The document summarizes key information about severe acute malnutrition (SAM). It discusses the global burden of malnutrition, criteria for identifying SAM, pathophysiology, changes in body organs and metabolism, screening and outpatient/inpatient management. It provides details on the stabilization, transition and rehabilitation phases of hospital management, following the 10 steps for routine care which include treating hypoglycemia, hypothermia, dehydration and infections, and correcting electrolyte and micronutrient deficiencies. It also describes starter diets like F-75.

1. SEVERE ACUTE MALNUTRITION
PRESENTED BY: SREETAMA CHOWDHURY
CHAIRPERSON: DR. SHIBANI PAL

2. GLOBAL BURDEN OF MALNUTRITION
• According to WHO, an estimated 50.6 million under 5 children are malnourished in developing countries.
• 43% and 36% of under 5 children in India are underweight according to NFHS 3and NFHS 4 respectively. NFHS 3
revealed 6.5% are severely wasted. 17 % suffered from MAM. NFHS 4 reveals 7.5% as severely wasted.
• Mortality rates in children with SAM were 9 times higher than well nourished children with infectious diseases (
Black et al, 2008)
• 20% children in West Bengal were wasted acc to NFHS 4.

3. IDENTIFICATION OF SEVERE ACUTE MALNUTRITION
• Recommended criteria for identifying SAM in infants > 6 months of age:
• 1. Weight-for-height less than –3 Z score according to WHO median growth chart and/or
• 2. Visible severe wasting and/or
• 3. Mid arm circumference <11.5 cm and/or
• 4. Oedema of both feet
• Recommended criteria for identifying SAM in infants <6 months age: (MOHFW)
Any infant more than 49 cm who has following features are treated as severe acute
malnutrition:
• 1.Weight-for-length less than -3 Z score according to WHO growth charts and/or
• 2. Visible severe wasting and/or
• 3.Oedema of both feet*

4. PATHOPHYSIOLOGY OF SAM:
Child's intake is insufficient to meet his daily requirements
Process of REDUCTIVE ADAPTATION sets in:
1. Fat stores are mobilised for energy --> mobilisation of protein in muscles, skin and GI tract
2. Reduced activity , BMR, reduced infalmmatory and immune responses

5. CHANGES SEEN IN BODY ORGANS AND METABOLISM:
1. Liver – a. Reduced glucose production hypoglycemia
b. Reduced ability to synthesise albumin, transferrin, transport proteins
c. Reduced ability to cope with dietary proteins and toxins
2. Reduced thermogenesis
3. Kidneys – Reduced renal excretion of excess fluids and sodium fluid overload
4. Heart- Smaller, weaker with reduced cardiac output propensity of cardiac failure if fluid overload
5. Sodium- Reduced activity of Na-K pump + leaky cell membranes increased intracellular
sodium fluid retention and oedema
6. Potassium – Cell leakage and urinary excretion
7. Muscle protein loss accompanied by loss of K, Mg, Zn and Cu.

6. CONTINUED...
8. GI – Reduced production of enzymes and gastric acid, reduced motillity easy colonization
9. Reduction in cell replication and repair easy tranlocation of organisms through gut mucosa
10. Impaired immune function , especially CMI
11. Reduced RBC mass iron release increased consumption of glucose and amino acids to be
converted to ferritin hypoglycemia and amino acid imbalance.
12. Micronutrient deficiency reduced free radical deactivation cell damage

7. SCREENING OF SAM
Screening of children : a. active screening by AWW, ASHA through house to house visit with MUAC tape and to
look for b/l pitting pedal edema
b. passive screening during growth monitoring, village health and nutrition days ( VHND)
using MUAC and b/l pitting edema AND screening of children coming to opd/ inpatient ward
Features of SAM No features of SAM
Medical complications No medical complications Nutritional counselling to mother
Immediate referral to NRC Refer to VHND or subcentre for assessment by ANM
after discharge
Transfer to community based programme for SAM
Appetite test: Child > 12 months: locally prepared food ( rosasted ground nut+ milk powder + sugar + coconut oil)
Good appetite: food consumed as follows: <4 kg = > 15 gm, 4-7 kg = > 25 gm, 7-10 kg = > 35 gm, 10-14 kg-
>50 gm

8. OUTPATIENT MANAGEMENT OF SAM
• Therapeutic food adhering to WHO and UNICEF specifications is to be provided eg RUTFs. Amount to be
consumed is 3- 4.9 kg  105-130 gm/day, 5-6.9 kg  200-250 gm/day, 7-9.9 kg 260-400 gm/day and
>10 kg  400-460 gm/day.
• The food must be given in 2-3 hrly feeds with plenty of water.
• Counselling about breastfeeding, supplementary care, hygiene, feeding, immunisation
• Non-responder/primary failure : failure to gain weight within 21 days and loss of weight within 14 days
• Secondary failure/ relapse: failure of appetite test at any visit or weight loss of 5% at any visit
• Discharge criteria : a. weight for height > -2 z score and no edema OR b. MUAC > 125 mm and no edema

9. CRITERIA FOR HOSPITAL ADMISSION IN SAM

10. NUTRITION REHABILITATION CENTRES (NRC):
• NRC is a unit in a health facility where children with SAM are admitted and managed
• Services provided: a. 24 hr care and monitoring
b. t/t of medical complications
c. Therapeutic feeding
d. Providing sensory stimulation and emotional care
e. Social assessment of family and counselling on feed, care and hygiene
f. Demonstration and practice
g. follow up of discharged children.
• At district hospital / Medical college, NRC has 10-20 beds. Unit must be in proximity to paediatric medicine ward.
• NRCs should have : Patient area, play and counselling area, nursing station, kitchen and food storage, Toilets
• Staff: 1 MO, 2 nursing staff, nutritionist, 2 cook cum caretaker, 1 attendant and 1 medical social volunteer

11. CONTINUED..
• Incentives provided: 100 rs per child to ASHA/ AWW for accompanying the child to NRC and Rs 100 per child for follow
up, Rs 200 per child for first visit and again for follow up to mothers for reimbursement.
• Children with SAM are admitted for 14-21 days. 4 follow up visits at intervals of 15 days are done.
• Discharge criteria: Absence of b/l edema for last 10 days, no medical complication and gain of weight on breast feed
alone for <6 m and more than 15% gain of weight from admission weight for 6-59m ( WHO 2009 criteria)
• As per the Press Information Bureau of MOHFW 2017, there are 966 NRCs in the country 1.7 lac children admitted.
• WB has 35 NRCs.
• NGOs associated with SAM management on community basis: CareIndia, Save the Children, Fight Hunger foundation,
Doctors for You.

12. MANAGEMENT OF SAM CHILDREN PRESENTING WITH
COMPLICATIONS:
• Triage
• Assessment : History and physical examination
• Laboratory Tests : Glucose, Hb/PCV , Serum electrolytes, TLC/DLC/Blood C/s, Urine re/me and c/s, CXR,
Mantoux
• Management

13. HISTORY AND PHYSICAL EXAMINATION:
• HISTORY
• Medical history:
• Usual diet before current episode of illness
• Breastfeeding history
• Food and fluids taken in past few days
• Recent sinking of eyes
• Duration and frequency of vomiting or diarrhoea, appearance of vomit or diarrhoeal stools
• Time when urine was last passed
• Contact with people with measles or tuberculosis
• Any deaths of siblings
• Birth weight
• Milestones reached (sitting up, standing, etc.)
• Immunizations

14. • PHYSICAL EXAMINATION
• Weight and length or height
• Oedema
• Enlargement or tenderness of liver, jaundice
• Abdominal distension, bowel sounds, “abdominal splash” (a splashing sound in the
abdomen)
• Severe pallor
• Signs of circulatory collapse: cold hands and feet, weak radial pulse, diminished
consciousness
• Temperature: hypothermia or fever
• Thirst
• Eyes: corneal lesions indicative of vitamin A deficiency
• Ears, mouth, throat: evidence of infection
• Skin: evidence of infection or purpura
• Respiratory rate and type of respiration: signs of pneumonia or heart failure
• Appearance of faeces

15. PRINCIPLES OF HOSPITAL BASED MANAGEMENT OF SAM:
• Three phases:
• STABILISATION PHASE: 1-2 days. F-75 feeding formula used.
• TRANSITION PHASE: 2-3 days. Pre requisites: At least the beginning of loss of edema AND return of
appetite AND No NG tube/infusions/medical complications AND alert,reactive child. Transition from F-
75 to F-100 diet in same amount.
• REHABILITATION PHASE: Pre requisite: Reasonable appetite( finished >90% of feed without significant
pause), major reduction or loss of edema and no other medical problem.

16. MANAGEMENT OF SEVERE MALNUTRITION:
• GENERAL PRINCIPLES FOR ROUTINE CARE:
• THE TEN STEPS
1.Treat/prevent hypoglycaemia
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

17. STEP 1: TREATMENT OF HYPOGLYCEMIA
• 1. If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl give:
• 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded
teaspoon of sugar in 3.5 tablespoons water), orally or by nasogastric
(NG) tube. Then feed starter F-75 every 30 min. for two
hours (giving one quarter of the two-hourly feed each time)
• 2. If the child is unconscious, lethargic or convulsing give:
• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose
or sucrose by Ng tube. Then give starter F-75 as above
• Monitor:
• blood glucose: if this was low, repeat dextrostix taking blood from
finger or heel, after two hours. Once treated, most children stabilise
within 30 min. If blood glucose falls to <3 mmol/l give a further 50ml
bolus of 10% glucose or sucrose solution, and continue feeding every
30 min. until stable
• rectal temperature: if this falls to <35.5oC, repeat dextrostix
• level of consciousness: if this deteriorates, repeat dextrostix

18. STEP 2: TREATMENT OF HYPOTHERMIA
• Axillary temperature < 35 degrees or rectal temperature(preferably with a low reading thermometer) < 35.5
degrees
• 1.Feed straightaway (or start rehydration if needed)
2.Rewarm the child: either clothe the child (including head), cover with a
warmed blanket and place a heater or lamp nearby (do not use a
hot water bottle), or put the child on the mother’s bare chest (skin to
skin) and cover them.
• Monitoring :
a. two hourly rectal temperature when rewarming until it rises to > 36.5
b. glycemic state of the child
c. ensuring that the child is covered at all times especially at night.

19. STEP 3: TREATMENT OF DEHYDRATION
• ReSoMal OR WHO low osmolarity ORS with potassium supplements
5 ml/kg every 30 mins, for 2 hours(orally/ NG tube)
5-10 ml/kg/h for next 4-10 hours: exact amount determined by how much the child wants,stool loss and vomiting. Replace the
ReSoMal doses at 4, 6, 8 and 10 hours with F-75 if rehydration is continuing at these times, then continue starter F-75
ASSESSMENT PRIOR TO REHYDRATION SIGNS OF OVERHYDRATION SIGNS OF IMPROVING HYDRATION
1.Weight 1.Increase in RR by 5 or PR by 15 1. Less thirst and lethargy
2.Edge of the liver on the skin 2. Engorged jugular veins 2. Reduction of tachycardia and
tachypnoea
3.Respiratory rate 3. Puffy eyes 3. Tears
4.Pulse rate
5.CRT STOP REHYDRATION ORS to replace stool loss

20. CONSTITUENTS OF REHYDRATION SOLUTION IN SAM
ReSoMal
• Water- 2 litres (WHO) or 1700 mls (NRHM)
• WHO-ORS- 1 one litre packet
• Sugar – 50 gms (WHO) or 40 gms (NRHM)
• Mineral solution – 40 ml( WHO) or 35 ml(NRHM)
(Potassium Chloride: 224 grams
Tripotassium Citrate: 81 grams
Magnesium Chloride: 76 grams
Zinc Acetate: 8.2 grams
Copper Sulphate: 1.4 grams
Water: make up to 2500 ml )
Reduced osmolarity ORS
(NRHM)
15 ml of potassium chloride syrup to 1 litre of ORS

21. STEP 4 : CORRECTION OF ELECTROLYTE IMBALANCE
• Electrolyte status: excess body sodium, potassium and magnesium depletion
• Potassium supplementation at 3-4 meq/kg/day upto 2 weeks (most commonly as syrup)
• Magnesium supplementation- Day 1- 50% magnesium sulphate at 0.3 ml/kg im (2 ml max).Day 2 onwards-
oral magnesium supplementation at 0.4 to 0.6 mmol/kg/day for 2 weeks
• Salt restricted diet

22. STEP 4: TREATMENT OF INFECTIONS
NRHM
CONDITION ANTIBIOTIC
1.No complications Oral amoxicillin 15mg/kg TDS 5 days
2.Complications other than dysentery, meningitis or shock Inj. Ampicillin 50 mg/kg/dose QDS + Inj Gentamicin 7.5
mg/kg/day OD 7 days
+ inj. Cloxacillin 100 mg/kg/day QDS if Staph suspected
3. Shock or deterioration/no improvement Inj Cefotaxime 150 mg/kg/day divided TDS or Inj
Ceftraixone 100 mg/kg/day divided BD + Inj Gentamicin
7.5 mg/kg/day OD
4. Meningitis Inj Cefotaxime 50 mg/kg/dose QDS or Inj Ceftriaxone 100
mg/kg/day divided BD + Inj Amikacin 15 mg/kg/day
5. Dysentery Inj Ciprofloxacin 15mg/kg/day divided BD for 3 days

23. STEP 6: CORRECTION OF MICRONUTRIENT DEFICIENCIES
• Vitamin A- 50,000 IU for <6 months, 100000 IU for 6-12 months and 2 lac IU for age > 12 months.Same
dose on day 1,2 and 14. Oral formulations (oil based ) preferred. Children > 12 months but weight < 8
kg- 1 lac IU (NRHM)
• Multivitamin supplements- Vit A,C,D,E and Vit B12 at twice RDA
• Folic acid- 5 mg on day 1, then 1 mg/day
• Elemental Zinc – 2 mg/kg/day
• Copper- 0.3 mg/kg/day
• Iron- no iron in stabilization phase. Started after 2 days of catch up feed, @ 3 mg/kg/day divided BD,
between meals

24. STEP 7: START CAUTIOUS FEEDING
• FEATURES OF FEEDING IN STABILISATION PHASE:
a.Small, frequent, low osmolarity, low lactose
b. Energy @ 100 kcal/kg/day, Protein @ 1-1.5 gm/kg/day, fluid volume@ 130 ml/kg/day (100 ml/kg/day if
child has severe oedema)
Days Frequency of feeding Volume of each feed
1-2 2 hourly 11ml/kg/feed
3-5 3 hourly 16 ml/kg/feed
6-7 4 hourly 22 ml/kg/feed

25. STARTER DIET: F-75 DIET
• 75 kcal and 0.9 gm protein per 100 ml of diet
Constituents in 1000ml Starter diet Cereal based starter diet
1. Fresh cows milk or toned dairy
milk
300 ml 300 ml
2. Sugar 100 gm 70 gm
3. Cereal (powdered puffed rice) - 35 gm
4. Vegetable oil 20 ml 20 ml
5. Water to make 1000 ml 1000 ml
ENERGY/LACTOSE 100 kcal and 1.2 gm/100 ml
PROTEIN 0.9 gm/100 ml 1.1 gm/100 ml

26. LOW LACTOSE STARTER DIETS
Contents per 1000 ml Amount
1.Egg white 50 gms
2.glucose 30 gms
3.Powdered puffed rice 70 gms
4.Vegetable oil 40 gms
5.Water to make 1000 ml
ENERGY 75 kcal/100 ml
PROTEIN 1 gm/100 ml
• For children with persistent diarrhoea low lactose diet is used
• Children continuing to have diarrhoea are provided lactose free diet

27. STEP 8: ACHIEVEMENT OF CATCH UP GROWTH
• In rehabilitative phase, vigorous approach taken for high intake and wt gain upto 10 gm/kg/day
• F- 100 diet ( 100 kcal and 2.9 gm protein per 100 ml) to replace F-75 starter diet
• Schedule: Replace F-75 with same amount F-100 for 48 hours
Increase the volume of each feed by 10 ml until feed remains unconsumed (@ 30 ml/kg/feed or 200 ml/kg/day) 
If Pulse rate increases by 25 and RR by 5 for 2 successive 4 hour readings, reduce volume of F-100 feed (16 ml/kg/feed for
48 hrs  19 ml/kg/feed for 48 hrs  22 ml/kg/feed for 48 hours) followed by 10 ml increase per feed as above 
After Transition phase : 4 hrly unlimited Catch up formula @ 150-220 kcal/kg/day and 4-6 gm protein/kg/day
Poor weight gain (< 5 gm/kg/day) : Reassessment
Moderate weight gain ( 5 -10 gm/kg/day) :target intake met/ infection

28. F 100 DIET: FOR CATCH UP
Constituents Amount
Full cream dried milk 110 gm
Sugar 50 gm
Vegetable oil 30 ml
Mineral mix 20 gm
Water to make up to 1000 mls

29. STEP 9 : PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
• TLC
• A cheerful, stimulating environment
• Structured play activity (15-30 mins /day ): Language skills, motor activities, ring on a string, rattle out
drum, in and out toys with blocks, posting bottles
• Physical activity
• Maternal involvement

30. STEP 10 : FOLLOW UP AFTER RECOVERY
• A child with 90% weight-for-height (-1 SD) : Recovery
• Teach parents to feed frequent energy rich food and give structured play environment
• Regular follow up checks
• Booster immunisations
• 6 monthly Vit A supplementation

31. MANAGEMENT OF SAM IN <6 MONTHS AGE
• Expressed breast milk for breast fed infants, mixture of breast feed and non cereal starter diet for
inadequately breast fed and sole non cereal starter diet for non breast fed.
• Support to re-establish breast feeding. SST.
• Good diet and micronutrient support to the mother.
• Diluted catch up diet in rehabilitation phase (135 mls instead of 100 mls)
• Non breast fed infants to be fed locally available animal milk by C/S on discharge
• Discharge when gaining weight for 5 days on breast feed alone and no complications

32. RELACTATION THROUGH SUPPLEMENTARY SUCKLING
TECHNIQUE
 Initiated with catch up diluted diet

33. EMERGENCY MANAGEMENT IN SAM
• MANAGEMENT OF SHOCK:
• Child has signs of shock,is lethargic or unconscious:
 Moist oxygen+ 10% glucose @ 5 ml/kg
 IVF : @ 15 ml/kg over 1 hr. ( RL with 5% D OR N/2+ 5% D OR half strength Darrow’s solution + 5% D OR RL if nothing
available)
 PR and RR measured initially and every 5-10 mins
Improvement( RR and PR fall) No improvement Deterioration
Repeat bolus+ Oral/NG ORS+ SD Septic Shock ( IVF @ 4ml/kg/hr + Dopamine +
antibiotics + refeeding)

34. CONTINUED…
• SEVERE ANAEMIA
• Hb below 4 gm/dl or between 4 to 6 gm/dl with Respiratory distress
Transfuse Whole blood @ 10 ml/kg over 3 hrs with Inj. Furosemide @ 1mg/kg at the start
If signs of cardiac failure : PRBC @ 5-7 ml/kg
If severe anaemia persists, donot repeat transfusion within next 4 days
Iron not be started until child starts to gain weight

35. TREATMENT OF ASSOCIATED CONDITIONS
• Vitamin A deficiency
• Dermatosis: Hypo/hyperpigmentation, desquamation, ulceration and exudation
Use barrier cream ( Zn+ castor oil/ petroleum jelly/ paraffin gauze) + Zn supplementation
• Parasitic Worms : Mebendazole 100 mg BD 3 days
• Continuing Diarrhoea : Metronidazole ( 7.5 mg/kg TDS 7 days for giardiasis), low lactose F-75 for lactose intolerance,
low osmolar or isotonic F-75 if osmotic diarrhoea (worsening on high osmolar starter diet, reducing on decreasing
sugar)
• TB
• HIV- ARV delayed until atleast 2 weeks and child is in recovery, cotrimoxazole prophyllaxis + ampicillin as per NACO
guidelines

36. FAILURE TO RESPOND TO TREATMENT
• High mortality: median case fatality 23.5 %.Untreated or delayed t/t of hypoglycaemia, hypothermia, septicaemia,
anaemia, Overzealous use of IV fluids, faulty use of diuretics and albumin, early initiation of catch up diet.
• Low weight gain during rehabilitation phase : Inadequate diet, proper night feeds, faulty technique, adequate quality
of care
• Specific nutrional deficiencies : Adequacy and shelf life of MVs, preparation of mineral mix
• Untreated infection
• Co-infection
• PRIMARY FAILURE: Failure to regain appetite or start to lose oedema by day 4, persistence of edema or weight gain <
5 gm/kg/day by day 10
• SECONDARY FAILURE: Failure to gain 5 gm/kg/day for 3 consecutive days during rehabilitation

37. DISCHARGE CRITERIA
• CHILD: a. good appetite( 120-130 kcal/kg/day consumed with micronutrients)
b. lost oedema
c. consistent weight gain > 5 gm/kg/day for 3 consecutive days
d. completed anti microbial management
e.appropriate immunisation
• MOTHER : a. can feed the child financially
b. motivated and able to understand advices
c. trained to prepare and provide adequate feed
Prior to complete recovery, a child can be discharged if > 12 months of age with 2 wk of minerals and vitamins
supplemented, mother is unemployed, able to visit weekly and near to hospital and local health workers are trained to
support.

38. COMMUNITY BASED MANAGEMENT OF SAM
• CMAM model: Developed by Valid International and endorsed by WHO and unicef.3 elements: a.feeding energy
dense micronutrient rich food b. community engagement and mobilisation c. screening for malnutrition in
communities
• RUTF rations are provided and monitored.
• RUTF: soft, crushable foods requiring no added water( no bacterial growth hence no refrigeration).
• RUTF: 2.5 % moisture, 520-550 kcal/100 gm, 10-12 % of total energy as proteins, max sodium of 290 mg/100 gm and
adequate minerals, vitamins.Added minerals are water soluble, doesnot alter acid base metabolism, moderate
positive non-metabolizable base sufficient to eliminate risk of metabolic acidosis.
• Routine medications in outpatient care: Vit A supplements, amoxicillin to all at admission TDS 7 days, antimalarials
at malarial endemic areas for > 2m and > 2kg children, mebendazole single dose to > 12 m on 2nd session, measles
vaccine on wk 4.

39. CMAM IN INDIA
• A trial of CMAM given at Biarul district in Darbhanga, Bihar by MSF in feb,2009.
• Stabilisation centre build at local PHC and over 3 yrs,5 ambulatory therapeutic feeding centres built at 5
places.
• Screening done by GNMs, ASHA, AWWs by MUAC tape and wt/ht measurement with Salter Scale.
• Outpatients provided with Ready to use, who-level, F-100 like lipid based food, informed that it was
medicine and instructed to feed 3 hrly with plenty of water.
• Inpatients managed at SC acc to MSF protocol.
• 88.4% of children who completed treatment were cured, depicting CMAM as effective

40. TAKE HOME MESSAGE
• Hospital mortality from SAM is 30-90 % which can be reduced to 5% via timely interventions
• Simple screening measures can be utilised by grass root level workers to detect SAM.
• Specialised units like NRCs equipped to deal with SAM form the backbone of the management.
• Proper and timely management is essential rather than overzealous drug therapy.
• Transition between diets is of prime importance

41. “IF WE CAN CONQUER SPACE WE CAN CONQUER CHILD
HUNGER”- BUZZ ALDRIN
THANK YOU.