Classification and management of malnutrition

1. Sever Acute Malnutrition
Sarra Osheik Ahmed

2. Definition
 WHO definition of SAM:
 1.Sever wasting and or bilateral odema.
 2.MUAC less than 11.5cm.

3. Sever wasting is defined as:
 Weight for height less than -3 Z Score.
 Mostly visible on thighs , buttocks, upper arms, between ribs, scapulae and
face (old man appearance).

4. Oedema:
Edema firstly involve feet then legs and quickly can became
generalized.
grade depth rebound
1 2 mm immediately
2 3-4 mm < 15 seconds
3 5-6 mm 10-30 seconds
4 8 mm > 20 seconds

5.  Moderate malnutrition:
 wasting (WFH -2 to -3 Z score)
 MUAC (11.5 to 12.5 cm)
 Can be treated as out patient if clinically well and have good appetite.

6. Pathophysiology:
 When the child nutrient intake is insuffient to meet the daily needs,
physiological and metabolic changes take place to conserve energy.
 This changes called reductive adaptive , it has many consequences.
 1.liver makes less glucose hypoglycemia.
 Less albumin and transferrin.
 2.less heat production hypothermia.
 3.kidneys execrates less sodium and water and more potassium
Na+ overload and k+ depletion.
 4.Gut produce less gastric acids and decrease motility leads to accumulation
of bacteria in stomach and small intestine ,destructs mucosa
malabsorption.

7.  5.Red blood cell mass is reduced , iron is released which need amino acids
and glucose to be converted into ferritin , this free iron leads to bacteria
growth and free radicals formation.
 6.Heart pumping effect decreased ( due to reduced action of Na+/k+ ATP
pump) leads to decrease cardiac output and fluid overload (heart failure).
 7. Reduced cellular immunity .
 8.micronutrients deficiency leads to skin (together with odema leads to skin
cracking and peeling patches (flaky paint dermatitis).
 and hair changes( spares, easily pulled out, loses its curls and its color may
changes into pale or reddish)

8. Criteria for admission of SAM 6-59 mo:
 1.Sever odema = grade 3.
 2.sever wasting and or any grade of odema plus medical complications.
 (lethargy, unconscious, poor appetite, hypoglycemia…..etc)
 Criteria for admission of SAM less than 6 mo:
 1.bilateral pitting odema.
 2.WFL -3 Z score.

9. Principles of management :
 10 steps in 2 phases :
 1.stabilization phase.(2-7 days)
 2.Rehabilitation phase.

12. Treat and prevent hypoglycemia:
 Blood glucose <3mmol/l
 All severely malnourished children are at risk
 It’s an important cause of death
 Signs include lethargy, limpness, convulsion, drowsiness, unconsciousness
 To prevent this, must feed every 2-3 hours day and night
Treatment
 If awake, rouse and give a drink of 10% glucose or F75 whichever is available
 If 50% glucose is the only available medication dilute 1:4 sterile water
 If child unconscious / cannot be roused give :
 5ml/kg of 10% glucose iv. Followed by NG
 If iv access not possible give by NG and continue orally when awake.

13. Treat and prevent hypothermia:
 Axillary . temp < 35.0 °C, rectal <35.5°C prevention
 Child should be warmed/kept dry
 Use kangaroo technique – skin to skin
 Cloth child well from head down with blanket and place under lamp (not
fluorescent) or hot water bottle for rewarming
 Must receive treatment for hypoglycemia and infection too.

14. Treat and prevent dehydration:
 Dehydration signs are no more reliable in severe malnutrition with many signs
seen in both dehydration and septic shock .
 Reliable signs: History of D, Thirst, sunken eyes of recent onset.
 Weak/absent radial pulse
 Cold hands and feet.
 Urine flow reduced or absent.
 In septic shock (apathy, limp and hypothermia)

15.  Not very reliable:
 Mental state may be seen also in hypoglycemia, hypothermia and septic shock.
 Dry mucous membranes
 Skin elasticity.
 Treatment:
 Rehydrate orally
 Use IV only if there are signs of shock
 Use ReSoMal with less sodium and more potassium, plus magnesium, zinc and
copper.
 Give 70-100ml/kg over 12 hours, i.e. ,5 ml/kg every ½ hour for first 2 hours. Then
give 5-10ml/kg every hour for 10 hrs.

16. Treatment of septic shock:
 Broad spectrum antibiotics
 Keep the child warm
 Prevent/treat hypothermia
 Feed to prevent hypoglycemia
 Iv fluids at 15 ml/kg/hr as:
 ½ Darrow’s with 5% glucose
 Ringer’s Lactate with 5%glucose
 ½ Normal Saline with 5%glucose

17.  Monitor for overhydration / cardiac failure
 As soon as radial pulse becomes strong and child regains consciousness
continue rehydration orally or by NG tube
 If signs of congestive cardiac failure develop or child does not improve,
give a blood transfusion 7-10mls/kg slowly over 3hrs
 After Tx begin with F-75 diet by NG Tube.

18. Electrolyte imbalance:
 All severely acutely malnourished children have excess body sodium
 Deficiencies of potassium and magnesium are present and may take at
least two weeks to correct. Oedema is partly due to these imbalances.
 Do NOT treat oedema with a diuretic
 Give:
 Extra potassium 3-4 mmol/kg/d
 Extra magnesium 0.4-0.6 mmol/kg/d
 When rehydrating, give low sodium rehydration fluid (e.g., ReSoMal)
 Provide ReSoMal

19. Dietary treatment:
 Continue to breast feed
 Give therapeutic milk formula diet
 F-75 used in the stabilization phase
 RUTF or F-100 used in rehabilitation phase
 May be easily prepared from basic ingredients or commercially available.
 Feed 2-3 hourly by day and night
 130 ml/kg/day
 NG feeding
 Initial phase ends when appetite returns.

20. Treat and prevent infection:
 Nearly all severely malnourished children have bacterial infections
 Often the usual signs are absent
 Assume presence of infection, Prescribe all severely malnourished children a
broad spectrum antibiotic starting on day of admission
 Children admitted with severe acute malnutrition and complications such as
septic shock, hypoglycaemia, hypothermia, skin infections, respiratory or
urinary tract infections, or who appear lethargic or sickly should be given
parenteral (IM or IV) antibiotics: ampicillin, IM or IV for 2 days, followed by
oral amoxycillin for 5 days together with IM of IV gentamicin for 7 days

21.  If no complication: Amoxicillin replace Cotrimoxazole
 If complications: same as before but changes in dosage and duration.
 Chloramphenicol and Nalidixic acid have been deleted from the list.
 In addition, give Metronidazole 7.5mg/kg 8hourly orally for 7 days to all
children with chronic diarrhoea. If a child fails to improve after 48 hours
you can used any third-generation cephalosporin.
 Give Cotrimoxazole (6-8mg/kg TMP once daily) to all children who are HIV+,
or have been exposed to HIV, to reduce risk of respiratory infections pcp.

22. Correct micronutrient deficiencies:
 Children with SAM should daily receive 5 000 IU vitamin A throughout the
treatment period.
 Additional vitamin A is not required if children with SAM are receiving F-75, F-
100 or RUTF that comply with WHO specifications (and therefore already
include sufficient vitamin A).
 A high dose of vitamin A should be given on admission only when non-fortified
therapeutic foods are being used (i.e., not fortified as recommended in WHO
specifications) and vitamin A is not part of other daily supplemen.
 A high-dose vitamin A supplementation (compared to no supplementation at
all) appears to confer some benefit in children with SAM who present with
severe diarrhea or shigellosis or have clear signs of vitamin A deficiency.

23.  In the context of feeding with F-75 or RUTF, adding potassium, zinc and
magnesium to an oral rehydration solution (such as is done in ReSoMal) may
be less important. Therapeutic foods already include adequate amounts of
these minerals and trace elements.

24. Start caution feeding:
 Planning feeding for 24- hour period for;
 A child taking F- 75.
 Gradual transition; F-75 to RUTF/F-100
 Feeding freely during rehabilitation
 Measuring and Giving feeds
 Recording on Daily care Chart
 Daily Care.
 Involving Mothers.

25.  F 75 is the starter formula and F 100 used as follow on formula.( Water based)
 RUTF is lipid based paste.
 They are mixed with water, therefore high chance of getting contaminated
 Should be used only for inpatients.
 Substitutes can be prepared using locally available ingredients.
 Feeding technique:
 Preferably Oral route. • Bottles should never be used.
 Cup Feeding.

26.  Naso-gastric feeding:
 *If child’s intake is less than 80% of total.
 Painful lesions in mouth.
 Disturbed conscious level.
 Cleft palate.

27. Feed F75 during stabilization
 F75 provide ,75 kcal and 0.9 gram protein per 100ml
 Ingredients: milk, sugar, oil, electrolyte, minerals.
 Keep using starting wt.; also in +++ edema.
 Except when rehydrated, use new wt. on next day
 If vomits, repeat estimated amount, usually (50%).
 Record the Feeding on Daily Care.
 Calculate total intake at the end of day.

28. Readiness for transition:
 Look for these signs, usually after 2 -3 days
 Return of appetite
 Reduced oedema or minimal oedema
 When these signs appear, the child is ready for transition.
 Start to introduce RUTF (100-135 kcal/kg/day) as tolerated.
 When the child eats 75% of RUTF per day discontinue the F75 or F100
 Be careful & slow – to prevent re-feeding syndrome deaths.
 Monitor very carefully

29. Requirements during rehabilitation
 Aim: To re-build wasted tissue and gain weight by High energy (150-220
kcal/kg/day)
 High protein (4-6g/kg/day)
 Feed frequently to appetite
 Or use Ready to Use Therapeutic Food 200kcal/kg.
 This is done at home The child is referred to outpatient care facility for
follow up and routine Medications.
 Good wt gain >10 g/kg/d. poor wt gain < 5 g/kg/d.

30. Day care during stabilization:
 Handle the Child Gently; While clothing, bathing (bathe Children daily unless
very sick).
 Talk softly and encourage mothers to provide care.
 Skin care:(Use regular soap in mild to moderate dermatosis).
 in Severe dermatosis, bathe for 10-15min/day in 0.01% potassium
permagnate.
 Apply barrier cream on raw areas.
 In case of Nappy rash, use Nystatin cream.

31. Eye care:
 Chloramphenicol/ Tetracycline Eye Drops for Eye Infection .
 Atropine Eye Drops used to relax the Eye in Corneal Involvement.

32.  Involving & Training Mothers
 Emotional support essential for Early recovery.
 Use Toys to stimulate admitted babies.
 Mother is the only person who can provide continuous support When involved
in care at ward can continue at home.
 Counseling for better Hygiene

33. Discharge Criteria from the Inpatient
Care
 Referred to outpatient care if edema reducing and/or
 medical complication resolving, and clinically well and Discharge if taking
feed clinically well and alert,
 MUAC >125 mm and no edema for 2wks.
 WFH of at least > -2Zscore for at least 2wks .

34.  Provide feedback to mother on discharge outcome
 Explain the mother on the importance of follow up to prevent relapse
 Note discharge outcome in the register and treatment card.
 Advice the mother to report to the nearest health facility if: high fever,
frequent/blody diarrhea.
 Write all drugs provided, in the yellow card that is used to refer the child
from inpatient.
 If possible communicate with the OTP care facility by telephone, radio
message