY MEDICINE; DORA NGNZA HOSPITAL

2. Outline
■ Introduction and Definition
■ Epidemiology
■ Classification
■ Nutritional Assessment
■ Defining Acute Malnutrition
■ Pathophysiology of Complications
■ Management of Emergencies
■ WHO 10 Steps Approach

3. What is Malnutrition?
■ According to WHO:
■ Malnutrition refers to deficiencies, excesses or imbalances
in a person’s intake of energy and/or nutrients

4. EPIDEMIOLOGY

5. Epidemiology
■ Malnutrition contributes globally to 35% of disease burden in children under
5years
■ The SA National Burden Of Disease Study indicated that being underweight
contributed to 12.3% of deaths in children under 5years
■ Top 5 causes of under 5 mortality in SA:
1. AIDS related including TB 40%
2. Deaths during neonatal period 18%
3. Diarrheal disease 11%
4. Pneumonia 6%
5. Severe Malnutrition 5%

6. Epidemiology
■ WHY IS MALNUTRITION A KILLER?
■ Malnutrition is not identified and diagnosed on contact with healthcare
workers
■ Initial management and management of emergencies is not optimal
■ WHO 10 steps are not applied

7. Global Trends in the Prevalence of
Malnutrition
■ Malnutrition is more common in developing countries of Africa, Asia and Latin-
America.
■ Although the overall prevalence of moderate-severe malnutrition has decreased
from 32% in1990 to 22% in 2008, the estimated number of cases for 2008 is 178
million, very similar to the 1990 level.
■ This is due to increased population. Most of the increment has come from Sub-
Saharan Africa and South- Central Asia.

8. Global Trends in the Prevalence of
Malnutrition
■ Does malnutrition happens in developed nations?
■ Yes, it does.
■ At a much lower prevalence, for example weight/age deficits in the USA and
Germany are above 1 %, it is usually associated with chronic diseases, and it’s often
referred to as Failure to Thrive.
■ Nevertheless it does occur, and many times is associated with some of the same
factors that produce malnutrition in the developing world e.g.: poverty, disrupted
families, low education, neglect, etc.

9. Global Trends in the Prevalence of Moderate-
Severe Malnutrition in Children Under Five

10. Prevalence (%) of Moderate-Severe Malnutrition
in Children Under Five in Selected Countries

12. Overview of childhood malnutrition in
South Africa: Severe Malnutrition
From Millennium Development Goals Republic of South Africa Country report UNDP 2010

13. Dual epidemic
• Under nutrition
• Over nutrition
Systematic review of nutrition studies in the Western Cape

14. Status of child nutrition: Underweight
• 1 in 10 children are underweight
• Figure showing percentage of children 1–9 years suffering from underweight
(MAM, SAM, severe mixed acute and chronic malnutrition) by province, 1999
and 2005 (Source: Department of Health, 2000)

15. Status of child nutrition: Stunting
■ 1 in 5 children are stunted, a consequence of chronic nutritional deprivation
■ Figure showing percentage of children 1–9 years suffering from stunting
(moderate and severe chronic malnutrition) by province,1999 and 2005.
■ Source: Department of Health (2000).

16. Status of child nutrition: Malnutrition by group
■ Younger children are most severely affected by malnutrition
■ Chronic undernutrition in early childhood results in diminished cognitive and
physical development, which puts children at a disadvantage for the rest of their
lives
■ Figure showing percentage of children 1–9 years suffering from stunting,
underweight and wasting by age group, 2005

17. Status of child nutrition: Severe Malnutrition
■ Close to 5% of children suffer from wasting and face a markedly increased risk of
death
■ Figure showing percentage of children 1–9 years suffering from wasting (moderate
and severe acute malnutrition) by province, 1999 and 2005

18. CLASSIFYING PATIENTS
WITH MALNUTRITION

19. Classification:
Undernutrition vs Over-nutrition
Malnutrition can be classified into Two Broad Categories:
1. Undernutrition
■ Stunting (low height for age)
■ Wasting (low weight for height)
■ Underweight (low weight for age. It is a combination measure, may be
result of wasting or stunting or both)
■ Micronutrient deficiencies/insufficiencies ( lack of important vitamins
and minerals
■ Most cases of malnutrition are considered to be undernourished
2. Overweight, obesity and diet-related non-communicable disease

20. Chronic Malnutrition (Stunting)
■ This form of malnutrition occurs over time and it manifests as Stunting
■ It reflects a sustained past episode/episodes of undernutrition
■ Moderate Chronic Malnutrition (MCM) is defined by
■ moderate stunting
■ HAZ of ≥-3 and <-2 z-score (Height-for-Age z-score)
■ Severe Chronic malnutrition (SCM):
■ HAZ score <-3 z-score
■ Others include Global Chronic malnutrition is mixed picture between
moderate and severe chronic malnutrition

21. Acute Malnutrition
■ Acute malnutrition is caused by a decrease in food consumption and/or
illness resulting in bilateral pitting pedal oedema and/or a sudden weight
loss.
■ There are two forms of acute malnutrition:
■ Moderate Acute Malnutrition (MAM)
■ Severe Acute Malnutrition (SAM)
■ Anorexia or poor appetite and medical complications are clinical signs
which indicate or aggravate the severity of acute malnutrition.
■ The goal is to see the end of children dying from acute malnutrition

22. Acute Malnutrition..
■ Severe Acute Malnutrition (SAM)
– It is defined by:
■ the presence of bilateral pitting pedal oedema or
■ severe wasting (very low weight for length / height <-3 z-score) or
■ MUAC <11.5cm (in children 6 – 59 months).
– It is associated with other clinical signs such as a poor appetite.
– A child with SAM is highly vulnerable and at high risk of death.
■ Moderate Acute Malnutrition (MAM) is defined by:
– moderate wasting
– (low weight for height/length z-score between -2 and -3 SD).
– MUAC between 11.5 and 12.4cm.

23. Extent of malnutrition: The Iceberg
Effect

24. NUTRITIONAL
ASSESSMENT:
POINTERS OF ACUTE MALNUTRITION

25. STEP 1: Look or Feel
LOOK and FEEL FOR:
Bilateral Pitting Oedema and Visible Severe Wasting

26. STEP 2: Measurements
■ MEASURE
■ MUAC (6 – 59
months)
■ Weight for Height
■ Length or Height

27. a. Mid-Upper Arm Circumference (MUAC)
■ The First measurement of the Nutritional assessment is:
■ Measurement of the Mid-Upper Arm Circumference (MUAC)
■ Not applicable below 6months
■ 6mo – 59mo (5yrs)
■ And classify into the colour categories as below based on the
outcomes of the assessment

28. Mid-Upper Arm Circumference (MUAC)
NAM – At risk
NAM – Not at Risk

29. b. WEIGHT FOR HEIGHT
■ The second measurement of the Nutritional Status Assessment is:
■ Measurement of Weight-for-height (WFH)
■ And classify into the colour categories as below based on the
outcomes of the assessment

30. b. WEIGHT FOR HEIGHT…/

31. Z-Scores/SD
■ A Z Score is the number of standard deviations below or above the
mean.
■ +2 SD is around the 97th percentile and -2 SD equates close to the 3rd
percentile.
■ 3 SD is therefore regarded as severely deviated from normal.

33. Interpretation of growth charts
■ Weight for height (wasting)
■ Malnutrition guidelines focus on weight for height
Plotting Interpretation
<= -3 Severely wasted (SAM)
-2 to -3 Wasted (MAM)
>= -2 Not wasted

34. Interpretation of growth charts
■ Weight for age (underweight)
Plotting Interpretation
<= -3 Severely underweight
-2 to -3 underweight
>= -2 Not underweight

35. Interpretation of growth charts
■ Height for Age (stunting)
Plotting Interpretation
<= -3 Severely stunted
-2 to -3 stunted
>= -2 Not stunted

36. DEFINING
ACUTE MALNUTRITION

37. Classification Type
&
Action
Any Criteria below
Severe Acute Malnutrition (SAM)
 Refer to Inpatient Care for
Admission
• Unable to Breastfeed
• Bilateral Pitting Oedema
• Weight for Height <-3SD
• Visible Wasting
• Weight Loss or Poor Weight Gain
• Any IMCI General Danger Sign
Moderate Acute Malnutrition (MAM)
 IMCI feeding Assessment &
Counselling
• WHZ between -3SD & -2SD
• Not gaining weight / Weight loss
Defining acute malnutrition: 0 - 6 months

38. Defining acute malnutrition: (6 – 59 months)
Classification Type
Bilateral Pitting
Oedema
MUAC WHZ
Severe Acute Malnutrition
(SAM)
Yes < 11.5 cm < -3SD
Moderate Acute Malnutrition
(MAM)
No
Bet. 11.5 and 12.4
cm
Bet. -3 and -2SD
Not Acutely Malnourished
(NAM), AND
At Risk (from growth curve
assessment)
No
> 12.5 and poor
weight gain,
weight loss or no
weight gain
≥ -2SD
Not Acutely Malnourished
(NAM), and growing well
NO ≥ 12.5 cm ≥ -2SD

39. Treating acute malnutrition
Classification Type TREAT
Severe Acute Malnutrition (SAM)
INPATIENT PROTOCOL (Emergency Treatment &
WHO Ten Step)
Moderate Acute Malnutrition (MAM) Outpatient Supplementary Programme (OSP)
Not Acutely Malnourished (NAM), AND
At Risk (from growth curve assessment)
Growth Monitoring and Promotion Support
Programme (GMPs)
Not Acutely Malnourished, AND
Not At Risk
Growth Monitoring and Promotion Routine
Programme (GMPr)

41. Nutrition assessment, classification and support > 5 years

42. ASSESS CLASSIFY
Lactation MUAC < 21cm or visible wasting /
bilateral oedema
SAM
MUAC 21 – 23cm MAM
Pregnancy MUAC < 21cm or visible wasting /
bilateral oedema
Assess weight gain in pregnancy –
refer to poster
SAM
MUAC 21 – 23cm MAM
Nutrition assessment, classification and support > 5 years…

43. PATHOPHYSIOLOGY OF
COMPLICATIONS

44. Pathophysiology
Heart
• Smaller &
Weaker,
cannot handle
excess fluids
• Calculated
feeding
volumes
Liver
• Reduced
ability to make
glucose/produ
ce energy
• Smaller,
frequent
feeds
Genitourinary
system
• Cannot excrete
excess fluids &
sodium, UTIs
common
• Correct fluid
amounts,
restrict sodium
GIT system
• Weaker,
thinner/
flattened
micro villi
• Smaller,
frequent
feeds
Skin, muscle,
glands
• Atrophied skin
and
subcutaneous
fat
• Smaller,
frequent
feeds

45. Cardiovascular system
■ Heart is smaller, weaker
■ Cannot handle excess fluid in circulation
■ Reduced CO,SV,BP
Renal perfusion and circulation time
Red cell volume
■ Infusion of saline may cause an increase in venous pressure
■ Any increase in blood volume can easily produce acute heart failure
■ Any decrease will further compromise tissue perfusion
PLAN
■ If the child appears dehydrated, give ORS or F75; do not give fluids
intravenously unless the child is in shock.
■ Restrict blood transfusion to 10ml/kg.

46. Liver
■ Reduced gluconeogenesis
■ increases the risk of hypoglycaemia during infection.
■ Reduced protein synthesis and bile secretion
■ Reduced capacity of liver to take up, metabolize and excrete toxins
■ Abnormal metabolites of amino acids are produced.
■ Slower energy production from galactose and fructose
PLAN
■ Do not give child large meals.
■ Ensure amount of protein given does not exceed metabolic capacity of the liver but
sufficient to support synthesis of proteins (0.9g/100ml)
■ Reduce the dosage of drugs that depend on hepatic disposal or are hepatotoxic.
■ Ensure sufficient carbohydrates given to child to avoid the need for gluconeogenesis.
■ Do not give iron supplements acutely , which may be dangerous because transferrin
levels are reduced

47. Genitourinary system
■ Cannot get rid of excess fluid and sodium
■ Glomerular filtration is reduced.
■ Sodium excretion is reduced.
■ Urinary phosphate output is low.
■ Urinary tract infection is common
■ Capacity of kidneys to excrete excess acid or a water load is greatly reduced.
PLAN
■ Prevent further tissue breakdown by treating any infection and providing adequate
energy.
■ Do not give child more protein than is required to maintain tissues.
■ Ensure that high-quality proteins are given, with balanced amino acids.
■ Restrict dietary sodium.
■ Ensure water intake is sufficient and not excessive

48. Gastrointestinal system
■ Gut weaker, micro villi thinner or flattened
■ Production of gastric acid is reduced.
■ Intestinal motility is reduced.
■ Pancreas is atrophied and production of digestive enzymes is reduced.
■ Absorption of nutrients is reduced when large amounts of foods are eaten.
PLAN
■ Give child small, frequent feeds.
■ If absorption is poor, increase the frequency and reduce the size of each feed
(feed 2hrly instead of 3 hourly or 4 hourly).
■ If there is malabsorption of fat, treatment with pancreatic enzymes may be
useful.

49. Skin, muscles and glands
■ Atrophied skin and subcutaneous fat (loose folds of skin)
■ Atrophied sweat, tear and salivary glands (dryness of the mouth and
eyes and reduced sweat production
■ Respiratory muscles are easily fatigued; the child is lacking energy
PLAN
■ Many signs of dehydration are unreliable; eyes may be sunken
because of loss of subcutaneous fat in the orbit.
■ Rehydrate the child with ORS or F75.

50. Immune system
■ damaged and weakened
■ All aspects of immunity are diminished.
■ Lymph glands, tonsils and the thymus is
severely atrophied.
■ Cell-mediated (T-cell) immunity is severely
depressed.
■ IgA levels secretions are reduced
■ Complement components are low.
■ Acute phase immune response is
diminished
■ Phagocytes do not kill ingested bacteria
efficiently.
■ Tissue damage does not result in
inflammation or migration of white cells to
the affected area.
■ Typical signs of infection (white cell count
and fever) are frequently absent.
■ Hypoglycaemia and hypothermia are both
signs of infection and are usually associated
with septic shock.
PLAN
■ Treat all children with broad spectrum
antimicrobial.
■ Because of the risk of transmission of
infection, ensure that the newly admitted
children are kept apart from children who
are recovering from infection.

51. Endocrine system
■ Insulin levels are reduced and the child has glucose intolerance.
■ Insulin growth factor 1 (IGF-1) levels are reduced, although growth
hormone factors are increased.
■ Cortisol levels usually increased.
■ Give the child small, frequent feeds.
PLAN
■ Do not give steroids.

52. Circulatory system
■ Basal metabolic rate is reduced by about 30%.
■ Energy expenditure due to activity is very low.
■ Both heat generation and heat loss are impaired; the child becomes
hypothermic in cold environment and hyperthermic in a hot environment
PLAN
■ Keep the child warm to prevent hypothermia; dry the child quickly and
properly after bathing and cover with clothes and blankets, ensure that
windows are kept closed at night and keep temperature of the living
environment at 25-30˚C.
■ If a child has fever, cool the child by sponging with tepid (not cold) water
(never alcohol rubs).

53. Cellular system
■ Cells are damaged and become leaky
■ Sodium pump activity is reduced and cell membranes are more
permeable than normal, which leads to an increase in intracellular sodium
and decrease in intracellular potassium and magnesium.
■ Protein synthesis is reduced.
PLAN
■ Give large doses of potassium and magnesium to all children.
■ Restrict Sodium intake.

54. MANAGEMENT OF
EMERGENCIES
INCLUDING WHO 10 STEP APPROACH

55. WHO 10 STEPS

56. WHO 10 STEPS
1. Treat/prevent hypoglycemia
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

57. WHO 10 STEPS, cont.: Steps 1-4
■ Steps 1 and 2 go hand in hand because frequent feeding is an important
aspect of preventing both hypoglycaemia and hypothermia and both
tend to occur together in severe infection.
■ Step 3, is similar to standard WHO case management of diarrhoea, but
is done more slowly because of the risk of fluid overload and death.
■ Step 4 is important because we now know that severely malnourished
children have excess sodium but not enough potassium or magnesium
in their bodies

58. WHO 10 STEPS, cont.: Steps 5-6
■ Step 5 Severely malnourished children are prone to infections but will often
not show the typical signs of infection such as fever.
■ Therefore, the WHO recommends that these children routinely get an
appropriate course of broad spectrum antibiotic, whether or not they show
clinical signs of infection.
■ Step 6 Give multivitamins, zinc and copper daily. Also, give a large dose of
vitamin A and folic acid on day one. The zinc and copper can be made as part
of the electrolyte/mineral solution and added to feeds.

59. WHO 10 STEPS, cont.: Steps 7 & 8
■ Steps 7 and 8 are very important and are fundamental to success.
■ The use of specially prepared milk is now recognised as the “gold
standard” in the management of severe malnutrition
■ Feeding is first done cautiously with small amounts, progressing to
unlimited amounts of the catch up formula.
■ Thereafter. energy and nutrient dense locally available foods such as
porridge with peanut butter, or samp with beans and margarine (eg
Rama) may be included

60. WHO 10 STEPS, cont.: Step 9
■ Step 9 Malnourished children are at risk of both developmental and
behavioural delay.
■ Therefore, children should be actively engaged and stimulated while in
hospital.
■ Structured play or play therapy promotes the development of language and
motor skills.
■ Toys for structured play can be made of locally available materials. Colourful
posters for the wards as well as educational toys are both important

61. WHO 10 STEPS, cont.: Step 10
■ Step 10 Preparation for follow-up and discharge should begin soon
after admission.
■ This step is an important one since we know that relapses are
common.

62. INPATIENT MANAGEMENT
OF CHILDREN WITH “SAM”:
IMAM GUIDELINES

63. Deadly triad
Infection
(“sepsis”)
Hypoglycemia
Hypothermia
Death
Consider and Manage all 3 conditions
simultaneously –
major cause of death in SAM patients

64. When do inpatient deaths occur?

65. Medical Emergencies
■ Hypoglycaemia
■ Hypothermia
■ Shock
■ Hypovolaemia
■ Septic (“severe sepsis”)
■ Severe dehydration (not in shock)
■ Severe Anaemia
■ Eye signs of Vitamin A deficiency
Golden Hour - Prompt Initial Management
Severity Index:
• High Risk
• Moderate Risk
• Low Risk

68. HYPOGLYCAEMIA

69. Hypoglycaemia : Prevention
■ Initiate “stabilizing” F-75 Feeds immediately (WITHIN 30MIN)
■ Do not miss feeds
■ Feed using cup and spoon
■ F-75 Volume: 130ml/kg/day .
■ Feed 3 hourly
■ Gross oedema: 100ml/kg/day
■ SAM with medical complications and general danger signs: Feed more frequently,
every 2 hours
■ If feeds are refused / not finished (does not complete >80% of feed volume in 24 hours
or 3 consecutive feeds) or child is unable to feed by mouth, give feeds via NGT
Defer feeding immediately in following cases:
While shock is being corrected
Surgical abdominal emergency

70. 1. Hypoglycaemia : Detect and treat
■ Test blood glucose level 3 hourly
■ (Stop once normal and stable for 24 hours AND child not severely ill)
■ If Glucose <3 mmol/L in asymptomatic child:
■ Oral:
■ Immediate feed with F-75 AND
■ Sugar solution, oral, 5ml/kg (1 tsp in 50 ml water) OR
■ 50ml bolus of 10% dextrose
■ Check blood glucose after 30 mins, if normal continue feeding,
monitor 3 hourly
Low blood glucose is defined as < 3 mmol/l

71. Hypoglycaemia : Detect and treat
■ Test blood glucose level 3 hourly
■ (Stop once normal and stable for 24 hours AND child not severely ill)
■ If Glucose <3 mmol/L and symptomatic or unresponsive
hypoglycaemia:
■ IV Dextrose 10%:
■ 2 ml/kg over 2-3 mins
■ Check blood glucose after 30 mins, if normal continue feeding,
monitor 3 hourly
Low blood glucose is defined as < 3 mmol/l

72. Hypoglycaemia : Detect and treat…
■ Start feeding F-75 ½ hour after giving glucose solution
■ Feed every 30min for first 2 hours
– ¼ of the amount for the 2hourly F-75 feed
■ After 2 hours check glucose:
– If glucose >3mmol/L  change to 2h feeds
– If glucose <3mmol/L  continue ½ hourly feeds
 antibiotics given?

73. HYPOTHERMIA

74. Prevent/Treat Hypothermia
■ Keep covered, especially head, all the time
■ Avoid drafts
■ Keep dry, change wet napkins regularly
■ Avoid exposure during examination and bathing
■ Keep child in warm area (Temp 25-30°C)
■ Ensure regular correct feeding
■ Check axillary temperature 3-4 hourly
■ Temp <36°C indicates urgent need to warm child
Rule out shock, dehydration, hypoglycaemia and sepsis

75. Prevent/Treat Hypothermia…
If Temperature <36.5°C, rewarm the child
■ Skin-to-skin contact (Mother-Child)
■ Wrap child with warm blanket
■ Place heater nearby
■ External warmer: Bear-Huggers, radiant heaters, Hot-water bottle
(beware of burning child!)
■ During rewarming, monitor body temp every 30 mins. Stop rewarming
when body temp stabilized >36.5°C
Rule out shock, dehydration, hypoglycaemia and sepsis

76. DEHYDRATION, SHOCK &
DIARRHOEA

77. Classifying dehydration
■ No visible dehydration
■ Some dehydration
■ Eyes sunken
■ Slow skin pinch (turgor) (<2 sec)
■ Drinks eagerly
■ Irritable/restless
■ Severe dehydration
■ Eyes sunken
■ Very slow skin pinch (>2 sec)
■ Drinks poorly

78. Managing diarrhoea with no dehydration
■ Prevent dehydration
■ Show mother how to give ORS with cup and spoon
■ Give frequent small sips
■ Give 10ml/kg after each loose stool until diarrhoea stops
■ Continue to feed
■ Reassess for dehydration frequently

79. Managing diarrhoea with some or severe
dehydration
■ Rehydrate to prevent hypovolemic shock
■ Give ORS 5ml/kg every 15 min (20 ml/kg/h) for 4 hours
■ Use frequent small sips
■ Continue to feed child
■ Reassess level of dehydration frequently
Review after 4 hours:
general condition, capillary filling time, level of consciousness, skin turgor, Sunken eyes,
respiratory rate, abdomen, passing urine, number/quality of stools

80. Managing diarrhoea with some or severe
dehydration…
■ If oral treatment for dehydration fails, rehydrate with ½ DD
■ Continue oral feeds
■ Response to assessment of child on IV treatment
2-10kg 10ml/kg/h
11-20kg 8ml/kg/h
21-50kg 6ml/kg/h

81. Managing diarrhoea with some or severe
dehydration…
Finding on assessment Response
Shock Treat for shock
No improvement or more
dehydrated
Increase drip rate by 25%
Improving clinical condition Continue current drip rate
No visible dehydration Decrease drip rate by 30% until low
enough to change to oral prevention
Repeat cycle 4 hourly until on oral prevention
Use IV rehydration in exceptional circumstances

82. Recognizing shock
■ Shock is regarded as an emergency sign requiring immediate
treatment
■ Do not transfer/move child until shock is treated and child circulation
is stable
■ Shock is not easy to identify in SAM, especially if very oedematous or
septic
■ Assume child in shock if history of profuse diarrhoea
■ Shock is recognized by one or more of following:

83. Recognizing shock
i. Compensated shock:
■ Delayed capillary filling time >3secs
■ Increased pulse rate (>140-160 bpm)
■ Cool peripheries
ii. Late (pre-terminal) shock:
■ Decreased level of consciousness (lethargic)
■ Decreased blood pressure
■ Decreased pulse volume
Shock is regarded as an emergency sign requiring immediate treatment
Do not transfer/move child until shock is treated and child circulation is stable

84. Treating Shock…
■ Resuscitate with fluid bolus:
– MRL or 0.9% NS
– Volume: 10ml/kg
– Time: over 10 mins
– Monitor for response (Watch for fluid overload)
■ If shock resolved, proceed to manage dehydration
■ If no response (pulse volume still decreased, prolonged capillary
filling time): Repeat Fluid bolus
■ If no circulatory overload AND not out of shock then repeat fluid
bolus up to 4 times (40ml/kg over 1 hour)

85. Treating Shock…
■ If still requiring further fluid support, suspect septic shock and admit to high
care/ICU: insert CVP line and commence inotropes
Other modalities:
■ Give oxygen
■ If the child is Hypoglycaemic or unsure of blood sugar level, give 10% glucose 2
ml/kg IV
■ Keep the child warm
■ IV Antibiotics
Routine monitoring and assessment of hydration

86. ELECTROLYTE IMBALANCE

87. Electrolyte Imbalance
■ High body sodium
■ Deficiency of potassium and magnesium
■ Oedema partly due to these imbalances
■ If potassium high – do not give additional potassium

88. INFECTION & ANTIBIOTICS

89. Infection and Antibiotics

90. Investigate for TB and HIV
■ Follow standard treatment protocols for management of children with
TB or HIV
■ Assess and Classify TB Status
■ Suspect TB in all cases of SAM
■ Investigate: TST/Mantoux, GW or sputum for AFB/Culture, CXR
■ Start TB treatment immediately if possible/probable or confirmed TB
■ Repeat TST once weight gain starts to demonstrate infection status
■ Assess and Classify HIV Status
■ Suspect HIV in all SAM cases
■ Investigate and test for HIV (DNA PCR or Elisa Ab testing)
■ All SAM HIV infected children are eligible for ART
■ Start ART once stabilized and in rehabilitation phase
Assess and Manage the Mother for TB and HIV

91. ELECTROLYTES &
MICRONUTRIENTS
SUPPLEMENTS

92. Micronutrients: Supplements
■ If child is receiving ready to use F75/F100/RUTF
■ Folate 5mg on Day 1
■ Iron in rehab phase (on F100), stop if on RUTF
■ If on milk kitchen mixed F75/F100
■ Folate 5mg on Day 1
■ Add CMV-C (Combined Mineral Vitamin Mix)
■ Iron in rehab phase (on F100), stop if on RUTF
■ If on specialised milk
■ All additional supplements

93. Micronutrients: Supplements
■ Multivitamins: 5ml daily (Do not give MVT if the child is on feed with
CMV or is on F75, F100 or RUTF)
■ Folate: 5mg on Day 1 (2,5mg daily if not on F75/100, RUTF)
■ Vit A: For vit A deficiency, severe measles and/or diarrhoea ONLY give
stat dose and repeat on day 2
■ Elemental Iron: 3mg/kg/d in rehabilitation phase, if not on RUTF
■ KCl: 3-4 mmol per kg per day

94. Micronutrients: Supplements
■ Mg++: 0.4-0.6mmol/kg/day only if the child is not on F75, F100 or RUTF
■ Zinc: 2mg/kg/day only if the child is not on F7, F100 or RUTF
■ Trace Element Mix: <10kg give 2,5ml daily
■ >10kg give 5ml daily
Trace element mix:
36mg/ml of Zinc; 0.1mg/ml of Copper; 280mg/ml of Magnesium

95. ANAEMIA

96. Severe Anaemia
■ Very Severe Anaemia: Hb <4g/dL
■ Severe Anaemia: Hb 4-6g/dL with Resp distress
■ Transfuse packed cells 10ml/kg over 4 hours
■ If signs of cardiac failure, give 5-7ml/kg
■ Give furosemide 1mg/kg IV at the start and end of transfusion
■ Watch for signs of fluid overload
■ Feed once child no longer severely distressed

97. Mild to moderate anaemia
■ Mild or moderate anaemia treated later with iron in the rehab phase
■ Malnutrition usually not the cause of very severe anaemia, therefore
investigate for other possible causes (malaria / intestinal parasites)

98. Eye care

99. SENSORY STIMULATION
AND FOLLOW-UP

100. Sensory stimulation and follow-up
■ Refer to occupational therapy
■ Play therapy, stimulation
■ Refer to social worker
■ Contact follow-up clinic
■ Discharge when oedema and medical complications resolved, feeding
well with good weight gain

101. IMPORTANT THINGS
NOT TO DO AND WHY?

102. Important things not to do and why?
■ Do not give diuretic to treat oedema
■ Oedema is partly due to K+/Mg++ imbalance, deficiency may
take up to 2 weeks to correct
■ Oedema will go away with proper feeding
■ Diuretic will cause more electrolyte imbalances and cause death!

103. Important things not to do and why?
■ Do not give high protein formula (>1.5 kg/kg/day) in initial phase
■ Too much protein will overwhelm the body’s metabolic
systems
■ Dangerous
■ Overload liver, heart, kidneys and
■ Cause death!

104. Important things not do and why?
■ Do not give iron during initial feeding phase
■ Add iron only when the child is on F-100 for at least 2 days, usually in
Week 2
■ No need to add iron if child is on RUTF

105. Important things not do and why?
■ Do not give intravenous fluids routinely
■ IV fluids can easily cause fluid overload in SAM
■ Only give IV fluids in children with signs of shock

106. Potential team members
■ Doctor
■ Nurse
■ Dietician
■ Mother / care-giver
■ Social worker
■ Physio / O.T.
■ Volunteers
■ NGO’s

107. REFERENCES
■ J Cloete 2015, Management of severe acute malnutrition
SAMJ July 2015, Vol. 105, No. 7
■ Minister Theuns Botha; Western Cape Government: Health;
UCT South African Medical Students Association; 6 March
2013
■ SOUTH AFRICA’S CHILDREN: Database on Child Rights
Indicators