The document discusses childhood malnutrition. It defines severe acute malnutrition in children aged 6-59 months as very low weight-for-height, mid-upper arm circumference below 115mm, or presence of nutritional edema. It outlines the 10 steps for managing severe acute malnutrition, including treating hypoglycemia, hypothermia, dehydration, infection, and micronutrient deficiencies. The steps also include initiating feeding with F-75, achieving catch-up growth, providing stimulation and support, and preparing for discharge.

1. CHILDHOOD
MALNUTRITION

3. MALNUTRITION
• WHO has defined malnutrition as a range of pathological conditions arising from
coincident lack, in varying proportions of protein and calories, occurring most
frequently in infants and young children and commonly associated with infections
• The term malnutrition is used to denote undernutrition,overnutrition and selective
nutritional deficiencies but childhood malnutrition is restricted to undernutrition

4. 1yr old boy , oedematous,weighing 5 kgs , with length of 55cm and muac of 9.5 cm…………
Interpretation?

5. SEVERE ACUTE MALNUTRITION
• Defined by - very low weight-for-height/length (Z- score below -3 SD of the
median WHO child growth standards),
and/ or
a mid-upper arm circumference < 115 mm,
and/ or
presence of nutritional oedema
WFA HFA WFH INTERPRETATION
NORMAL NORMAL NORMAL NORMAL
DECREASED NORMAL DECREASED ACUTE MALNUTRITION
DECREASED DECREASED NORMAL CHRONIC MALNUTRITION
DECREASED DECREASED DECREASED ACUTE ON CHRONIC MALNUTRITION

7. CLINICAL FEATURES-
A)-growth-retardation- m/c feature of malnutrition
B)- hepatomegaly-d/t fatty infiltration
start from periphery to central of lobule.
C)-hair changes- more evident at the root of the hair - acute malnutrition.
hypochromotrichia-sparsh,easily pluckable and hypopigmented hairs.
flag sign-when the nutritional status regained.
D)-SKIN CHANGES-flaky paint dermatosis-is pathognomic
crazy pavement dermatosis
currently-” nutritional dermatosis”

9. Approach to child with severe acute malnutrition
Severe acute malnutrition in children 6 to 59 months of age
Presence of
1.weight-for-height/length (Z- score below -3 SD of the median WHO child growth
standards),
and/ or
2.a mid-upper arm circumference < 115 mm,
and/ or
3.presence of bipedal oedema
Assess for the following complications
1.Severe edema (+++)
2.Low appetite(failed appetite test)
3.Medical complications
4.One or more danger signs as per IMNCI
NO YES
UNCOMPLICATED SAM COMPLICATED SAM
SUPERVISED HOME BASED MANAGEMENT INPATIENT MANAGEMENT IN NEAR FACILITY

13. EMERGENCY SIGNS
 Not breathing at all or gasping
 Obstructed breathing
 Central cyanosis
 Severe respiratory distress
 Shock
 Coma
 Convulsions
 Diarrhoea and severe dehydration : any of
the following two signs -

15. Management of
uncomplicated
SAM
1. Nutritional therapy :energy dense food supplying 175 kcal /kg/day
protein : 4-5g/kg/day
• Either home based food or RUTF
• Frequency of feed : 6-8/day
• If on breast feed : continue it.
2. Sensory stimulation and emotional support : structural play
therapy (15-30 min/day )
3. Home visit by ASHA or ANM worker : Initially daily visit later
twice weekly
4. Additional therapies :
• Oral amoxicillin for 5 days
• Oral albendazole 400 mg single dose above 2 year age
• If vitamin A deficiency features : Single mega dose of vitamin A
5. Age appropriate vaccination.

16. Management of
complicated SAM
in hospital
Hospital stay
1st 7 days
(stabilization
phase )
2nd wk – 6wk
Rehabilitation
phase
Step 1. Treat hypoglycemia
Step 2. Treat / Prevent hypothermia

17. Time frame and 10
steps
Step 1. Treat hypoglycemia
Blood glucose < 54mg/dl or 3 mmol/L
Asymptomatic : 50 ml of 10% dextrose or sucrose solution Oral
Symptomatic : 10 % dextrose 5ml/kg iv bolus
50 ml 10 % dextrose/sucrose oral
Monitor RBS every 30 min till blood glucose rise above 54 then 3hrly and then 6hrly
Step 2. Treat / Prevent hypothermia
Axillary temp <35 C or rectal temp < 35.5 C
Treat by covering exposed part
Provide warmth ( skin to skin contact , radiant warmer , heat convector )
Avoid rapid rewarming
Ensure feeding and consider antibiotic

18. 3) To treat dehydration
4) To treat electrolyte imbalance

19. Step3. Treat / prevention Dehydration :
Difficult to assess in SAM, assume all with watery diarhoea have some dehydration
1. Treatment in Some and severe dehydration without shock:
Oral fluid : ReSoMal : ideal but not available . Make it from WHO recommended ORS.
Give slowly orally or by NG tube @ 5-10 ml/kg/stool
Continue Breast feeding, start F75 after 2-3 hr of starting rehydrationtherapy
Step 4. correct electrolyte imbalance
Management of hypokalemia : if Sr. K<2 mEq/L or < 3.5+ ECG changes( ST depression , presence of
U wave )
Add kcl 0.3-0.5 mEq /kg/hr under ECG monitoring
All Sam children In hospital : supplemental potassium : 3-4 mEq/kg/day for 2 wks
Mg supplementation :
Day 1 0.3 ml/kg 50% MgSO4 I.M
Day 2 onwards : 0.8-1.2 mEq /kg/day mixed with feed orally
Salt restriction diet

20. Step 5. Treat / prevent infection :
Step 6. correct micronutrient deficiency :

21. Step 5. Treat / prevent infection :
Send relative investigation and start empirical antibiotic :
I.M or I.v ampicillin ( 50 mg /kg/day ) 6hrly for 2 days
From 3rd day onwards , change ampicillin to oral amoxycillin 15 mg /kg/dose 8 hrly for 5 days
Step 6. correct micronutrient deficiency :
Upto twice RDA foor daily supplementation
Vit K : single dose 2.5 mg im in all SAM at admission
Vit A Single mega dose in day 1
Folic acid : 5 mg on day 1  1 mg per day
Zinc : 2mg /kg/day
Copper : 0.2 -0.3 mg/kg /day
Iron : In rehabilitation phase : 3 mg /kg/day for 2 month

22. Step 7 . Initiate feeding :
Step 8. Achieve catch up growth :

23. Step 7 . Initiate feeding :
Start F-75 feed every 2hrly orally or NG
BF ad libitum
Calories needed : on day 1 : 80 kcal /kg/day  100 kcal/kg/day(day 6-7)
Approx 11 ml /kg/feed every 2 hourly
Step 8. Achieve catch up growth :
Shift to f100
Gradually increase amount to 200 l/kg/day
Target cal. And protein : cal : 175-180kcal /kg/day
prot : 4-6g/kg/day
Breast feed ad libitum
Gradual shift from F- 100 to RUTF  home based balanced diet

24. Step 9. Provide sensory stimulation and emotional support
Step 10. prepare for discharge and follow up :

25. Step 9. Provide sensory stimulation and emotional support
Structural play therapy : 1-3 hr/day
Happy children eat more, happy children grow more
Step 10. prepare for discharge and follow up :
• Anti helminthic therapy to all before discharge
• 12-23 month : albendazole 200 mg single dose.
• >2 yr : albendazole : 400 mg

26. Criteria for discharge
Wt gain of 15 % from baseline and daily wt gain @ 5g/kg/day on 3
consecutive day.
MUAC > 12.5cm or weight for Ht above -2 SD of mean
Absence of edema with good appetite
No complication and immunized for age