failure to thrive case scenarios

1. SEVERE ACUTE MALNUTRITION
MANAGEMENT AND PROGNOSIS
Dr.S.N.SIVARAJ ,Post Graduate.
PROF.DR.G.DURAIARASAN.
DR.K.BAKYALAKSHMI.
DR.M.LINGESWARAN.
DR.C.R.VIGNESH KUMARAN.
M2 UNIT.ICH.

2. Emergency Stabilisation
Rehabilitatio
n

3. SAM MANAGEMENT
TEN STEPS-
1. HYPOGLYCEMIA
2.HYPOTHERMIA
3.DEHYDRATION
4.ELECTROLYTE CORRECTION
5.INFECTIONS.
6MICRONUTRIENTS
7. INITIATE FEEDING
8.CATCH UP GROWTH
9.SENSORY STIMULATION
10.FOLLOWUP

4. EMERGENCY TREATMENT-
SHOCK
• Lethargic or unconscious
• Cold hands
Plus either:
• CRT >3 sec or
• Weak pulse.
Hypoglycemia and hypothermia
and infection often coexist .

5. SAM having sign of shock and lethargic or has lost consciousness:

6. Asymptomatic
• 10% D(50 mL),/ a feed / 1 tsp
sugar under tongue, whichever
is quickest.
• Feed every 2 hr for at least first
day. Initially give 1⁄4 of feed every
30 min.
Symptomatic
• Give 5 mL/kg 10% dextrose IV.
• 50 mL 10% dextrose or sucrose
by nasogastric route.
• Repeat blood glucose after 30
minutes. If <54 mg/dL then
repeat the bolus.
1# HYPOGLYCEMIA-blood glucose <54mg/dl

7. • Feed every 3 hr day and night
(2 hr if ill).
• Feed on time.
• Keep warm.
• Treat infections
Prevention-
Avoid long
gaps without
food and
minimize
need for
glucose.

8. RECTAL TEMPERATURE -<32 C
• Warm humidified oxygen
• 10%D 5 mL/kg IV immediately / 50 mL of 10%by
NGroute .
• WARMTH-overhead warmer/ skin contact /heat
convector.
• Avoid rapid rewarming and monitor temperature
every 30 minutes
• Give warm feeds immediately-oral/NG feeds.
• Start maintenance IV fluids (prewarmed).
• Start intravenous antibiotics
2# HYPOTHERMIA-

9. HYPOTHERMIA-
Axillary temperature <35°C
or rectal temperature <35.5°C
Lethargy and poor feeding
• Cover the head by cap and
limbs by socks and mitten
• Kangaroo mother care

10. Preventio
n
• Maintain
room
temperatur
e of 25°C
• Feed
immediat
ely and
then
regular
interval
• Cover the
child
including
head,
soles, and
palm
• Stop
draughts
in the
room
•
Promptly
change
wet
clothes or
bedding

11. 3# Dehydration-Do not give IV fluids except in shock.
PREVENTION-
ReSoMal after
each watery stool.(
low-sodium
rehydration
solution )
• TREATMENT-
• ReSoMal 5 mL/kg every 30 min for
first 2 hr orally or NG tube.
• 5-10 mL/kg in alternate hours for
up to 10 hr. Amount depends on
stool loss and eagerness to drink.
• Feed alternate hour.

13. 4# -INFECTIONS-empirical antibiotics
WITH COMPLICATION No complication in SAM child: Oral
amoxicillin 15 mg/kg 8 hourly for 5 days
Duration of Antibiotics
• Suspicion of clinical sepsis: At least
for 7 days
• Urinary tract infections (UTI) for 7–
10 days
• Culture positive sepsis: 10–14 days
• Meningitis: 14–21 days
• Deep seated infection like arthritis
or osteomyelitis atleast for 4 week

14. 4#-INFECTIONS-PREVENTION
Avoid overcrowding
Wash hands
Give measles
vaccine to
unimmunized
chidren age >6mon.

15. 5# Correct electrolyte imbalance—deficit of potassium and
magnesium, excess sodium
• Potassium chloride: 3–4 mEq/kg/d for 14 days.
• Magnesium sulfate:
• 0.3 mL/kg of maximum 2 mL intramuscular followed by
0.3 mL/kg orally for 13 days .
• Food without added salt in order to avoid sodium
• Do not treat edema with diuretics

16. • Very severe anemia
• Hb 4-6g/dL and respiratory distress.
• Whole blood 10 mL/kg –IV over 3-4
hr.
• signs of heart failure- 5-7 mL/kg
packed cells.
• Furosemide 1 mg/kg IV at the start
of the transfusion.
• Emergency eye care/Corneal
ulceration
• vitamin A immediately (age <6
mon: 50,000 IU; 6-12 mon:
100,000 IU; >12 mon: 200,000
IU)
• Instill 1 drop atropine (1%) into
affected eye to relax the eye and
prevent the lens from pushing
out.

17. Micronutrient deficiencies-
• On admission and given for 2 weeks.
• Iron - 3 mg/kg is started after 7 days of admission.
• vitamin A on day 1 (<6 mon 50,000 units; 6-12 mon 100,000 units; >12
mon 200,000 units).
• Eye signs of vitamin A deficiency or has had recent measles. Repeat this
dose on days 2 and 14.

18. • Multivitamin supplement (should contain vitamin A, C, D, E, and B12 and
not just vitamin B complex): Twice recommended daily allowance.
• Folic acid: 5 mg stat then 1 mg for 13 days.
• Zinc: 2 mg/kg for 14 days.
• Copper: 0.3 mg/kg.
• Iron: 3 mg/kg/day to be started after 7 days of patient admission
• Cautious feeding .
Zinc
I
r
o
n

19. Stabilisation phase:
• Aim- achieve weight for height.
• Calories - 150–200 kcal/kg/day. 4 g protein and 100–150 mL/kg of
water per day.
• Calorie requirements - actual weight.
• Initially liquid diet started-divided into 6–8 feeds/day including a late
night and an early morning feed to prevent hypoglycaemia in night.
• Tube feeds -severe anorexia and apathy.
• Vitamins and micronutrients .
• Deworming .
• Family pot feeding.

20. Starter Diet:
• 8-12 small feeds -130mL/kg/day, F75- 75kcal/100ML, 1-1.5g
protein/kg/day.
• Edema-100 mL/kg/day.
• Keep a 24-hr intake chart. Measure feeds carefully. Record leftovers.
• If child has poor appetite, encourage to finish the feed.
• If unfinished, reoffer later.
NG tube if eating ≤80% .
Encourage continued breastfeeding /F75.
• Daily wg monitoring.

21. Rehabilitation phase
• Aim- weight for age/food supplementation along with
rehabilitation.
• To prevent -back to PEM again by maintaining adequate
nutrition/ periodic growth monitoring/
immunization/routine medical care.
• Health education.
• Reduced or minimal edema and return of appetite.
• F75 F100 ( 100 kcal and 3 g protein per 100 mL),
or ready-to-use therapeutic food RUTF.

22. • If F-75 and F-100 are not available.
• Calculate the amount of starter feed (prepared with cow’s milk, sugar,
rice powder, and vegetable oil to provide approximately 75 kcal and
0.9 g protein per 100 mL) .
• Catch-up diet (to provide approximately 100 kcal and 2.9 g protein
per 100 mL) to be offered .
• Based on daily weight measured.

23. STARTER DIET-F 75
INGREDIENT F 75(100ML) F 75(CEREAL
BASED-100ML)
MILK(ml) 30 30
SUGAR(gm) 9 3
PUFFED RICE
POWDER(gm)
- 6
COCONUT OIL(ml) 2 3
WATER(ml) 100 100
ENERGY(K.Cal) 75 75
PROTEIN(gm) 0.9 1.1
CATCH UP DIET-F 100
INGREDIENT F 100(100ML) F 100(CEREAL
BASED-100ML
MILK(ml) 95 75
SUGAR(gm) 5 2.5
PUFFED RICE
POWDER(gm)
- 7
COCONUT
OIL(ml)
2 2
WATER(ml) 100 100
ENERGY(K.Cal) 100 100
PROTEIN(gm) 2.9 2.9

24. 9#-Provide sensory stimulation and emotional support.-
reduces the risk of permanent mental retardation and emotional impairment.
• A cheerful ,stimulant environment.
• Age appropriate structured play therapy for atleast 15-30min.
• Tender loving care.

26. Discharge from Nutrition Rehabilitation Centre
• Edema- resolved
• weight gain >15% and satisfactory weight gain for 3 consecutive days
(>5 gm/kg/day).
• Child is eating an adequate amount of nutritious food that the
mother can prepare at home.
• All infections and other medical complications treated.
• Micronutrients.
• Immunization is updated.

27. • Failure criteria of SAM
management:
• Day 4.
• Failure to gain appetite.
• Failure to start to lose edema.
• Day 10
• Edema still present
• Failure to gain at least 5 g/day
for 3 successive days.
• After feeding freely on catch-up
diet.
• Look for the cause of failure:
• Insufficient food given.
• Vitamin or mineral deficiency.
• unrecognized infections.

28. • Mother/caregiver:
 To prepare appropriate foods and to feed the child.
 Give prescribed medications, vitamins, folic acid and iron at home.
 To make appropriate toys and play with the child.
 To give home treatment for diarrhoea, fever and acute respiratory
infections .
 To recognize the signs for which medical assistance needed.
 Follow-up plan is discussed and understood.
 community based program is well functioning, child can be
transferred from facility based care to community based care for
achieving target weight gain of 15 %.

30. Outcome and prognosis
• Long term effects-stature,developmental,cognitive function.
• 1st
6month-stunted despite treatment-25-60%
• Early diagnosis and intervention –needed to prevent long term
effects.

32. Take home message!
• Be Slow and steady ,No aggressive treatment.
• No diuretics for edema
• No iv fluids for dehydration(except in shock).
• No high protein diet in early phase of treatment.
• Low sodium diet .
• No iron therapy in stabilisation phase.

33. References
-Nelson text book of pediatrics
22nd
edition.
-Guideline for IP treatment of
SAM-WHO.
-ICMR ,NIN guideline.
-STG-IAP.

34. THANK YOU