This document discusses severe acute malnutrition (SAM) in children, detailing its definitions, classifications, and clinical syndromes such as marasmus and kwashiorkor. It emphasizes the importance of early detection and treatment criteria, nutritional rehabilitation methods, and prevention strategies, including community health monitoring and specific feeding practices. It underscores the need for comprehensive care that addresses dietary, social, and health factors contributing to malnutrition.

1. SEVERE ACUTE MALNUTRITION
DR. GOOLLA AKHILA
PG RESIDENT

2. • BALANCED DIET:
Defined as nutritionally adequate & appropriate intake of food
items that provide all the nutrients in required amounts & proper
proportions to ensure normal growth, development, disease free
optimum health among children and adolescents.
• CARBOHYDRATES-55-60% ( 4kcal/g)
• FATS-30-35% ( 9kcal/g)
• PROTEINS-10-15% ( 4kcal/g)

3. • MALNUTRITION
Refers to deficiencies, excesses or imbalances in a person’s intake of energy
and or nutrients ( WHO).
• The term malnutrition is used to denote
UNDERNUTRITION
OVERNUTRITION
SELECTIVE NUTRITIONAL DEFICIENCIES
• Undernutrition occurs due to
-inadequate intake
-poor absorption
-excessive loss of nutrients
• Overnutrition includes overweight and obesity.

4. • PEM
It is defined as range of pathological conditions arising from coincidental lack
of proteins and calories in varying proportions in infants and young children.
-commonly associated with infections.
- one of the major causes of death in children below 5years of age.
CAUSES OF PEM:
• Primary causes: due to lack of adequate intake of food
Poverty
Traditional habits
Social and cultural factors
Congenital defects like cleft lip and cleft palate
IUGR and Maternal malnutrition predisposes the child to undernutrition

5. • Secondary causes: despite adequate amount of food intake
- Chronic illness and infections increasing metabolic demand and decrease
in appetite.It includes :
• Inborn errors of metabolism
• GIT infections: cleft lip,cleft palate,malabsorption
• Pancreas: pancreatic insufficiency
• Renal : UTI, RTA
• Respiratory causes: asthma, recurrent respiratory tract infections
• Endocrine : GH deficiency, hypothyroidism, DM
• Neurological : MR, Cerebral palsy
• Malignancies

6. SPECTRUM OF PEM
• Kwashiorkor
• Marasmus
• Marasmic kwashiorkor
• Pre kwashiorkor
• Nutritional dwarfing
• Under weight
• Early lactational failure syndrome
• Severe acute malnutrition

7. INDICATORS OF PEM
• Weight for age(W/A)
• Weight for Height(W/H)
• Height for age(H/A)
INDICATORS ACUTE MALNUTRITION CHRONIC MALNUTRITION
Weight for age Low Low
Height for age Normal Low
Weight for height Low Normal

8. CLASSIFICATION CRITERIA AS PER WHO GRWOTH
STANDARD
Underweight Low weight for age Weight for age < -2SD
Stunting Low height or length for
age
Height for age <-2SD
Wasting Low weight for height Weight for height <-2SD
CLASSIFICATION OF UNDERNUTRITION

9. CLINICAL SYNDROMES OF UNDERNUTRITION
• Moderate and severe malnutrition is associated with one of the classical
syndromes namely Marasmus and Kwashiorkor.
• MARASMUS : Most common in preschool children.
Diet deficient in both calories and proteins
Decreased levels of Insulin & Increased levels of cortisol
Decrease in GH Levels

10. • SALIENT FEATURES OF MARASMUS:
-Weight < 60% of expected ( acc. To WELLCOME TRUST CLASSIFICATION) with
no edema.
- child appears very thin and no fat with severe wasting at shoulders, arms,
buttocks and thighs.
-loss of buccal pad of fat creates aged or wrinkled appearance that is referred
to as monkey facies.
-Baggy pants appearance refers to loose skin of the buttocks hanging
down.Axillary pad of fat may also be diminished.
-Affected children may appear to alert inspite of their condition.

11. • KWASHIORKOR:
It usually affects children between 1-4 years of age.
• GENERAL APPEARANCE:
Child may have fat sugar baby appearance.
• EDEMA:
It may be mild to gross approximating 5-20% of body weight,
• MUSCLE WASTING:
It is always present. The child is weak, hypotonic and unable to stand or
walk.
• SKIN CHANGES:
Increased pigmentation, desquamation, dyspigmentation
Flaky paint or individual enamel spots usually on buttocks, thighs.
petechiae over the abdomen
peeling of outer layers of skin and ulcerations

12. • MUCOUS MEMBRANE LESIONS:
Smooth tongue , cheilosis, angular stomatitis
• HAIR:
Dyspigmentation
Loss of characteristic curls and sparseness over temples and occipital
regions
Loss of lusture and easily pluckable
alternate bands of hypopigmented and normally pigmented hair
resembling Flag sign
• MENTAL CHANGES: include
unhappiness, apathy, irritability,intermittent cry ,
no signs of hunger

13. • GIT: Anorexia,Abdominal distension
• stools may be watery or bulky or semisolid with low Ph and unabsorbed
sugars,
• NUTRITIONAL ANEMIA
• CVS: Bradycardia, prolonged capillary refilling time, decreased cardiac
output and hypotension
• RENAL : There is aminoaciduria and inefficient excretion of acid load

16. FLAG SIGN
BAGGY PANTS

17. IDENTIFICATION OF SEVERE ACUTE MALNUTRITION
Criteria for identifying SAM in children < 6 months of age:
• Weight for height less than -3SD
• Edema of both feet
Criteria for identifying SAM in children > 6months of age:
• Weight for height less than -3SD on WHO Growth Standard
• Oedema of both feet
• Mid upper arm circumference < 11.5cms

18. PATHOLOGICAL CHANGES SEEN IN SAM
• Liver -Reduced glucose production causing HYPOGLYCEMIA
-Reduced ability to synthesize albumin,transferrin,transport
proteins
• Kidneys - Reduced excretion of sodium and excess fluids causing
FLUID OVERLOAD
• Cardiovascular system-Reduced myocardial mass,atrophy,patchy
necrosis of myocardium
• Respiratory system- Atrophy of intercostal muscles
• Reduced thermogenesis

19. • GIT-Mucosal atrophy,reduced gastrointestinal enzyme secretions
Delayed mucosal repair
Atrophy of intestinal villi(malabsorption)
• Endocrine system-
Decrease in- Thyriod hormone Increase in Cortisol levels
Insulin
Growth hormone
• Immunological system-Cell mediated immunity is reduced
Impaired T and B lymphocytes function
Decreased Lymphocyte count
• Micronutrient deficiency- Reduced free radical deactivation leading to
cell damage

20. CRITERIA FOR IDENTIFYING CHILDREN WITH SAM FOR
TREATMENT
• Early detection of children with SAM will ensure that these children
will be identified before they develop medical complications.
• MUAC is the simple measure for detection of SAM.
• MUAC in children from 6months to 59 months and look for bilateral
pitting edema.
• MUAC is less than 11.5 cms or any degree of bilateral pedal edema
immediately child is referred for full assessment and further medical
management.

21. SCREENING OF SAM
• Active screening of children by AWW,ASHA through house to house visit and measuring of
MUAC using tape and look for bilateral pitting pedal edema.
• Passive screening during growth monitoring,village health nutrition days using MUAC and b/l
pitting pedal edema
If features of SAM present look for complications
-severe edema +++
-poor appetite (failed appetite test)
-medical complications-severe anemia
pneumomia
diarrhoea
dehydration
cerebral palsy, TB, HIV, Heart disease
-one or more IMCI danger signs

22. SUPERVISED HOME MANAGEMENT OR OUTPATIENT
MANAGEMENT OF UNCOMPLICATED SAM
• Counselling about breast feeding,supplementary
feeding,immunization and hygiene.
• Community health care workers or peer counselors are involved to
support the family.
• Theraputic food adhering to WHO and UNICEF specifications to be
provided like RUFTs( ready to use therapeutic food).
• 2-3 hourly feeds with plenty of water.
• Periodic monitoring of growth and medical condition
• Child should be monitored by health care workers for signs of under
nutrition(weight,height,MUAC,edema etc., every week.

23. MANAGEMENT OF COMPLICATED SAM IN HOSPITAL
• All children with complicated SAM should be admitted to a
Nutritional Rehabilitation Centre(NRCs) or health facility.
• Children with severe malnutrition has a complex backdrop with
dietary, infective, social, economic factors.
• History of events leading to child’s admission should be obtained.
• Socio economic history and family circumstances should be explored
to understand the underlying and basic causes.

24. Initial assessment of severely malnourished
child
• History & Examination
Recent intake of foods and fluids including breast feeding
Usual diet before the illness
Duration and frequency of diarrhea and vomiting
Loss of appetite
Bowel and bladder habits
Known or suspected HIV & TB contact
Immunization history
History of measles infection in the past
Developmental history

25. • On examination
Anthropometry
Edema
Anemia
Signs of dehydration and shock
Eye signs of vitamin A deficiency
Localizing signs of infections
Skin changes of kwashiorkar
Fever,Hypothermia(<35.5*c)
Signs of dehydration and shock
Severe anemia
Extensive skin lesions,mouth ulcers and eye lesions
Localizing signs of infections

26. PRINCIPLES OF HOSPITAL MANAGEMENT OF SAM
• The general treatment includes 10 steps in two phases
• STABILIZATION PHASE-
It focuses on restoring homeostasis and treating medical
complications.It usually takes 2-7 days.
• REHABILITATION PHASE-
It focuses on rebuilding wasted tissues and may take 2-6 weeks

28. MANAGEMENT OF SAM
HYPOGLYCEMIA –
• Blood glucose levels < 54mg/dl or 3mmol/l
• Hypoglycemia, Hypothermia, Infections occur together in
malnourished children.
TREATMENT-
• Asymptomatic hypoglycemia-
50ml of 10% glucose or sucrose solution followed by first feed with F 75 every
2hourly day and night.
• Symptomatic hypoglycemia- 10% D IV 5ml/kg
follow with 50ml of 10%D or sucrose solution by nasogastric tube
Feed with F 75 every 2hourly day and night
Start with appropriate antibiotics
PREVENTION- feed 2 hourly and prevent hypothermia

29. HYPOTHERMIA- Rectal temperature < 35.5 degree C or 95.5 degree F
Axillary temperature <35 degree C or 95 degree F
TREATMENT-
• Cloth the child with warm clothes; head covered with cap
• Provide heat using headwarmer,skin contact or heat convector
• Avoid rapid rewarming as this may lead to disequilibrium
• Feed the child immediately
• Start appropriate antibiotis

30. DEHYDRATION- Difficult to assess the dehydration status in severely
malnourished child.
• Assume that all the children with watery diarrhea have some dehydration
TREATMENT-
• Use reduced osmolrity ORS solution with potassium supplements for
rehydration and maintainence.
• Initiate feeding within 2-3 hours of starting rehydration:use F75 formula on
alternate hours.
• Be alert with signs of dehydration
PREVENTION-
Give reduced osmolarity ORS at 5-10ml/kg after each watery stool
If breastfed continue breastfeeding

31. ELECTROLYTES-
• Supplemental potassium at 3-4mEq/kg/day for 1-2 weeks
• 50% of MgSO4 0.1-0.2ml/kg/dose in 2 divided doses for 1-3 days
• Sodium is restricted to 2-3meq/kg/day
• INFECTIONS-majority caused by gram negative bacteria.
TREATMENT-
• Give broad spectrum antibiotics, penicillins or ampicillin with aminoglycosides
• If no improvement occurs with in 48 hours change to IV Cefotaxime or
Ceftriaxone.
PREVENTION-
Follow hand hygiene

32. MICRONUTRIENTS-
• On day1 give oral Vitamin A.
• Folic acid 1mg/day
• Zinc 2mg/kg/day
• Iron 3mg/kg/day once child starts gaining weight after first week
INITIATE FEEDING-small and frequent feeds
• Oral or nasogastric feeds
• Continue breast feeding
• Start with F75 feeds every 2hourly
• In persistent diarrhea give cereal based low lactose F75 diet as starter diet
• If diarrhea continues on low lactose diet give F75 lactose free diet

33. CATCH UP GROWTH-
• Return of appetite within one week signals Rehabilitation phase
• Increase volume offered at each feed and decrease the frequency of feeds
• Continue breast feeding
• Make gradual transition from F75- F100 diet
• Increase calories from 150-200kcal/day and proteins to 4-6g/kg/day
• Add complementary feeds as soon as possible
SENSORY STIMULATION- A cheerful stimulating environment
• structural play therapy for 15-30min
• physical activity as soon as the child is healthy
• Tender loving care

34. COMPLICATIONS OF TREATMENT:
• Protein overload syndrome
• Encephalitis like syndrome
• Nutritional Recovery syndrome
• Pseudotumor cerebri
• Refeeding syndrome

35. REFEEDING SYNDROME

36. FAILURE TO RESPOND TO TREATMENT:
Primary failure when the child donot improve after treatment.
failure to regain appetite -4th day
failure to start losing edema -4th day
presence of edema -10th day
failure to gain atleast 5g/kg/day - 10th day
Secondary failure- failure to gain at least 5g/kg/day for 3 consecutive days in
rehabilitation phase

37. CRITERIA FOR DISCHARGE
 No edema for atleast 2 weeks plus
W/H -2SD or higher on WHO Growth Standard
Absence of infection
Completed immunization appropriate foe age
Caretakers sensitized to home care
Return of social smile
Eating atleast 120-130kcal/kg/day
Consistent weight gain (5g/kg/day) for 3 consecutive days on exclusive oral
feeding

38. PREVENTION OF UNDER NUTRITION
• In around 1/3rd of children with PEM it is sequel of low birth
weight.Hence antenatal care should be emphasized and
strengthened.
• The stratagies for prevention can be summarized as NIMFES
N-NUTRITION & GROWTH MONITORING
I- IMMUNIZATION
M-MEDICAL CHECKUP AND MEDICAL CARE
F-FAMILY WELFARE( timing,spacing,limiting of births)
E-EDUCATION
S- STIMULATION ( tender love caring)

39. ICDS ( Integrated child development services)
• A package of 6 services provided under ICDS Scheme:
1. Supplementary nutrition for mother and child
2. Immunization of pregnant women and child as per NIS
3. Non formal preschool education
4. Health checkups
5. Referral services
6. Nutrition and health education

40. THANK YOU