(_nut)LECTURE_SAM[2].pptx

Introduction
General trend of improvement as judged by nutrition
indicators over the last few decades
declining rates of undernutrition among women and children
 improvements very slow
unequally across the population/regions/districts
Undernutrition is still a serious problem despite increased
food production and availability’
Overweight /Obesity and NCDs increasing
GENERAL FOOD AND NUTRITION INSECURITY
2

The Nutrition Landscape I
3
• 10 Things everyone should know about child nutrition in Ghana
1. Stunting has reduced from 23% to 19% among children in
Ghana
2. Only 1/3 of children suffering from malnutrition received
adequate medical attention
3. Most of the health cost associated with undernutrition occur
before a child turns 1 year old
4. 24% of all child mortality cases in Ghana are associated with
undernutrition
5. 10.5% of all repetitions in school are associated with stunting

The Nutrition Landscape I
4
6. Undernourished children achieve an average of 0.8 years
less at school than well nourished children
7. Child mortality associated with undernutrition has reduced
Ghana’s workforce by 7.3%
8. 37% of the adult population in Ghana suffered from stunting
as children
9. The annual cost associated with child undernutrition are
estimated at 4.6 billion GHS, which is equivalent to 6.4% of
the GDP
10.Eliminating stunting in Ghana is a necessary step for
sustained development in the Country

Regional Disparities in Food
and Nutrition Security
5
Source: MOFA 2016
Household food security is a
major underlying determinant of
nutritional status
Some 3.2 million Ghanaians are
food insecure or vulnerable to
becoming food insecure

Food Insecure Households in Northern Ghana
6

Food consumption by wealth quantiles
7
Source: World Bank, 2011

Percentage of households unable to afford minimum cost of a
nutritious diet by region (Staple Adjusted Nutritious Diets)
Source: WFP/GHS (2016). Ghana fill the nutrition gap

Under nutrition Profile in Ghana
among children under 5 years
9
Source: GDHS, 2015

Breastfeeding profile
Almost all children in Ghana (98%) are breastfed at some point in
their life
 52% of children younger than 6 months exclusively breastfed
 Median duration of exclusive breastfeeding is about 4 months
 73% of breastfed children are given complementary foods by age 6-9
months
 Only 13% of children ages 6-23 months meet the minimum standards
set by the 3 core infant and young child feeding (IYCF) practices
Dietary diversity
Feeding frequency
Nutrient density 10

% of children 6-23 months receiving minimum
acceptable diets by region

Micronutrient
– Micronutrient malnutrition is highly prevalent and
persistent
 66% of children age 6-59 months anaemic
 27% mildly anaemic
 37% moderately anaemic
 2% severely anaemic
12

BMI profile of women and men of reproductive age
13
Source: GDHS, 2015

WHO CONCEPTUAL
FRAMEWORK ON
CHILDHOOD:
CHRONIC MALNUTRITION

CONTEXT
Community and societalfactors
Politicaleconomy
•Political
stability
•Poverty,
income and
wealth
•Financial
services
•Employment
and
livelihoods
•Food prices
and trade
policy
•Marketing
regulations
Health &
Healthcare
•Access to
healthcare
•Qualified
healthcare
providers
•Availability of
supplies
•Health care
systems and
policies
Education
Access to
healthcare
Access to
quality
education
Qualified
teachers
Qualified
health
Educators
Infrastructure
(schools &
training
institutions
Society &
Culture
Beliefs
and
norms
Social
support
networks
Child
caregivers
(parental
and non-
parental)
Women’s
status
Agriculture
and Food
Systems
•Food
production
& processing
•Availability
of micronut -
rich foods
•Food safety
and quality
Water,
Sanitation and
Environment
• Water and
sanitation
• infrastructure
and services
• Population
density
• Climate
change
• Urbanization
• Naturaland
manmade
disasters

Household and family factors Inadequate Complementary Feeding Breastfeeding Infection
Maternalfactors Home environment Poor quality foods Inadequate Food andwater Inadequate infection
• Poornutrition • Inadequatechild • Poormicronutrient practices safety practices • Entericinfection:
during stimulationand quality • Infrequent • Contaminated • Delayed Diarrhoealdisease,
pre-conception, activity • Lowdietary feeding foodand initiation environmental
pregnancyand • Poor care
practices
diversity • Inadequate water • Non-exclusive enteropathy,
lactation •Inadequate andintake of feeding • Poorhygiene breastfeeding helminths
• Shortmaternal sanitation animal- duringandafter practices • Early cessationof • Respiratory
stature and watersupply sourcefoods illness • Unsafestorage breastfeeding infections
• Infection • Foodinsecurity • Anti-nutrient • Thinfood and • Malaria
• Adolescent • Inappropriate content consistency preparationof • Reduced
pregnancy intra- • Lowenergy • Feeding foods appetitedue
• Mentalhealth householdfood contentof insuﬃcient toinfection
•IUGR andpreterm allocation complementary quantities • Inflammation
birth • Lowcaregiver foods • Non-
• Shortbirth education responsive
spacing
• Hypertension
feeding
CAUSES

Stunted Growth & Development
Currentproblems& Short
term
consequences
Long termConsequences
Health
↑Mortality
↑Morbidit
ies
Developmental
↓Cognitive,
motor,
and
language
developme
nt
Economic
↑Health
expenditure
s
↑Opportunity
costs for
care of sick
child
Health
↓Adult stature
↑Obesity and
associated co-
morbidities (NCDs)
↓
Reproductive
health
Developmental
↓School
performanc
e
↓ Learning
capacity
Unachiev
ed
potential
Economic
↓
Work
capaci
ty
↓ Work
productivity
WHO, Complementary Feeding (2012)

VERY
IMPORTANT
•Most of these barriers and causes in the conceptual
frame work overlap.
•Success in changing behaviours is highly dependent
on considering all the barriersand causes that may
be prevailing in resulting in malnutrition

DEFINITION
Underweight is the clinical sign of negative energy
and protein balance resulting in the depletion of
body fat and/or fat-free mass stores resulting in the
loss of weight 10% to 20% below that normal for
their age and height.
Underweight is term describing a human whose
body weight is considered too low to be healthy

Underweight and its causes
In underweight is not
considered as a disease or
clinical condition in most
medical corridors and
resources
Underweight is mostly
considered as secondary to a
disease condition, an eating
disorder, a psychological
problem or other factors.

Underweight and its causes
Inadequate food intake, both in quantity and quality.
Increased physical activity without an increase in food intake
leading to energy deficit.
Pathological conditions like fevers, cancer, tuberculosis in
which appetite is poor and energy needs are greatly
increased.
Hormonal imbalance like hyperthyroidism increases the
metabolic rate and hence the energy needs of the body.
Eating disorders due to obsession for slimming may be a
cause as in cases of anorexia nervosa and bulimia nervosa.

Underweight and Infectious diseases

Health problems related to underweight
Underweight results in growth retardation in
growing children.
Lowered resistance to infection and poor general
health.
Decreased work efficiency.
Increased chances of complication during
pregnancy.
Increased risk during surgery.
Increased susceptibility to certain
infections like tuberculosis.

Undernutrition and its
causes
 It includes being
• underweight for one's
age,
• too short for one's age
(stunted),
• dangerously thin for
one's height (wasted)
and
• deficient in vitamins
and minerals
(micronutrient
malnutrition)

Measures of Undernutrition
Stunting
(Chronic)
Underweight
(Both) Wasting (Acute)
Index Height for Age Weight for
Age
Weight for Height
or MUAC
Moderate < -2 SD < -2 SD < -2 SD
Severe < - 3 SD < - 3SD < - 3SD

Stunting
(Chronic)
Underweight
(Both) Wasting (Acute)
Index H/A W/A W/H or MUAC
Moderate < -2 SD < -2 SD < -2 SD
Severe < - 3 SD < - 3SD < - 3SD
Severe Acute
Malnutrition
(SAM)

Definition - SAM
• SAM is defined as
– a very low weight for height (below -3 z scores1 of the median
WHO growth standards),
– by visible severe wasting,
– or by the presence of bilateral pitting oedema, and
– an arm circumference less than 11.5cm
– In children aged 6–59 months
– An indication of major nutrient deficiency (macro- and micro-)

• Globally, it is estimated that there are nearly 20 million
children with SAM
• Most of them live in south Asia and in sub-Saharan Africa.
• Children with SAM have a 5–20 times higher risk of death
compared to well-nourished children.
• SAM can be a direct cause of child death, or
• It can act as an indirect cause by dramatically increasing
the case fatality rate in children suffering from such
common childhood illnesses as diarrhoea and
pneumonia.
• Current estimates suggest that about 1 million children die
every year from SAM

CAUSES AND RISK FACTORS
• Causes of SAM are categorized into primary and secondary type
1. PRIMARY TYPE is due to dietary deficiency
This begins at the fetal stage and continues into infancy and childhood.
Dietary factors contributing to SAM are;
A. Inadequate Diet
a. inadequate breast feeding by the mother due to inability of
mother’s body to make milk due to inadequate nutrition,
b. stopping breastfeeding early in case of working mothers and
inadequate supplementation of other foods,
c. ignorance of weaning and weaning foods,
•.

CAUSES AND RISK FACTORS…….
c. Low purchasing power; inappropriate choice of foods; non-availability of
foods.
d. Prolonged breastfeeding, late introduction of supplementary foods.
e. Diarrhea and intestinal parasitism in children due to unhygienic feeding
habits.
B. Physiological problems with mother
– Problems in the mother such as which may lead to poor lactation to meet
the demand of the infants.
• mental or psychiatric illnesses,
• post-natal depression (severe cases),
• poor maternal health like anaemia and
• having too many children in quick succession or having twins

CAUSES AND RISK FACTORS…….
C. Poor Nutritional Knowledge
• Ignorance of the requirements of a growing child and the improper
use of available resources.
D. Traditions, Customs, and Beliefs
• Traditional methods which are harmful to the baby may be
practiced in villages and rural areas such as not offering colostrum
• Primary causes of SAM are mostly referred to as Sam without
complications
– In developing countries, Uncomplicated SAM are in the majority
2. Secondary causes of malnutrition arises due to a serious illness
and other factors. E.g. tuberculosis, cancer, pneumonia, GIT
problems
• SAM caused by disease conditions is described as SAM with

Shown: 1-year old twins in Chittagong,
Bangladesh Left: Male Right: FemalePhoto

CATEGORIES OF SAM
• SAM with complication
• anorexia,
• infection,
• dehydration
• SAM without complications,
• appetite.
• gaining weight,
• stable

Clinical Types of Severe Acute Malnutrition
Marasmus (gross wasting) Kwashiorker (oedema)
Case Fatality of
20% to 30%
Case Fatality
of 50% to 60%
1. Kwashiorkor
2.Marasmus
3.Marasmic-
Kwashiorkor

CLINICAL CLASSIFICATION
• Decreased subcutaneous tissue: Areas that are most affected are the
legs, arms, buttocks, and face
• Edema: Areas that are most affected are the distal extremities and
anasarca (generalized edema)
• Oral changes: Cheilosis, angular stomatitis, and papillar atrophy
• Abdominal distention secondary to poor abdominal musculature and
hepatomegaly secondary to fatty infiltration
• Skin changes: Flaky paint dermatitis, Dry, peeling skin with raw,
exposed areas; hyperpigmented plaques over areas of trauma
• Nail changes: Fissured or ridged nails
• Hair changes: Thin, sparse, brittle hair that is easily pulled out and
that turns a dull brown or reddish color

KWASHIORKOR
1. Kwashiorkor: associated with excess carbohydrates intake in relation to
low protein intake
• It occurs after protein rich foods are discontinued during weaning and
the child is given food low in proteins and calories.
• Kwashiorkor comes from an African word meaning `displaced child’
referring to the illness of the older infant who is denied breast milk
when the new baby is born. Named by Cecilly Williams in 1933 Nurse or
Pediatrician??

• Kwashiorkor is also called edematous
malnutrition and is common in children
between 1-5 years.
• Children with edema who are 60 to 80%
of weight-for-age are classified as
having evidence of kwashiorkor
• Weight loss is generally less severe in
Kwashiorkor than in marasmus,
although very variable, (a lot of children
are low in weight while others have
normal weight-for-age, even after the
loss of edema.
• Highest mortality – 50 to 60%

• Children appear smaller than their age
• Muscles are limp and underdeveloped
• Digestive problems (including Diarrhea)
• Edema: Bilateral Pitting Edema,
distended abdomen, swollen hands and
ankles.
• Very thin limbs,
• Lethargy and look unhappy, moon face
• Anaemia
• Irritable, difficult to feed
• Electrolyte abnormalities

Occasionally presented signs of Kwashiokor
• Hepatomegaly
• Dehydration (diarrhea. & Vomiting)
• Flaky paint dermatitis
• Cardiomyopathy & failure
• Signs of vitamin deficiencies
• Signs of infections
Dermatitis in Kwashiokor
• Acrodermatitis Entropathica
• Scurvy
• Pellagra
• Dermatitis Herpetiformis

MARASMUS:
2.Marasmus
• This condition is generally seen in
infants less than one year old.
• It occurs due to a deficiency of
proteins, carbohydrates and fats.
• Marasmus is the childhood
equivalent of starvation in adults
and is more serious than
Kwashiorkor.

Symptoms of marasmus
• A large face over a shrunken body
• Eyes are sunken, cheeks are hollow giving a
prematurely aged look
• Skin is dry, loose and wrinkled due to loss of
fat below the skin
• Hair may be normal or dry, thin and light
coloured.
• Muscles are wasted and have poor tone
• Bones are prominent due to absence of fat
around them
• Often stunted
• Hungry, relatively easier to feed

Marasmic Kwashiorkor:
3.Marasmic Kwashiorkar
• This includes symptoms of
both Marasmus and
Kwashiorkar
• It represents the gravest form
of SAM.

Diagnosis of SAM
1. Using weight-for-height:
• WHO and UNICEF recommend the use of a cut-off for weight-for-
height of below -3 standard deviations (SD) of the WHO standards to
identify infants and children as having SAM. OR
2. Using MUAC:
• WHO standards for mid-upper arm circumference (MUAC)-for-age
for children aged 6–60 months with a MUAC less than 11.5 cm. OR
3. Presence Bilateral Pitting Edema OR
4. Presence of visible severe wasting;
• For infants below 6 months, Criteria (1) or (3) or (4) above should be
used

TREATMENT: A Team Work
Approach
• Doctor
• Nurse
• Dietician
• Mother / care-giver
• Social worker
• Physio / O.T.
• Volunteers
• NGO’s

WHO: triage and resuscitation
• Screen children for signs of
SAM
• Assess dehydration in
malnourished children using
additional signs
• Children with kwashiorkor and
marasmus must be given IV
fluid with caution

WHO Guidelines: management of severe
malnutrition (the ‘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

Time frame for the management of
a child with severe malnutrition
Stabilization Rehabilitation
Days 1-2 Days 3-7 Weeks 2-6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients no iron with iron
7. Initiate feeding
8. Catch up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: WHO

INITIAL ASSESSMENT
History
•Recent intake of food and fluids
•Breastfeeding
•Duration and frequency of diarrhea and vomiting
•Type of diarrhea
•Family circumstances
•Chronic cough
•Contact with TB
•Known or suspected HIV infection

ON EXAMINATION
•Signs of dehydration or shock
•Severe palmar pallor
•Eye signs of vitamin A deficiency
•Localizing signs of infection
•Fever or hypothermia
•Mouth ulcers
•Skin changes of kwashiorkor:
•Hypo or hyperpigmentation
•Desquamation
•Ulceration

GENERAL TREATMENT
General treatment of severe malnutrition involves
two phases:
•An initial stabilization phase
•A longer rehabilitation phase
• Initial stabilization phase addresses management
of complications, micronutrient deficiency and
initiation of the catch up growth.
• Rehabilitation phase strengthens what has been
achieved in the initial phase with the catch up
growth, electrolyte balance and sensory
stimulation.

Treatment of SAM
SAM MANAGEMENT
Independent
additional
criteria
•No Appetite
•Medical complication
•Appetite
•No Medical
complication
Type of
therapeutic
feeding
Facility-based Community-based
Intervention F75
F100/RUTF
And 24 hour medical
Care
RUTF, basic
medical care
Discharge
criteria
(Transition
criteria
from facility to
Reduced oedema
Good appetite
(with acceptable
intake
of RUTF)
15 to 20%
weight gain

WHO: Stabilisation phase
• Hypoglycaemia (prevent, monitor & treat):
– 2-3 hourly fortified milk feeds (60-130ml/kg/d)
• Hypothermia (prevent, monitor and treat):
– 3 hly temp, warm skin-to-skin, use hat, no baths
• Dehydration: (prevent and treat):
– Treat shock cautiously, rehydrate orally
• Suspect and treat infection:
– Assume infection, give broad spectrum antibiotics
– Monitor appetite, weight: if not better, change
antibiotics after 48 hours

WHO: Stabilisation phase (cont.)
• Correct electrolyte imbalances:
– Hypokalemia: oral K, if K<2.5, add IV KCl (!)
– Hyponatremia: do not give Na supplements
• Treat micronutrient deficiencies:
– Vit A stat – reduces morbidity and mortality
– Multivitamins, Zink sulphate, Phosphate,
Folic acid, copper
– Give Fe later – once infection is controlled

MANAGEMENT OF COMPLICATIONS
Hypoglycaemia:
•Where blood glucose results can be obtained
quickly (eg with Dextrostix), this should be
measured quickly.
•Hypoglycaemia is present when blood glucose is
<3 mmol/l (<54 mg/dl)
•Give 50mls of 10% glucose.
•Give 2 hourly feeds, day and night at least for
the first day.
•If the child is unconscious. Treat with IV glucose.

MANAGEMENT OF COMPLICATIONS
Hypothermia(<35C):
•Is associated with increased mortality in
severely malnourished children.
•Feeding the child, ensuring adequate clothing
and appropriate antibiotics forms the
management.

Initial Treatment: Stabilisation phase
(cont.)
 Infections
o ↓ fever, inflammation
o Measles vaccine
o 1st line, all children
 Cotrimoxazole
 Complications: ampi + gent
 2nd line, > 48 hr ATB
 + chloramphenicol
 Malaria, candidiasis
 Helminthiasis
 TB
 Dermatosis Kwashiorkor
– 1% K permanganate soaks
– Nystatin
– Zinc + castor oil
 Vitamin deficiencies
o Folic acid
o Vit mix: riboflavin, ascorbic acid,
pyridoxine, thiamine, fat soluble vit D,
E, K
o Vit A PO or IM
• Eye pads NS solution
• Tetracycline + atropine eye
drops
• Bandage eyes
 Severe Anemia
– Transfusion PRC/WB (CHF)
– No Iron at this stage
 CHF
– Overhydration (>48hr)
– Stop feeds. Give furosemide

WHO: Stabilisation phase (cont.)
• Initial Refeeding:
– Frequent small feeds orally/nasogastrically
– 100 kcal/kg/day; protein: 101.5g/kg/day;
liquid:100- 130ml/kg/day
• Monitor:
– 3 hourly temperature and dextrostix for first 72
hours
– Daily weight (same conditions)
• Audit outcome
– Weight gain (good: >10g/kg/day), mortality (

WHO: Rehabilitation phase
• Catch-up growth:
–Return of appetite then gradual transition
–Frequent feeds, up to 200ml/kg/day (!)
–150-200 kcal/kg/day; protein 4-6
gram/kg/day
Stimulation and support
–Visual and emotional stimulation
–Social support: child care grant
application, etc.
• Prepare for follow-up
–Follow IMCI feeding recommendations

Traditional Response
Phase I – Stabilization* Phase II – Rehabilitation
Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**
Care Attend to complications (e.g. shock, hypoglycemia)**
Feed F-75 Therapeutic Milk F-100 Therapeutic Milk
Quantity 130ml/kg/day** 200ml/kg/day**
Length of Time 1-7 Days, 3 to 4 Weeks
*
Case Fatality
of less than
10%

Community-Based Management of
Acute Malnutrition (CMAM)
Phase I – Stabilization Phase II – Rehabilitation
Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**
Care Attend to complications (e.g. shock, hypoglycemia)**
Feed F-75 Therapeutic Milk RUTF
Quantity 130kcal/kg/day** 250kcal/kg/day**
Length of Time 1-7 Days, 3 to 4 Weeks
Outpatient
Care

The PlumbyNut
• Development
of
PlumpyNut–a
Ready to Use
Therapeutic
Food (RUTF)
equivalent to
F-100

Rehabilitation
• Principles & criteria
– Eating well
– MS improved: smiles, responds to stimuli
– Dev appropriate behavior
– Nl temperature
– No V/D
– No edema
– Gaining Wt: > 5g/kg of body wt/d x 3 days
• Most important determinant of recovery:
– Amount of energy consumed: calories, protein, micronutrients (K, Mg,
I, Zn)

Nutrition for children < 24 mo
• F-100 diet q 4 hr (day & night)
• ↑each feed by 10ml
• 150-220 kcal/kg/d
• Folic acid + Iron, Vit & Mineral mix
• Attitude of care giver crucial
• Decreasing edema
• F-100 continued till Target Wt (-1 SD/ 90% of median NCHS/WHO
reference value for WFH)
• Wt daily plotted on graph
• Target wt usually reached 2-4 wks

Nutrition for children > 24 mos
• ↑ amounts F-100 (practical value in refugee camps, # different diets )
• Introduce solid foods
• Local foods should be fortified
– ↑ content of Energy (oil), minerals &Vitamins (mixes)
– Milk added (protein)
– Energy content of mixed diets: 1kcal or 4/2kj/g
– F-100 given between feeds of mixed diet
• 5-6 feeds /d
• Folic acid (5mg on day 1, 1mg/d) + Iron ( 3mg/kg elemental iron/d x 3mo)

Emotional & physical stimulation
• 1ary/2ary prevention DD, MR, ED
• Start during rehabilitation
• Avoid sensory deprivation
• Maternal presence
• Environment
• Play activities, peer interactions
• Physical activities

Rehabilitation
• Parental teaching
– Correct feeding/food preparation practices,
– Stimulation, play, hygiene
– Treatment diarrhea, infections
– When to seek medical care
• Preparation for D/C
– Reintegration into family & community
– Prevent malnutrition recurrence

Criteria for D/C
Child
 WFH reached -1SD
 Eating appropriate amount of diet that mother can prepare at home
 Gaining wt at normal or ↑rate
 Vit/mineral deficiencies treated/corrected
 Infections treated
 Full immunizations
Mother
 Able & willing to care for child
 Knows proper food preparation
 Knows appropriate toys & play for child
 Knows home treatment fever, diarrhea, ARI
Health worker
 Able to ensure F/U child & support for mother

Follow up
• Child usually remains stunted w/ DD
• Prevention of recurrence severe malnutrition
• Strategy for tracing children
• F/U: 1,2, 4 weeks, then 3 & 6 mos, then 2x/yr till
age 3yrs
• WFH no less than -1SD
• Assess overall health, feeding, play
• Immunizations, treatments, vitamin/minerals
• Record progress

Severe Malnutrition:
Before and After

Conclusion
“Many things we need can
wait. The Child cannot.
Right now is the time his
bones are being formed, his
blood is being made and his
senses are being
developed. To him we
cannot answer “Tomorrow”.
His name is “Today”.”
- Gabriela Mistral -

(_nut)LECTURE_SAM[2].pptx

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