This document discusses severe acute malnutrition (SAM) in children. It defines SAM and describes its etiology as primarily being due to inadequate dietary intake, though secondary causes like infection can also play a role. The pathophysiology involves a vicious cycle between undernutrition and infection that impacts multiple organ systems. Complications of SAM include hypoglycemia, hypothermia, and electrolyte imbalances. The principles of management outline a 10 step process including stabilization, infection treatment, rehydration, micronutrient supplementation, refeeding, and follow up care. Refeeding syndrome is also discussed as a potential complication.

1. Presented By-
BIBHU PRASAD SAHU
RUPSY
DIYA SAHA
HITESH KHATUA
ARPIT PATEL
PRITHVI SENA JAS

2. 1. Definition
2. Etiology
3. Pathogenesis/ Pathophysiology
4. Complications
5. Principles of management
6. Summary

3.  Hunger– Physiological state when food is not able to
meet energy needs.
 Malnutrition– Malnutrition refers to deficiencies or
excesses or imbalances intake of energy and/or
nutrients in a person .
It could be under-nutrition or over-nutrition(obesity) .
 Undernutrition – most common form of malnutrition
in developing countries.
 Overnutrition(obesity)- common on developed
countries

4. Fig: Undernourished and Obese

6. WHO and UNICEF defines Severe Acute Malnutrition
(SAM) for children aged 6 months to 60 months as :
◆ Weight for height below -3 SD score of the median
WHO growth standards.
◆ By visible severe wasting.
◆ Bipedal oedema ; and
◆ Mid upper arm circumference below 115mm.

9. • Primary - when the otherwise healthy
individual's needs for protein, energy, or both
are not met by an adequate diet. (most
common cause worldwide)
• Secondary - result of disease states that may
lead to sub-optimal intake, inadequate
nutrient absorption or use, and/or increased
requirements because of nutrient losses or
increased energy expenditure.

10.  Lack of food (famine, poverty)
 Inadequate breast feeding
 Wrong concepts about nutrition
 Diarrhoea & malabsorption
 Infections (worms, measles, T.B)

12. The “Vicious Cycle”of Undernutrition & Infection
Disease:
. incidence
.severity
.duration
Appetite loss
Nutrient loss
Malabsorption
Altered metabolism
Inadequate
dietary intake
Weight loss
Growth faltering
Lowered immunity
Mucosal damage
F i g u re 2. T h e Synergistic cycle o f infection an d malnutrition

13. Across all organ systems !!
13

15. Infection : lung , blood, UT, GIT, skin
Metabolic
hypoglycemia
hypocalcemia
hypomagnesemia
Hypothermia

18. • Severe vomiting/ intractable vomiting
4/10/2016 44

23. Hypothermia:
axillary’s temperature < 35°C
or rectal < 35.5°C
Fever > 39°C
4/10/2016 45

28. The WHO has developed guidelines have been
adapted by the Indian Academy of Pediatrics.
*The general treatment involves ten steps in two
phases:
i. The initial Stabilization phase focuses on restoring
homeostasis and treating medical complications
and usually takes 2-7 days of inpatient treatment.
ii. The Rehabilitation phase focuses on rebuilding
wasted tissues and may take several weeks.

30. Step 1: Treat/Prevent Hypoglycemia
*Blood glucose level <54 mg/dl or 3 mmol/l.
*If blood glucose cannot be measured, assume hypoglycemia.
*Hypoglycemia, hypothermia and infection generally occur
as a triad.
Treatment
*Give 50 ml of 10% glucose or sucrose solution orally or by
nasogastric tube followed by first feed.
*Feed with starter F-75 every 2 hourly day and night
Prevention
*Feed 2 hourly starting immediately.
*Prevent hypothermia.

31. Step 2: Treat/Prevent Hypothermia
*Rectal temperature less than <35.5°C or 95.5°F or
axillary temperature less than 35°C or 95°F.
Treatment
*Clothe the child with warm clothes.
*Provide heat using overhead warmer, skin contact or heat
convector.
*Avoid rapid rewarming as this may lead to disequilibrium.
*Feed the child immediately.
Prevention
*Place the child's bed in a draught free area.
*Always keep the child well covered
*Feed the child 2 hourly starting immediately after
admission.

32. Step 3: Treat/Prevent Dehydration
with Shock
*All severely malnourished children with watery
diarrhea have some dehydration.
Treatment
*Use ORS with potassium supplements.
*Initiate feeding within two to three hours of starting
rehydration.
Prevention
*Give ORS at 5-10 ml/kg after each watery stool, to
replace stool losses.
*If breastfed, continue breastfeeding.
*Initiate refeeding with starter F-75 formula.

34. Step 4: Treat/Prevent Infection
*Multiple infections are common.
*Majority of bloodstream infections are due to gram-
negative bacteria.
Treatment
*Treat with parenteral ampicillin 50 mg/kg/ dose 6 hourly
for at least 2 days
*followed by oral amoxicillin 15 mg/kg 8 hourly for 5 days
and
*gentamicin 7.5 mg/kg once daily for 7 days.
*If other specific infections are identified, give
appropriate antibiotics.
Prevention
*Follow standard precautions like hand hygiene.
*Give proper vaccination if not immunized and is of
suitable age

35. Step 5: Correct Electrolyte Balance
*Give supplemental potassium at 3-4
mEq/kg/ day for at least 2 weeks.
*On day 1, give 50% magnesium sulphate IM
once. Thereafter, give extra magnesium
(0.8-1.2 mEq/kg daily)
Step 6: Correct Micronutrient
Deficiencies
*Use up to twice the recommended daily
allowance of various vitamins and minerals
*On day 1, give....

36. *Micronutrient
supplementation
GOI OPERATIONAL GUIDELINES ON
MALNUTRITION 2011
36
MICRONUTRIENT DOSING
Vitamin A
Vitamin A,C, D, E and B12 TWICE RDA
Zinc 2 mg/kg/day
Iron Start after two days on catch up diet, elemental
iron @ 3 mg/kg/day
Copper 0.3 mg/kg/day (if separate preparation not
available use commercial preparation containing
copper)
Folate 5 mg on day 1, then 1 mg/day
Micronutrient Supplementation

37. Step 7: Initiate Re-feeding
*Start feeding as soon as possible as frequent small feeds.
*If unable to take orally, initiate nasogastric feeds.
*Total fluid recommended is 130 ml/kg/day.
*If breast feeding, then continue breast feeding.
*Start with F-75 starter feeds every 2 hourly.
*If persistent diarrhea, give a cereal based low lactose F-75
diet as starter diet.
Step 8: Achieve Catchup Growth
*Once appetite returns in 2-3 days, encourage higher intakes
*Increase volume offered at each feed and decrease the
frequency of feeds to 6 feeds per day.
*Make a gradual transition from F-75 to F-100 diet.
*Increase calories to 150-200 kcal/kg/ day, and proteins to
4gm/kg/day.

38. Step 9: Provide Sensory Stimulation & Emotional
Support
*A cheerful, stimulating environment.
*Age appropriate structured play therapy for at least 15-
30min/ day.
*Tender loving care.
Step 10: Prepare for Follow-up
*Primary failure to respond is indicated by:
*Failure to regain appetite by day 4.
*Presence of edema on day 10.
*Failure to gain at least 5 g/kg/day-by-day 10.
*Secondary failure to respond is indicated by:
*Failure to gain at least 5 g/kg/day for consecutive days
during the rehabilitation phase.

39. 39

41.  Clinical complex, which includes
electrolyte changes associated
with metabolic abnormalities that
can occur as a result of nutritional
support ( enteral or parenteral), in
severely malnourished patients.
 Also called “the hidden syndrome”
 History

43.  Nausea, vomiting, and lethargy
 Respiratory insufficiency, cardiac
failure, hypotension, arrhythmias,
delirium, coma, and death

44. Refeeding a malnourished patient can result in
Heart failure due to:
 Atrophic myocardium in malnutrition
 Muscle depletion of Mg, K, P
 Sodium and water overload

45. Feeding and correction of biochemical
abnormalities can occur in tandem
without deleterious effects to the
patient.(NICE)
Early identification of at risk individuals,
Monitoring during refeeding , and
An appropriate feeding regimen are
important.

46. Sam is major burden in deveoping countries.
SAM is a medical emergency
Pathophysiology still elusive and incomplete
Ten steps are the key to successful management
Community based treatment has revolutionised
management of SAM
Special needs for young infants and follow up
issues need to be recognised

47. *