Guided by

Asso prof Dr sunil k agarawalla

Presented by
Dr minakhi kumari sahu( JR-1)
SAM in children (6 to59 mo )
is defined by WHO as presence of any of
the following.
 Wt/Ht – below 3SD of the median WHO
growth reference.
 Visible severe wasting
 Presence of bipedal edema
 MUAC –less than 11.5 cm
 For infants < 49 cm
Visible severe wasting

 For infants > 49 cm

Wt/Ht - <3 SD and/or
Bi-pedal edema
LOOK AT THE FRONT VIEW

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 Mild(+)-edema in both feet or ankles
 Moderate(++)- edema in both feet +lower legs,hands
or lower arms
 Severe (+++)-generalised edema
 Age-group  6 to 59 M.
 Steps ??
 Around the LEFT Arm.
 Record LMUAC to the nearest 0.1 Cm.
 Colour-coded Tape.
 Important:-
 Repeat Measurement TWICE to ensure
Accuracy.

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 More common in Oedema than in Wasted.

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1) Complications
2) Poor appetite
3) Severe edema
 Presence of any emergency sign
 Persistent vomiting
 Very weak/apathetic
 Fever-axillary temp> 38.5 deg celsius
 Children with fast breathing /chest indrawing/cyanosis
 Diarrhea with dehydration
 Severe anemia
 Jaundice
 Bleeding tendecy
 Hypothermia
 Any other general sign which the clinician feels for
admission
In addition to above criteria if the care giver is unable to
take care of the child at home , the child also should be
admitted.
 HOW TO TEST-:
 For children 7-12 month- Offer 30-35ml/kg of
catch up diet.If the child takes >25ml/kg,
then appetite is good.
 For children >12 month- Feed locally
prepared therapeutic food.
 Amount of local therapeutic feed that a child
with SAM should take to PASS the APPETITE
TEST-:
BODY WT WT IN GRAMS
<4kg 15gm or more
4-7kg 25gm or more
7-10kg 33gm or more
 Not breathing at all or gasping
 Obstructed breathing
 Central cyanosis
 Severe respiratory distress
 Shock
 Coma
 Convulsion
 Diarrhea with severe dehydration
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 In all admitted children first measure blood
glucose
 Hypoglycemia- If RBS<54mg/dl
 If child is conscious, alert- Give 50ml 10% glucose
bolus orally
 If child is conscious but not drinking-give 50ml 10%
glucose or sucrose by NG tube
 If child is unconscious, lethargic or convulsing- Give
5ml/kg sterile 10% glucose iv f/b 50ml 10% glucose
bolus by NG tube.
 Start feeding as soon as possible with F-75 diet.
 (give it every ½ hr for 1st 2hr)
HYPOTHERMIA??
If axillary temp<35deg cel(95 deg F)
Or not recordable by thermometer
Or rectal temp<35.5deg cel(95.9 deg f)
TREATMENT
Treat for hypoglycemia and infection
Feed immediately then 2hrly.
Kangaroo technique.
Rewarm by overhead warmer.
Prevent from draughts of air.
Monitoring .
 Signs of dehydration
 Diagnosis-a definite history of significant recent
sudden onset of frequent diarrhea/ history of a
recent change in the child’s appearance
 Treatment- they should be rehydrated slowly
either orally or by nasogastric tube using oral
rehydration solution for malnourished children
 Solution- resomal, half strength WHO low
osmolarity ORS + pottasium and glucose
 Amount
 Every 30 min for 1st 2 hr-5 ml/kg BW
 Alternate hour for upto 10 hr – 5 -10 ml/kg
Signs of overhydration- PR>15,RR>5,
puffiness of eyes, jugular veins engorged

Signs of rehydration- no longer thirsty,less

lethargic,skin pinch less slow ,PR decrease,
RR decrease

If there is ongoing loss – for <2 yrs- 50 ml

/each loose stool, for >2 yr- 100ml /each
loose stool
If the child is having cold hands / slow
capillary refill(>3 sec)/weak and fast pulse
 Weight the child
 Give oxygen
 Make sure child is warm
 Insert an iv line and draw blood for
emergency labarotory

Give iv 10% glucose(5 ml/kg)

Give iv fluid 15 ml/kg over 1 hour of either

RL/2D5 or NS/2D5
 t
a
Measure the PR and RR r at the start and every 5-10 min
t
a
n
d
e
v
If the child
e If the child deteriorates(RR
Signs of fails to
r increases by 5/min or PR by
improvement( improve
y 15/min then stop infusion
PR and RR after the
5 and reasses
fall) first
-
15ml/kgIV
1
0
m
i
Repeat same fluid n
IV 15ml/kg over u
1hr,then switch to t
Assume the child has septic shock and give
oral or nasogastric e
maintainance fluid(4ml/kg/hr) and review antibiotic
rehydration with treatment s and start dopamine.then initiate refeeding
ORS 10ml/kg/hr up as soon as possible.
to 10 hr
 Give k+ at 3-4 meq/kg/day for 2 wk
 On day 1 give 50% mag sulphate IM once(0.3
ml/kg) up to max of 2ml.
 Thereafter give extra mag (0.4-0.6
mmol/kg/day) orally.
 Sodium should be restricted.
Status antibiotics

All admitted cases with Inj Ampicillin 50mg/kg/dose 6 hrly and

any complications other Inj Gentamicin 7.5mg/kg once a day for
than shock , meningitis 7 days.
or dysentry Add inj cloxacillin 100mg/kg/day 6hrly
if staphylococcal infection is suspected.
For septic shock/ Give 3rd gen cephalosporin like inj.
worsening/ no Cefotaxim 150mg/kg/day in TID or inj.
improvement in initial Ceftriaxone 100mg/kg/day BD PLUS
hours inj.gentamycin 7.5mg/kg in single dose.
IV cefotaxim 50mg/kg/dose 6hrly or
inj.ceftriaxone 50 mg/kg/dose BD plus
meningitis inj. Amika 15mg/kg/day OD.
Inj. Ceftriaxone 100mg/kg/day BD for 5
days.
Dysentery
 To all admitted cases give IV antibiotic as per
disease.
 To child with no complications give oral
amoxicillin 15mg/kg TID for 5 days.
DURATION OF ANTIBIOTIC THERAPY-
-Suspicion of clinical sepsis-1wk
-Urinary tract infection-7-10 days
-culture positive sepsis-2wk
-meningitis- 3wk
-Deep seated infection- 4wk

 IF POOR RESPONSE-Ensure AB has been given

Reasses and suspect resistant infection.
 To all SAM children give a dose of vit A on day 1.
 In presence of eye signs of vitA def give therapeutic
dose(50,000IU,1lacIU,2lacIU)on day 1,2and 14.
 Multivitamin supplement(2RDA)
 Folic acid 5mg on D1 then 1mg/day.
 Elemental zinc 2mg/kg/day.
 Copper0.3mg/kg/day.
 Fe-3mg/kg/day after 1wk.
 Feeding should be small and frequent.
 Starter F-75- 75 kcal and 0.9gm protien
/100ml.
 On day1- every 2hr(12 feeds in 24hr)
including night.
 If no vomitting and no diarrhhoea, increase
amount.( 3hrly and 4hrly)
 Total amount of feed- 130ml/kg/day.
 Feed the child orally/NG Tube.
 If the child takes 80% of the total feed orally,
then remove NG tube.
 Record intake and output on a 24hr food
intake chart.
 AllSAM children with medical complications or poor
apetite after stabillisation and children without
complications and good apetite will need catch up
diet to rebuild wasted tissues.
 F 100 diet - 100 kcal and 2.9gm protein/100ml.
 During first 2 days replace starter formula with the
same amount of catch up diet.Then on 3rd day
increase each feed by 10ml until some feed remains
uneaten.
 Give 8 feeds over 24 hr, (5 feeds of catch up diet
and 3 of family meals high in energy and protein)
 Daily measure the weight
Diet content for 100ml F – 75 starter F – 100

Cows milk or equivalent (ml) 30 95

Sugar (gm) 9 5

Vegetable oil (gm) 2 2

Water make up to (ml) 100 100

Energy Kcal 75 101

Protein (gm) 0.9 2.9

Lactose (gm) 1.2 3.8 23

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 play full activities (language and motor activities ,
activities with toys)
 Teach the child local songs and games using the fingers
and toes.
 Encouage the child to laugh ,vocalise and describe wat
he or she is doing
 Encourage the child to perform next appropriate motor
activities
 Immobile children- passive limb movement
 Mobile children - rolling or tumbling on a mattress,
kicking and tossing a ball, and climbing stairs.
 Mothers and care givers should be involbed in all aspects
of management of her child.
 After 10 to 15 days of hospital stay,the child
requires follow up for another 4 to 6 month for full
recovery.
 The parent understand the cause of malnutrition
and prevent it’s recurrence by correct feeding
practices.
 T/t for helminthic infection should be given to all
children before discharge.
 Inform the ANM at the nearest PHC or subcentre to
ensure follow up.
 All SAM children should be followed up by health
providers in the programme till s/he reaches Wt/Ht
of -1 SD
Child:
 Achieved weight gain of >/= 15% and 5gm/kg/day for 3
consecutive days .
 Edema has resolved
 Child eating freely that the mother can prepare at home
 No medical complication and infection
 Child is provided with micronutrients
 Immunisation
Mother /caregiver
 Knows how to prepare appropriate food and to feed the child
 Knows how to make appropriate toys and play with the child
 Knows how to give home treatment for diarrhea,fever and
acute respiratory infections and how to recognise the signs
that he must seek medical assistance
 Follow up plan is completed
 Indication for BT
1)Hb<4 gm/dl
2)Hb 4-6 gm/dl and signs of resp disstress
How to give transfusion??
- No CHF-10ml/kg packed cell
-Presence of CHF- 5-7ml/kg packed cell
-Give inj lasix (1mg/kg)
-Look for signs of CHF
 Initial steps are same.
 Feed the infant with EBM or noncereal starter or
artificial milk feed.
 Give good diet and micronutrient to mother.
 In rehabillitation phase give support to the mother
and establish EBF. In artificially fed babies give
diluted catch up diet.
 Discharge- Wt gain for 5 days and no medical
complications.
 Relactation through supplementary sucking
technique- Used in lactation failure.
 In SAM children who are infected with HIV/TB basic
principles and steps of management are same.
 Start T/t of malnutrition 2 wks before the
introduction of ART/ATT.
 Children with hiv- cotrimoxazole pplx against
pneumocystis pneumonia as per NACO
guidelines.Amoxicillin should also be given
 For severe pneumonia in HIV infected children give
adequate anti staphylococcal and gram negative
antibiotic coverage ( ampicillin and gentamycin).
 Criteria after Admission Time

 Primary Failure:-
 Failure to regain appetite  Day-04.
 Failure to start to loose O   Day-04.
 Oedema still Present   Day-10.
 Failure to gain at least 5g/kg/D  Day-10.

 Secondary Failure:- Failure to gain

at least 5 g/kg/D during Rehabilitation
for 3 Successive Days.
43
 SAM with complication is a medical
emergency.
 Treat for hypoglycemia and infection and
look for emergency signs.
 Never give IVF unless the chid is in shock.
 Prevent hypothermia.
 Give micronutrients and multivitamin.
 Never forget to give vit-A.
 Initiate feeding as soon as possible.
 Discharge – wt gain >5gm/kg/day
 Follow up