This document describes the case of a 10 month old male patient presenting with symptoms of shortness of breath, fever, and post-prandial vomiting for 6 months. On examination, the patient appeared chronically ill, wasted, and dyspneic. Anthropometric measurements revealed severe wasting. Differential diagnoses for this case of severe acute malnutrition include marasmus, kwashiorkor, and marasmic-kwashiorkor. The standard 10 step approach is recommended, involving treating hypoglycemia, hypothermia, dehydration, infections, and providing cautious refeeding with F75 or F100 formulas.

2. Malnutrition

3. Case
Initials: H.M.A 10 months old male patient
CC: SOB ,fever for 1 week and post prandial vomiting 6 months
HPI: postprandial vomiting started 6 months ago with a projectile vomitus of milk like
and 1 week ago he developed a non productive cough associated with fever and poor
feeding and the symptoms were progressively increasing. Consulted nearest DH to
CHUB.
PMHx: recurrent UTI and Malaria.
BW:3,7kg>>then 5,4kg at 9’5mo,born by SVD cried immediately
Vaccination calendar: measles vaccine of 9mo is not yet taken
Delayed developmental milestones: not crawling, only sitting unsupported.
P/E: Chronically ill looking, wasted and dyspneic, alert face
◦Vs:HR:144bpm; To :37,4oc ; spo2:97 % on RA
◦RR:64bpm

4. CASE CONT’
Anthropometry:
◦ Weight:5,4kg (<3rd
perct), Height:65cm(<3rd
percent),
◦ Weight for height (<-3 zscore), HC:44cm (1,0 Z) ,MUAC:10cm
Peripherals: pallor no joundice
RS:nasal flaring,intercostal recession,tachypnea,chest expansion is
normal ;Lungs are clear.
GIT: Distended abdomen tender at epigastric area.
MSK: wasted baby,no edema,loss of subcutaneous fat, deltoid and
gluteus muscle are wasted. No skin lesions.
Other system : No remarkable findings.
What are your DDX ??
how can you approach this infant??

5. INTRODUCTION
Malnutrition is a condition of having the inappropriate level
of a micro and/or macro- nutrient.
It includes both:
◦Undernutrition
◦Over nutrition

6. Epidemiology
Malnutrition is a significant factor in approximately one third
of the nearly 8 million deaths per year in children who are
under 5 years of age worldwide.
Severe acute malnutrition affects nearly 20 million preschool-
age children, mostly from Africa and south-east Asia
Rwanda,38% of < 5 children are stunted and only 2.8 % are
wasted.
WHO REPORT 2017 , RDHS 2015

7. 3 scores to define the nutritional status:
◦Weight-for-Height (W/H):Wasting (Acute)
◦Weight-for-Age (W/A): Underweight
◦Height-for-Age (H/A): Stunting (chronic)
◦Weight is first to be affected : acute maln
◦If height is affected: chronic malnutrition

8. CLASSIFICATION OF MALNUTRITION

9. Pathophysiology

10. SEVERE ACUTE MALNUTRITION
SAM
Defined by one of the
following:
Severe wasting
(W/H < -3SD)
Bipedal edema
MUAC<11.5 cm under 5
year of age
SAM has 3 types
Marasmus
Kwashiorkor
Marasmic-Kwashiorkor

11. Marasmus (low calories)
Symptoms:
very low weight for height (extremely
wasted)
looks skinny
subcutaneous fat and muscles are
reduced
“old man´s face”
big belly
low body temperature
shows hunger
miserable and cries a lot

12. Kwashiorkor ( low protein)
Symptoms:
•oedema of feet/legs, hands, face
• normal or moderately
low weight-for-height
• very often stunted
• pale, sparse hair with weak roots
• pale, thin and peeling skin, sores
• poor appetite
• no interest in the environment,
apathetic, miserable
•weak muscles

13. Marasmic Kwashiorkor
Symptoms:
• very low weight for height
• looks skinny, but has
oedema
• very miserable
• any other signs of Marasmus
or Kwashiorkor

14. 10 steps in SAM Treatment
Treat/Prevent Hypoglycemia
Treat/Prevent Hypothermia
Treat/Prevent Dehydration
Correct electrolytes imbalances
Treat/Prevent Infection
Correct micronutrient deficiencies
Initiate feeding
Catch-up growth
Sensory stimulation
Follow-up

15. 1. Hypoglycaemia
Diagnosis:
Blood glucose < 3 mmol/l (< 54 mg/dl)
If not possible to measure assume hypoglycaemia
Child is weak, drowsy, very often also hypothermic.
Treatment:
• Give the first feed of Starter Formula (F-75) orally or by
nasogasric tube,
• If not available immediately, give 5ml/ kg of 10%
Dextrose.
• Feed 2-hourly at least for the first day

16. 2. Hypothermia
Diagnosis:
axillary temperature < 35 °C
rectal temperature < 35.5 °C
cold hands, cold feet
Treatment:
• Warm blanket or incandescent light directed on,but not touching the
child‘ s body.If not available put the child on the mothers bare breast
or abdomen.
•ensure that the child is clothed (including the head) and covered,
especially at night and keep the child dry
• Feed the child immediately start with F75

17. 3. Dehydration (Also check for Anemia)
Deyhdration tends to be overdiagnosed in children with severe
malnutrition!
Diagnosis:- sunken eyes and fontanelle
- standing skin-fold
- dry mouth, skin
Treatment:
Correct dehydration according to the severity (follow protocal)
If Hb < 5g/dl transfuse PRBCs 10ml/kg in 3hrs+ Lasix 1mg/kg
- Don‘t use Standard-ORS for malnourished children, has too high
sodium and too low potassium content (Electrolyte imbalances)!

18. 4. Electrolyte Imbalances
In SAM: * Excessive Sodium
* Deficient potassium
* Deficient magnesium
Treatment:
• Use commercial F75
• If not available mineral mix 4mmol/kg/day of oral potassium
• give extra magnesium (0.4 to 0.6 mmol/kg daily)
Remember: Two weeks minimum to correct
Prepare meals w/o salt (bcz of ↑ Na)
Do NOT use a diuretic to treat edema

19. 5. Infection
Treat all severly malnourished children with:
 a broad spectrum antibiotic while waiting blood culture results (WHO
recommendation)
 IV Penicillin (or Ampicillin) and Gentamicin with Nystatin /
Clotrimazole for oral thrush
 Mebendazole after 7 days treatment.
 Tetracycline eye ointment (+ atropine drops) for pus /
ulceration in the eye
 Zinc sulfate if no F 75/F100/RUTF
Adjust the treatment according to the germ and antibiogram.

20. 6. Micronutrient Deficiency
Correct micronutrient deficiencies by giving:
 Vitamin A If visible eye signs on admission ,day 2 and
14.
• If < 6 months give 50000 IU
• 6-12 months give 100000 IU
• >12 months give 200000 IU
 Multivitamins for at least 2 weeks if no Plumpy-nut or
F75/F100
 Folic acid 2.5mg alt days if no Plumpy-nut or F75/F100
Start iron only when the child is gaining weight.

21. 7. Cautious Refeeding
Start feeding as soon as possible after admission!
F75 Marasmus
130 mls/kg/day
Kwashiorkor
100 mls/kg/day
Calories 100 kcal/kg/day 75 kcal/kg/day
Protein 1 – 1.5 g/kg/day
0.75 – 1.3
g/kg/day

22. A feeding plan
Admission
F75
Appetite
recovers
RUTF or F100
RUTF
20g/kg/day
F100 at same
volume as F75

23. 8. Catch-up feeding /Rebuild tissues
 Return of appetite, decreasing of oedema or start of weight gain are
signs for entering the Rehabilitation phase.
 Replace the Starter-formula (F75 to F100) with the equal amount
of Catch-up-formula for 2 days (130ml/kg of F-100).
 Increase the amount every day by 10 ml/kg/day till 200ml/kg/day
(every 3-4 hrs) or until some of the feed remains uneaten.
 Target weight gain (>10g/kg/day), continue rehabilitation until
the child reaches target weight (W/H = -1)

24. 9. Sensory Stimulation
Severe Malnutrition can cause delayed physical and mental
development. Therefore another important part of rehabilitation is
sensory stimulation.
Provide:
• Loving care
• Toys/play therapy
• Physical activity as soon as the child is well enough
• Involve and teach the caretakers
•90% expected weight for height ready for discharge

25. Discharge criteria

26. 10. Preparation for Discharge and Follow-up
Target weight for malnourished children is W/H SD-score=-1
•Nutritional education: Good feeding hygiene, care and
sensory stimulation should be continued at home
•Immunization: booster immunizations and 6 monthly
Vitamin A
•Home visit
•Follow Up (Review in the hospitals)

27. TAKE HOME MESSAGE
Beware of direct cause of death
Follow up is an important pillar in the management of SAM

28. References
WHO Guidelines for SAM Management 2016
Basic pediatric protocols ,2014 (Rwanda)
Rwanda demographic and health survey 2015
National Institute of Statistics Rwanda, Ministry of Health
Rwanda report 2016
National nutritional protocal
Uptodate ,2018

29. 03/19/19