Severe acute malnutrition

1. SEVERE ACUTE
MALNUTRITION
MOERATOR: DR PAVAN KUMAR (ASSOCIATE PROFESSOR)
PRESENTER: DR REVATI (PG)

2. 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

3. • Recommended criteria for identifying SAM in infants <6 months age:
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 lead to HYPOGLYCEMIA
b. Reduced ability to synthesis albumin, transferrin,
transport proteins
c. Reduced ability to cope with dietary proteins and toxins
• 2. Reduced thermogenesis lead to HYPOTHERMIA
• 3. Kidneys – Reduced renal excretion of excess fluids and sodium
leads to FLUID OVERLOAD

6. • 4. Heart-Smaller and weaker and has reduced cardiac output and fluid
overload readily leads to cardiac failure
• 5. Sodium- Reduced activity of Na-K pump + and leaky cell
membranes increased intracellular sodium leads to FLUID RETENTION
AND ODEMA
• 6. Potassium – Cell leakage and urinary excretion
• 7. Muscle protein loss accompanied by loss of K, Mg, Zn and Cu.

7. 8. GI – Reduced production of enzymes and gastric acid, reduced
motillity easy bacterial colonization of stomach and small
intestine,damaging the mucosa and deconjugating bile salts leading to
IMPAIRED DIGESTION AND ABSORPTION.
9. Reduction in cell replication and repair leading to easy translocation
of organisms through gut mucosa
10. Impaired immune function , especially cell mediated immunity
leading to increased risk of undiagnosed INFECTIONS

8. 11.RBC mass reduced , releasing iron which requires of glucose and
amino acids to be converted to ferritin, increasing the risk of
hypoglycemia and amino acid imbalance.
If conversion to ferritin is incomplete, unbound growth and formation
of free radicles.
12. Micronutrient deficiency leads to reduced free radical deactivation
cell damage

9. SCREENING OF SAM
• a. Active screening by 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

10. SHAKIRS TAPE

11. • Features of SAM with Medical complications - NRC
• If no medical complications Refer to subcentre for
assessment by ANM and transfer to community based
programme for SAM
• No features of SAM -- Nutritional counselling to mother

12. APPETITE TEST
• Decides if the patient should be sent for in-patient or out patient
management
• The appetite test has been standardised using Ready to use
Therapeutic Food (RUTF).
• For children 7–12 months: Offer 30-35 ml/kg of Catch-up diet. If the
child takes more than 25 ml/kg
• then the child should be considered to have good appetite.
• For children >12 months: Feed locally prepared with the following
food items may be offered.

13. • Amount of local therapeutic feed that a child with SAM should take to
PASS the appetite test.
BODY WEIGHT(KG) MINIMUM AMOUT OF RUFT TO BE
CONSUMED FOR PASSING
3-4.9 105-130g/day
5-6.9 200-260g/day
7-9.9 260-400g/day
10-14.9 400-460g/day

14. • DAVNGERE MIX:
-Ragi hittu
-Bengal gram-roasted and powdered
-Groundnut - roasted and powdered
-Jaggery syrup
TOTAL: 100 g ball
Calories : 400kcal
Protein : 14g

15. • HYDERABAD MIX:
-Whole wheat: 40g
-Bengal gram: 16g
-Groundnut : 10g
-Jaggery : 20g
TOTAL : 86G
Calories :330kcal
Protein : 11.3g

16. OUT PATIENT CARE
• Children with SAM who do not have criteria for admission
can be managed under outpatient program.
• There is a need to provide therapeutic food broadly adhering
to the WHO and UNICEF specifications.
• One form of therapeutic food is RUTF.
• The amount to be given in 2-3hourly with plenty of water
• Breast feeding should be continued while the child is on
therapeautic food. Other foods my be given if child has good
appetite and has no diarrhea

17. • OUTCOME OF TREATMENT AS FOLLOWS:
a) NON RESPONDER/PRIMARY FAILURE:
1)Failure to gain weight for 21 days (or)
2)Weight loss since admission to program for 14 days
b)SECONDARY FAILURE OR RELAPSE:
1)Failure of appetite test at any visit (or)
2)weight loss of 5% body weight at any visit. Non responders and
children who develop danger signs at any time, during first 4 weeks
should be referred to hospital
c)DEFAULTERS:Not traceable for at least 2 visits

18. • Children can be discharged from the progam if any of the
following criteria are satistifed:
a)children admitted to SAM prgram on the basis of W/H
criteria should be discharged when W/H becomed > or equal
to -2 Zscore
b)Children admitted on basis on MUAC or b/l pedal edema
should be discharged when MUAC becomes > or equal to
12.5cm and there is no edema

19. CHILDREN WITH MEDICAL COMPLICATIONS
ADMITTED TO NRC
•Very weak, Apethic
•Persistent vomitings
•Diarrhoea with dehydration
•Fast breathing/chest indrawings/cyanosis
•Fever>38.5c / Hypothermia < 35c

20. •Presence of any emergency signs
•Odema
•Extensive skin lesions, eye lesions
•Severe anemia
•Any general sign that clinician warrents transfer to in-
patient

21. NUTRITIONAL REHABILITATION CENTERS
•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. Treatment of medical complications
c. Therapeutic feeding

22. 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.

23. PRINCIPLES OF HOSPITAL BASED MANAGEMENT
• STABILISATION PHASE: 1-2 days for treating hypoglycemia,
hypothermia and dehydration. Then F-75 feeding formula is started.
• TRANSITION PHASE: 2-3 days to correct electrolyte imbalances, treat
infections and correct micronutrient deficiencies. Transition from F-
75 to F-100 diet in same amount
• REHABILITATION PHASE:For catch-up growth.

25. TREATMENT OF HYPOGLYCEMIA
1. If the child is conscious with blood glucose
<54mg/dl, immediately give the child a 50 ml bolus of
10% glucose or 10% sucrose.

26. 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.
Start feeding with starter diet, 1/2hour after giving glucose.Give it
half-hourly during first 2 hours.
For a Hypoglycemic child, the amount to give every half-hour is 1/4th
of 2 hourly amount.

27. TREATMENT OF HYPOTHERMIA
• If the Axillary temperature < 35 degrees or rectal temperature < 35.5
degrees
• ACTIVELY REWARM THE HYPOTHERMIC CHILD:
- Ask the mother to hold the child with skin to skin contact(kangaroo
technique). Keep the child’s head covered.

28. -Provide heat with overhead warmer, incandescent lamp or radiant
heater.
-Monitor temp every 1/2 hourly during rewarming.Stop rewarming if
temp becomes normal.
If the rectal temp<32 degrees c, child has severe hypothermia:
-Give humidified oxygen
-Give 5ml/kg of 10% IV Dextrose immediately or 50ml of 10%Dextrose
by NG tube
-Start intravenous antibiotics

29. -Give warm feeds if childs takes orally, else feed through NG tube
-Start maintenance IV fluids(prewarmed),if there is feed intolerace or
contraindication for NG feeding.
GENERAL MEASURES TO PREVENT HYPOTHERMIA
Feed immediately,Cover the child including head, Maintain Room temp
of 25-30 degree c, change wet cloths or bedding

30. ASSESSMENT AND CLASSIFICATION OF
DEHYDRATION IN SAM
IF ANY TWO OF THE FOLLOWING SIGNS ARE
PRESENT
-LETHARGIC OR UNCONSCIOUS
-SUNKEN EYE
-NOT ABLE TO DRINK OR DRINKING POORLY
-SKIN PINCH GOES BACK VERY SLOWLY
THE CHILD HAS SEVERE
DEHYDRATION
IF ANY TWO OF THE FOLLOWING SIGNS ARE
PRESENT
-RESTLESS,IRRITABLE
-SUNKEN EYES
DRINKS EAGERLY, THIRSTY
SKIN PINCH GOES BACK SLOWLY
THE CHILD HAS SOME
DEHYDRATION

31. DIAGNOSIS OF DEHYDRATION IN SAM
• IN CHILDREN WITH SAM CLASSICAL SIGNS OF DEHYDRATION ARE
UNRELIABLE THUS:
-IN SEVERELY WASTED CHILD, SKIN NORMALLY IS IN FOLDS AND IS
INELASTIC SO SKIN PINCH WILL BE POSITIVE WITHOUT BEING ANY
DEHYDRATION
-EYES ARE NORMALLY SUNKEN WITHOUT BEING ANY DEHYDRATION

32. THEREFORE DIAGNOSIS COMES FROM HISTORY:
-H/O SIGNIFICANT RECENT FLUID LOSS-USUALLY DIARRHOEA WHICH IS
CLEAR LIKE WATER AND FREQUENT WITH A SUDDEN ONSET
-H/O RECENT CHANGE IN CHILD’S APPERANCE
-EYES HAVE CHANGED TO BECOME SUNKEN SINCE DIARRHOEA
STARTED

33. TREATMENT OF DEHYDRATION IN SAM CHILD
WITHOUT SHOCK
• WHO RECOMMENDS USE OF REHYDRATION SOLUTION FOR
MALNOURISED CHILDREN (ReSoMal)
HOW OFTEN TO GIVE ReSoMal AMOUNT TO GIVE
EVERY 30 MINUTES FOR THE 1ST 2 HOURS 5ML/KG BODY WEIGHT
ALTERNATE HOURS FOR UP TO 10 HOURS
(STARTER DIET F-75 IS GIVEN IN ALTERNATE
HRS)
5-10 ML/KG

34. *AFTER REHYDRATION ,WHEN THE CHILD HAVE 3 OR MORE SIGNS OF
HYDRATION, STOP GIVING ORS IN ALTERNATE HOURS.
• FOR EVERY EPISODE OF WATERY STOOL GIVE ORS(ReSoMal) TO
REPLACE STOOL LOSSES
-FOR <2 YEARS : 50ML AFTER EACH LOOSE STOOL
2 YEARS AND OLDER : 100ML AFTER EACH LOOSE STOOL
*DURING REHYDRATION BREAST FEEDING SHOULD NOT BE
INTERRUPTED
*RESOLUTION OF THE SIGNS OF DEHYDRATION:
-Stop all rehydration treatment and start the child on starter diet of F-
75

35. CONSTITUENTS OF REHYDRATION
SOLUTION(ReSoMal)
INGREDIENT AMOUNT
WATER(BOILED AND COOLED) 2000ML
WHO-ORS(NEW FORMUATION) ONE PACKET
SUGAR 40G
ELECTROLYTE-MINERAL SOLUTION 40ML

36. COMPOSITION OF REHYDRATION
SOLUTION(ReSoMal)
COMPONENT CONCENTRATION(MMOL/L) WHO ORS
GLUCOSE 125 75
SODIUM 45 75
POTASSIUM 40 20
CHLORIDE 70 65
CITRATE 7 10
MAGNESIUM 3 -
ZINC 0.3 -
COPPER 0.045 -
OSMOLARITY 300 245

37. MANAGEMENT OF SHOCK IN SAM
• Shock is a dangerous condition with severe
weakness,lethargy,unconsciouness,cold extremities, and fast, weak
pulse. Consider shock if :
-Has cold hands with
-Slow capillary refill(longer than 3 seconds), AND
-Weak and fast pulse
* 2months-12 months : 160bpm
*12months-5 years : 140bpm

38. EMERGENCY MANAGEMENT IN SAM
SHOCK

40. -Give maintenance IV fluid (4 ml/kg/hr)
-Transfuse whole blood 10ml/kg over 3 hours. If there are
signs of heart failure give packed cells @ 5-7ml/kg
-Start broad spectrum antibiotics(3rd generation
cephalosporins)
*INJ CEFOTAXIME 150MG/KG/DAY IN 3 Divided doses
(OR)

41. *INJ CEFTRIAXONE 100MG/KG/DAY IN 2 Divided doses
+
INJ GENTAMYCIN 7.5MG/KG in Single dose
- If no improvement with fluid bolus, Start DOPAMINE @
10MCG/KG/MIN

42. CORRECTION OF ELECTROLYTE IMBALANCE
• Electrolyte status: High sodium, Low potassium and magnesium
- Potassium supplementation at 3-4 meq/kg/day upto 2 weeks (most
commonly as syrup available as 20meq/15ml. It should be diluted in
water.)
- Magnesium supplementation-
• Day 1- Inj. 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

43. TREATMENT OF INFECTIONS
• In SAM children the usual signs of infections are often absent, hence
appropriate antibiotics should be started as a part of initial
management
• SELECTION OF ANTIBIOTICS:
-If the child appears to have no complications give oral AMOXICILLIN
15MG/KG, 8TH
hourly x 5 days
-If the child has complications select antibiotic as follow:

45. • Duration of antibiotic therapy depends on the diagnosis.
• The following guideline can be followed in general:
-Suspicion of clinical sepsis: at least 7 days
-Urinary tract infection: 7-10 days
-Culture positive sepsis: 10-14 days
-Meningitis: at least 14-21 days
-For Deep seated infections like arthritis and osteomyelitis: at least 4
weeks.
*Treat associated conditions like malaria,TB,amoebiasis or HIV as per
the national guidelines.

46. CORRECTION OF MICRONUTRIENT
DEFICENCY
• Multivitamin supplements- Vit A,C,D,E and Vit B12 at twice
the 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 BD,preferably between meals

47. START CAUTIOUS FEEDS
• FEATURES OF FEEDING IN STABILISATION PHASE: a.Small,
frequent, low osmolarity, low lactose STARTER DIET F-75 is
used
• Started diet is specially made to meet the child’s needs
without overwhelming the body’s systems at this early stage.
• Recipe for starter diet as follows

48. CONTENTS (PER 1000ML) STARTER DIET (F-75) STARTER DIET (F-75)
CEREAL BASED
FRESH COW’S MILK OR
EQUIVALENT MILD (Eg.TONED
MILK)
300 300
SUGAR (g) 100 70
CEREAL FLOUR(powered puffed rice - 35
VEGETABLE OILD 20 20
WATER MAKE UTO (ML) 1000 1000
ENERGY (KCAL/100ML) 75 75
PROTEIN (G/100ML) 0.9 1.1
LACTOSE (G/100ML) 1.2 1.2

49. LOW LACTOSE STARTER DIET
FOR CHILDREN WITH PERSISTENT DIARRHOEA

50. • DETERMINE FREQUENCY OF FEEDS:
• On 1st
day feed the child every 2 hourly(12 feeds/24hrs, including
night).
• -After the 1st
day increase the volume per feed gradually.
DETERMINE AMOUNT OF STARTER DIET NEEDED PER FEED
-Given the child’s starting weight and the frequency of feeding, use the
reference table to look up the amount needed per feed
-If the child has severe(+++) edema, his weight maybe 30% higher due
to excess fluid. To compensate give only 100ml/kg/day of starter diet.

53. RECORD THE CHILD 24 HOUR FEEDING PLAN

54. ADJUST THE CHILDS FEEDING PLAN FOR NEXT
DAY
• Criteria for increasing/decreasing frequency of feeds
- If vomiting, lots of diarrhoea, or poor appetite, continue 2-hourly
feeds.
- If little or no vomiting, modest diarrhoea and finishing most feeds,
change to 3-hourly feeds.
- After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and
finishing most feeds, changes to 4-hourly feeds.

55. REHABILITATIVE PHASE
CATH UP GROWTH
When the child is stabilized(usually 2-7 days), ‘catch-up’ formula or
catch-up diet is used to rebuild wasted tissues. Catch up diet contains
100kcal and 2.9 g protein per 100ml
1)FEED THE CHILD IN TRANSITION
-It is extremely important to make the transition to free feeding on
catch-up diet gradually and monitor carefully.If transition is too rapid,
heart failure may occur

56. a)Recognize readiness for transition:
-Following signs after 2-7 days
*Return of appetite (easily finishes 4-hourly feeds of started
diet)
*Reduce edema or minimal edema
*Child may also smile at this stage

57. b)Begin giving catchup diet slowly and gradually:
Transition takes 3 days with catch-up diet
FIRST 48 HOURS(2 DAYS): Catch up diet given every 4 hours in the same
amout as last starter diet. Do not increase for 2 days
THEN, ON THE 3RD DAY: Increase each feed by 10ml as long as the child
is finishing feeds------->if does not finish feed offer the same amount at
the next feed------> if the feed is finished, increase by 10ml.

58. 2) FEED FREELY WITH CATCH UP DIET
-Transition usually takes 3 days. After transition, the child is in
Rehabilitation phase and can feed freely on catchup diet to upper limit
of 220kcal/kg/day.
-Most children will consume at least 150kcal/kg/day(max of
220kcal/kg/day); any amount less than this indiactes the child is not
being fed freely or is unwell.

59. CRITERIA FOR TRANSFER TO A REHABILITATION CARE
-Eating well
-Responds to stimuli, interest im surroundings
-Minimal or no odema no NG tube, IV infusions stopped
-Gaining weight >5m/kg pe day for 3 successive days

60. F-100 DIET: FOR CATCH UP
CNTENTS PER 100ML CATCH UP DIET CATCHUP DIET
COWS MILK/TONED DAIRY
MILK(ML)
900 750
SUGAR 75 25
VEGETABLE OIL 20 20
PUFFED RICE - 70
WATER TO MAKE (ML) 1000 1000
ENERGY(KCAL/100ML 100 100
PROTEIN(G/100ML) 2.9 2.9
LACTOSEG/100ML) 4.2 3

61. PROVIDE SENSORY STIMULATION AND
EMOTIONAL SUPPORT
• A cheerful, stimulating environment
• Emotional and physical stimulation plays crucial role for child recovery
• When mothers are involved in care at the hospital they learn how to
continue care at home
• Encourage mother to prepare food,feed child,bath and change
• Structured play activity (15-30 mins /day ): Language skills, motor
activities, in and out toys with blocks
• Physical activity

63. CRITERIA FOR DISCHARGE
• Achieved weight gain of ≥ 15% ,and has satisfactory weight gain for 3
consecutive days (>5 gm/kg/day)
• Odema has resolved
• Child eating an adequate amount of nutritious food that the mother
can prepare at home
• All infections and other medical complications have been treated
• Child is provided with micronutrients
• Immunization is updated

64. Treatment for Helminthiasis
Treatment for helminthic infections should be given to all
children with SAM before discharge. Give a single dose of any
of the following antihelminthics orally:
*200 mg albendazole for children aged 12-23 months
* 400 mg albendazole for children aged 24 months or more
OR
*100 mg mebendazole twice daily for 3 days for children aged
24 months or more.

65. FOLLOW UP AFTER DISCHARGE
• 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: every 2 weeks 1st month then monthly, If
WFH >-1SD.
• Booster immunisations as per schedule
• 6 monthly Vit A supplementation(9-59 months)

66. MANAGEMENT OF SAM < 6MONTH
• DBF and EBM for breast fed infants is preferred, mixture of breast feed
and non cereal starter diet for inadequately breast fed infants 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 (diluted by 1/3rd extra water
to make 135 ml instead of 100 ml)
• Non breast fed infants to be fed locally available animal milk on discharge
• Discharge when gaining weight for 5 days on breast feed alone and no
complications

67. RELACTATION THROUGH SUPPLEMENTARY
SUCKLING TECHNIQUE

68. AMOUNT OF CATCHUP DIET DILUTED FOR
INFANTS PUT ON SST

69. REFEEDING SYNDROME
• May occur if high energy feeding is started too soon or vigorously and it
may lead to sudden death with signs of heart failure.
• Onset is usually 24-48 hours after the start of high energy feed
• Clinical signs and symptoms :
• BREATHLESSNESS, RAPID PULSE, WATERY DIARRHEA, RAPID
ENLARGEMENT OF LIVER
• Increase supply of carbohydrates-----> increase Na+ pump activity----->
Rapid release of accumulated Na from cells-----> expansion of extra
cellular and plasma volumes.
• Increase uptake of Potassium, Magnesium,Phosphate----->leads to
lowered serum concentration of above electrolytes.

70. • Apparent worsening with increase in liver size, hypertrichosis,
gynecomastia,parotid swelling, abdominal distension, ascites,
spleenomegaly and eosinophilia during therapy marks
Refeeding syndrome.
• Self limiting tremors known as kwashi shake may also occur
• Dysmyelination,vitamin deficiencies,neurotransmitter
imbalance and high solute load on kidneys are other possible
reasons.

72. PREVENTION
• to minimize the risk, initial stabilization phase which includes
providing maintenance amounts of energy and protein.
• Correcting electrolyte imbalances and micronutrient
deficiencies.
• Followed by a controlled transition to high-energy feeding.
Milkbased diets are desirable because milk is a good source of
phosphate.

73. DERMATOSIS
+ mild: discoloration or a few
rough patches of skin
+ + moderate: multiple patches on
arms and/or legs
+ + + severe: flaking skin, raw skin,
fissures (openings in the skin)
• Useful ointments are zinc and
castor oil ointment, petroleum
jelly, or paraffin gauze dressing.

74. EYE SIGNS
• BITOT SPOTS: superficial foamy
white spots on conjuctiva
• CONJUCTIVAL AND CORNEAL
XEROSIS
• PUS AND INFLAMMATION: signs of
infection
• CORNEAL ULCERATION: sign of
severe vit A deficieny. It is
emergency and needs treatment
with vit A and atropine. Can cause
blindness.

75. WHO CLASSIFICATION OF VITAMIN A
DEFICIENCY

76. TREATMENT
• If eye signs of deficiency, give orally: Vitamin A on days 1, 2, 14
• >12 months = 200,000 IU (Weight > 8 kg)
• 6-12 months = 100,000 IU
• 2-5 months = 50,000 IU
• <2 months, it is given with caution and preferably may be given to
the mother.

77. CONTINUING DIARRHOEA
• Common feature but it should subside during the 1st week of
treatment with cautious feeding
• In the rehabilitation phase, loose, poorly formed stools are no cause
for concern
• provided weight gain is satisfactory.
• Mucosal damage & giardiasis
-Give Metronidazole (7.5 mg/kg ,8 hourly for 7 days)

78. • Lactose intolerance
• Treat only if continuing diarrhea is preventing general
improvement
• Substitute milk feeds with yogurt or lactose-free infant
formula.
• Reintroduce milk feeds gradually in the rehabilitation phase.

79. OSMOTIC DIARRHOEA
• Suspected if diarrhea worsens substantially with
hyperosmolar starter F-75.
• Ceases when the sugar content is reduced and osmolarity is
<300 mOsmol/L.
• In these cases, use isotonic F-75 or low osmolar cereal-based
F-75. Introduce F-100 gradually.

80. MANAGEMENT OF SEVERE ANEMIA
• Hb below 4 gm/dl or PCV<12% or hb 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.

81. PARASITIC INFECTIONS
• Giv MEBENDAZOLE 100 MG ORALLY, TWICE FOR 3 DAYS OR
ALBENDAZOLE SINGLE DOSE
TUBERCULOSIS
If strongly suspected (contacts with adult TB patient, poor growth
despite good intake, chronic cough, chest infection not responding
to antibiotics):
-Tuberculin test (false negatives are frequent)
-Chest X-ray & Gastric aspirate for AFB stain, culture & CBNAAT.
-If test is positive/strong suspicion of TB, treat according to National
TB Elimination Programme (NTEP) Guidelines.

82. REFERENCES:
• IAP 2013 GUIDELINES
• KE ELIZABETH NUTRITION AND CHILD DEVELOPMENT
• MINISTRY OF FAMILY AND WELFARE GOVERNMENT OF INDIA,2013

83. LOW LACTOSE CATCHUP DIET
CONTENTS PER 100 ML EGG BASED
MILK (COWS OR TONED DAIRY MILK) 250
EGG WHITE 120
VEGETABLE OIL 40
CEREAL FLOUR 120
ENERGY(KCAL/100ML) 100
PROTEIN (G/100ML) 2.9
LACTOSE(G/100ML 1