2. Terms/Acronyms
F75 -Therapeutic milk used only in Phase 1 of treatment for SAM
F100 -Therapeutic milk used in Transition Phase and Phase 2 of treatment of
SAM (for in patients only)
IU -International Units
MUAC- Mid Upper Arm Circumference
OTP -Out-patient Therapeutic Programme (treatment of SAM at home)
ReSoMal -Oral RE hydration SO lution for severely MAL nourished patients
RUTF- Ready-to-Use Therapeutic Food
SAM -Severe Acute Malnutrition (wasting and/or nutritional oedema)
SFP- Supplementary Feeding Programme
TFU- Therapeutic Feeding Unit (in hospital, health centre or other facility)
TFP- Therapeutic Feeding Programme
3. Introduction
• Food insecurity indicates inadequate access to food
for whatever reason.
• Hunger is the immediate physiologic manifestation of
inadequate food intake.
• Undernutrition describes the biochemical and/or
physical consequences of long-term inadequate intake.
4. • Approximately 18% of all individuals in developing
countries are undernourished.
In Ethiopia
Stunting: National=47%
wasting : National=10.5%
Severe wasting: National=2.2%
Underweight: National=38.4%
More than 50% under five deaths have underlying
malnutrition
Most health facilities currently have over 20%
mortality due to SAM
5. Causes
Immediate :
Inadequate food intake
Disease
Underlying causes :
House Hold food insecurity,
Care & social env’t ( drought, war ) ,
Poor access to health & the health env't
Basic causes :
Formal & Informal Infrastructure,
Education,
Political Ideology & Resources
6. Problems and causes of
under nutrition
low birth Weight
Maternal under nutrition
deficiencies of specific Nutrients (iodine, vitamin A, iron,
zinc)
Diarrhea
HIV infection and other infectious diseases
Chronic illness
inadequate infant and child Feeding practices
Time constraints
limited household Income
limited agricultural Production
food insecurity, Environmental degradation
Urbanization
7. Prevention
food insecurity and undernutrition arise from a
variety of social, economic, and ecologic
situations that vary from time to time and from
place to place.
8. SEVERE CHILDHOOD
UNDERNUTRITION
• Deficiency of a single nutrient is an example of
undernutrition or malnutrition, but deficiency of a single
nutrient usually is accompanied by a deficiency of
several other nutrients.
• Protein-energy malnutrition (PEM) is manifested
primarily by inadequate dietary intakes of protein and
energy
10. Cont.…..
Marasmus (Non-edematous SCU) believed to result
primarily from inadequate energy intake
kwashiorkor (edematous SCU )was believed to
result primarily from inadequate protein intake.
marasmic kwashiorkor, has features of both
disorders (wasting and edema).
11. Victims of SAM
chronically ill patients in neonatal or pediatric
intensive care units
patients with burns, HIV, cystic fibrosis, failure to
thrive, chronic diarrhea syndromes, malignancies,
bone marrow transplantation, and inborn errors of
metabolism
12. End organ effects of
malnutrition
Body composition
Total body water increases(ECF)
Increased Na+
Decreased K+ and Mg++
Muscle and fat loss
GIT
Villus atrophy
Reduced enzymes
Bacterial over growth
13. End organ effects of
malnutrition
Liver
Reduced synthesis of protein
Impaired gluconeogenesis
Decreased metabolism of toxins and substances
Cardiac
Myocardial atrophy, reduced cardiac out put , decreased BP
Hematology :anemia
Metabolic
Hypoglycemia
Reduced metabolic rate
14. End organ effects of
malnutrition
Immunity
Impaired especially the Cell mediated
Reduced IgA
Reduced phagocytosis
Inflammatory response
Impaired acute phase response
Reduced chemotaxis of WBC to site of infection/
inflammation
Prone to infectious agents/subtle signs
15. Marasmus
• characterized by the wasting of muscle mass and the
depletion of body fat stores.
• It is the most common form of PEM and is caused by
inadequate intake of all nutrients, but especially dietary
energy sources (total calories
• Physical examination findings include:
• Diminished weight and height for age
• Emaciated and weak appearance
• Bradycardia, hypotension, and hypothermia
• Thin, dry skin
• Redundant skin folds caused by loss of subcutaneous fat
• Thin, sparse hair that is easily plucked
16. Kwashiorkor
• characterized by marked muscle atrophy with normal or increased body fat
• caused by inadequate protein intake in the presence of fair to good energy
intake.
• Anorexia is almost universal.
• Physical examination findings include:
• Normal or nearly normal weight and height for age
• Anasarca
• Pitting edema in the lower extremities and periorbitally
• Rounded prominence of the cheeks ("moon-face")
• Pursed appearance of the mouth
•
17. Cont…
Dry, atrophic, peeling skin with confluent areas of
hyperkeratosis and hyperpigmentation
• Dry, dull, hypopigmented hair that falls out or is easily
plucked
• Hepatomegaly (from fatty liver infiltrates)
• Distended abdomen with dilated intestinal loops.
• Adequate protein intake restores hair color, resulting in
alternating loss of hair color interspersed between bands
of normal pigmentation (flag sign)
20. Marasmus -kwashiorkor
• occur in a child who has inadequate dietary intake of
all nutrients and subsequently develops a common
infectious illness of childhood.
• the undernourished child develops hypoalbuminemia
and edema because the acute loss of nutrients
associated with an inflammatory response is
superimposed on the chronic wasting of body fat and
muscle nutrient stores.
21. Anthropometric assessment
– During periods of nutritional deprivation, weight deficits
occur initially, followed by length or height deficits and,
finally, by head circumference deficits.
– height-for-age an index of the cumulative effects of
under nutrition during the life of the child.
– weight-for-age reflects the combined effects of both
recent and longer-term levels of nutrition.
– weight-for-height reflects recent nutritional
experiences.
– Values <80–90% of expected are considered
abnormally low.
– Non specific to reflect causes
22. Gomez , welcome, waterlaw
Gomez : wt for age=wt of subject/wt of normal child of
same ageX100
Short comings
Did not differentiate b/n acute vs chronic and types of
malnutrition.
Age may not be known in developing countries
Wt for age Degree of malnutrition
90-109% normal
75-89% mild
60-74 moderate
<60 severe
23. Welcome
Welcome uses the weight for age measured by
Harvard curve. It differentiate b/n the types of
malnutrition but not whether whether acute or chronic.
Wt for age
Edema 60-80% <60%
absent Under wt Marasmus
present kwashiorkor Marasmic-
kwsahiorkor
24. Water low
Water low is better in understanding the type of malnutrition and its
duration. Wasting showing acute malnutrition and stunting showing
chronic malnutrition.
Wt for ht % Nutritional
status
Ht for age% Nutritional
status
90-100 normal >95 normal
85-90 Mild wasting 90-95 Mild stunting
75-85 Moderate
wasting
85-90 moderate
<75 Severe wasting <85 Severe stunting
25. Laboratory Features of
Severe Malnutrition
VARIABLES INFORMATION DERIVED
Hemoglobin, hematocrit, erythrocyte count,
mean corpuscular volume
Degree of dehydration and anemia; type of
anemia (iron/folate and vitamin B12
deficiency, hemolysis, malaria)
Glucose Hypoglycemia
Electrolytes and alkalinity
Sodium Hyponatremia, type of dehydration
Potassium Hypokalemia
Chloride, pH, bicarbonate Metabolic alkalosis or acidosis
Total protein, transferrin,(pre-)albumin Degree of protein deficiency
Creatinine Renal function
C-reactive protein, lymphocyte count,
serology, thick and thin blood films
Presence of bacterial or viral infection or
malaria
Stool examination Presence of parasites
26. As needed urine, stool, and blood culture cane be
done .
If there is any clue for pneumonia, tuberculosis or
CXR can be ordered.
29. Criteria for OTP(6month-18yrs)
All children with SAM, which means
weight for height>70%,
MUAC>11cm
edema +/++) and:
Who passed appetite test
Clinically well
Alert
No +++ edema
Do not have marasmic kwashiorkor
30. Inpatient care(6month-18yrs)
• Bilateral pitting oedema Grade 3 (+++)
• Marasmus-Kwashiorkor (W/H<70% with oedema or
MUAC<11cm with oedema)
• Severe vomiting/ intractable vomiting
• Hypothermia: axillary’s temperature < 35°C or rectal <
35.5°C
• Fever > 39°C
• respiratory distress
31. Inpatient care(6month-18yrs)
• Extensive skin lesions / infection
• Very weak, lethargic, unconscious
• Fitting/convulsions
• Severe dehydration based on history & clinical signs
• Any condition that requires an infusion or NG tube
feeding.
• severe anaemia
• Jaundice
• Bleeding tendencies
• Failed appetite test
32.
33. There are ten essential
steps
1.Treat/prevent hypoglycemia
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
35. Treatment of complications in SAM
Dehydration
Hypovolemic shock
Septic shock
Absent bowel sounds, gastric dilatation and
intestinal splash with abdominal distension
Heart Failure
Hypothermia
Severe anemia
Hypoglycemia
K.Dermatosis
36. Hypoglycemia
Blood glucose<3mmol/L(<54mg/dl)
Important cause of death in 1st 2days
Hepatic energy production from galactose & fructose is
much slower
Gluconeogenesis is limited
Serious infection/not fed in the last 4-6hr, vomited or
too weak to fed or waiting for admission
S/S include: hypothermia, limpness/drowsiness,
lethargy, loss of conscousness,lid retraction
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37. Treat Hypoglycemia
50ml 10% glucose/sucrose immediately oral/NGT
If only 50% glucose: 1 part in 4 part of sterile solution or
boiled water
(5-10ml/kg 10% SW=50ml or F75 or F100 by mouth or NGT)
Unconscous-5ml/kg 10% glucose solution iv followed by 50ml
10% glucose or sucrose via NGT
second line antibiotic for all suspected
Start feeding F75 half an hour after glucose, give 1/4th of the
2hourly dose Q30min in the 1st 2 hrs
Usually respond rapidly to this treatment, if not suspect other
causes
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38. Marasmus and dehydration
• History is important than the physical findings
• Change in mentation/behavior
• Urine volume decreases if there is dehydration
• Recent change in weight if dehydrated
• Eye ball sunken in both
• Quality of pulse – weak and thready when dehydrated.
• The oral mucosa is dry if there is dehydration (may be
wet if vomited recently).
• Skin pinch goes slowly in both
39. distinguishing clinical features
b/n dehydration and sepsis
• Hx of diarrhea/vomiting can occur in both conditions
• Urine amount may be decreased in both
• Hypothermia is common in sepsis than dehydration
• weak or absent pulses, are likely to occur in septic
shock rather than dehydration (although cold hands
and feet may occur in either condition).
40. distinguishing clinical features
b/n dehydration and sepsis
• thirst, and sunken eyes and fontanel, which are
characteristic of dehydration and do not occur in
sepsis.
• typical signs of dehydration (eg, lack of moisture of the
mouth and poor skin elasticity) are not reliable in
severely malnourished children.
• Mental status changes are present in some/severe
dehydration and sepsis.
41. Diagnose & treat Dehydration
Dehydration Dx and Mgt in Marasmus
Diagnosis
Difficult, needs definite history of significant fluid loss/diarrhea AND recent change
in child’s appearance-sunken eyes proven by mother.
No edema.
Diagnosis is presumptive not definite.
Shock with dehydration: weak pulse, cold hands and feet, if unconscious
severe shock
42. Treatment of dehydration
Never use the standard protocol for well nourished child & not
ORS but RESOMAL
Whenever possible hydrate only orally
IV fluids are dangerous, use only if severe shock with loss of
consciousness from confirmed dehydration
Re-Hydrate the child until wt deficit is corrected (usually 5%)
Give a total of 50ml per kg in 12hr
- Start 5ml/kg Q30min for 1st 2hrs then 5-10ml/kg per hour
44. Dehydration Rx …
- Assess wt, liver size, PR, RR, heart sounds Q1hr
- For dehydrated 6-24month child give 30ml Resomal per
loss
If still losing wt=>increase rate of Resomal by 10ml/kg/hr
If No wt gain=> increase rate by 5ml/kg/hr
Wt gain and child deteriorates=> stop Resomal & give F75
Wt gain and no improvement=>change to F75 or alternate
with Resomal
If improving but still with signs of dhn=> continue until
target wt with Resomal alone or alternate with F75
45.
46. Shock from dehydration
Definite dehydration+ semi/unconscious, rapid weak
pulse/slow capillary refill & cold feet & hands
Use IV fluid-R/L with 5%dextrose or half strength
saline with 5%dextrose
Give 15ml/kg over first hour & reassess, if still wt loss
or stable wt repeat the same until wt gain but if no
improvement assume septic shock and manage
As soon as child is conscious with good pulse-stop IV,
give oral or by NGT-follow by wt change
NO IV DRIP NEAR MALNOURISHED CHILD
WHO CAN DRINK OR USE NGT.
47. Kwashiorkor and dehydration
All edematous children have high water and sodium
retention hence over hydrated
If there is definite watery diarrhea & child clinically
deteriorating-replace with Resomal 30ml per watery
diarrhea
Septic shock
signs similar with shock of DHN
Manage the same + antibiotics (1st & 2nd line
antibiotics), treat hypoglycemia, prevent hypothermia
48. Management of heart failure
HF when?
-usually starts after mgt of SAM-iv infusion/ORS/high Na diet,
blood or plasma transfusion, severe anemia
-deterioration with wt gain
-RD with wt gain -Enlarged tender liver
-Increase in RR-Fast breathing/RD
-grunting, creptations, prominent superficial &
neck veins
-Triple rhythm, increase/appearance of edema
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49.
50. Treatment of heart failure
Stop all oral or IV intakes/No fluid or food for 24-48 hours until managed
Give sugar water to prevent hypoglycemia
Furosemide 1mg/kg single dose
Digoxin 5microgram/kg single dose
If there is also severe anemia, treat the HF first than the transfusion
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51. Severe anemia
Hgb<4gm/dl or Hct<12% in first 24 hours after
admission
Give Packed cell or whole blood 10ml/kg over 3hours
Keep child NPO during and 3hours after transfusion
Do not transfuse a child between 48hrs after the start of
F75 and 14days later
? Furosemide 1mg/kg iv (WHO)
No Iron treatment in the first phase
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52. Prevent/treat Hypothermia
Rectal temp <35.5dc or axillary <35dc
Children should always sleep with their caretakers, dry
well after bath, keep away from open window, cover
head
Keep warm- cover at night kangaroo technique, wrap
with mother, hot drinks to mother, blanket
Keep room temperature 28-32dc
Treat hypoglycemia
Give second line antibiotics/treat infection
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53. Treat Infection/Vit A/FA/Antimalarial
Start with amoxicillin oral (1st line) to all cases with SAM
If complications-ampicillin + gentamycin(2nd line)
Usually add antibiotic if no improvement in 48 hours of
amoxicillin
Consider 3rd line: Cloxacillin, Ceftriaxone
Consider antifungal: fluconazole in sepsis
Treat Oral thrush
Vit.A (none edema) & FA (for anemic cases)
Ant malarial(national protocol)
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54. HIV and other condition
• Management of SAM is the same
• Start nutritional treatment at least a week before ART, anti TB
(except miliary TB)
• If a must to start in PI start with reduced dose
• Cotrimoxazole preventive therapy will not replace amoxil
• Avoid toxic drugs
• Standard doses of drugs for HIV/TB are used in PII/OTP
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55.
56. Phase 1
• Patients with poor appetite and/or a major medical
complication.
• F75(130ml = 100kcal) promotes recovery of normal
metabolic function and nutrition-electrolytic balance.
• Breast-fed children should always be offered breast-
milk before the diet and always on demand.
• Rapid weight gain at this stage is dangerous, that is
why F75 is formulated so that patients do not gain
weight during this stage.
57. Feeding and NGT use
Indications for NGT use
Taking <75% of prescribed milk in 24h in phase one
Pneumonia with rapid RR/Respiratory distress
Cleft palate or other oral deformities
Painful mouth lesions
Unconscious or lethargic child
Use NGT only in Phase I and for max 3 days, try oral feeding at every
feeding.
58. Criteria to move from Phase I to transition
phase or Stabilization Center(SC) /TFU
Exit criteria
Return of appetite
Edema reduced
Clinically well
No NGT or IV line
If there is an OTP these children are transferred to OTP
59. Transition Phase
• Important to avoid electrolyte disequilibrium.
• The diet used is F100(100ml=100kcal)
• Quantity of F100 given is equal to the quantity of F75
given in Phase 1or an equivalent amount of RUTF.
• Expected weight gain should be around 6 g/kg/day.
60. Move the child back to
Phase 1
If the patient gains weight more rapidly than 10g/kg/d
increasing or new onset oedema
rapid increase in the size of the liver
significant re-feeding diarrhoea and weight loss.
If patient develops medical complication
If Naso-Gastric Tube is needed
Patient taking less than 75% of the feeds in Transition
Phase.
61. CRITERIA TO PROGRESS FROM
TRANSITION PHASE TO PHASE 2
A good appetite, taking at least 90% of the RUTF or
F100 prescribed for Transition Phase.
Oedematous patients (kwashiorkor) should remain in
Transition Phase until there is a definite and steady
reduction in oedema (now at + level).
Inpatients should remain in Transition Phase until they
have lost their oedema entirely.
Out -patients can go when their appetite is good
(taking all the diet in Transition Phase - not just in the
moderate range) and they have reduced their oedema
to ++ or +.
62. Phase 2
• Whenever patients have good appetite and no major
medical complication they enter Phase 2.
• Many patients with a good appetite can be admitted
directly into Phase 2.
• Give RUTF (used in both in-patient and out-patient
settings) or F100 (used in in-patient settings only)
according to look-up tables.
• Expected weight more than 8 g/kg/day.
• Start deworming and iron supplementation
63. MOVE BACK FROM PHASE 2 TO PHASE
1
Failure of the appetite test
Increase/development of oedema
Development of refeeding diarrhoea sufficient to lead to
weight loss.
Fulfilling any of the criteria of “failure to respond to
treatment”
Weight loss for 2 consecutive weighing
Weight loss of more than 5% of body weight at any visit.
Static weight for 3 consecutive weighing
Major illness or death of the main caretaker in OTP so
that the substitute caretaker requests inpatient care
65. Discharge /transfer criteria
inpatient & outpatient 6mo-18yrs
Option I: WFH >85% if no SFP or >80% where there is SFP(
for 2days in INP and 2 weeks in OTP) and no edema for
10days in INP or 14days in OTP
Option II: Target weight gain reached and no edema for 10days in
INP or 14days in OTP
All discharges send to Supplementary Feeding Program (SFP)
66. The Do NOT DOs
1. Do NOT give DIURETICS to treat Edema
2. Do NOT give IRON during the Initial feeding phase-add
iron only after the child has been on F100 for 2days
3. Do NOT provide high protein formula, over 1.5gm/kg/day
in initial phase
4. Do NOT give IV Fluids routinely
67. Infants< 6 months
ADMISSION CRITERIA
Infant less than 6 months or less than 3 kg with no
prospect of being breastfed
W/L (weight-for-length ) < 70% or
presence of bilateral oedema.
68. PHASE 1 - TRANSITION – PHASE 2
When there is no prospect of being given breast milk
then severely malnourished, less than 6 month’ old
infants, should be treated according to the standard
protocol with the following modifications. Phase 1
Wasted, marasmic infants of less than 6 months can
be given F100 diluted in Phase 1.
Oedematous infants of less than 6 months should
always be given F75 during phase one.
69. Transition Phase and Phase 2
During Transition Phase, only F100 diluted should be
used.
These small infants should not be treated with full
strength F100.
DISCHARGE CRITERIA
When they reach 85% weight for length they can be
switched to infant formula.
All infants less than 6 months old discharged from
therapeutic feeding have to be followed-up monthly until
their reach six months of age.
70. FAILURE TO RESPOND
Problems with the treatment facility
Problems of individual children
72. References
Nelson text book of pediatrics 18th edition
Up to date 18.2
Ethiopian guideline for SAM, March 2007.
WHO guideline for SAM, 2003
Pediatrics and child health lecture note for Health
science students, Jimma university, 2006.
