UPDATES ON SEVERE ACUTE MALNUTRITION

PREPARED BY DR. ABDI KEBEDE {R1}

MODERATOR DR. HAREG, PEDIATRICIAN

JANUARY / 2019
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Outline
 Introduction
 Definition
 Epidemiology
 Clinical manifestations
 Diagnosis
 Up dates on management
 CMAM
 Nutrition targets on sustainable development goals

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INTRODUCTION
 It is estimated that 19 million preschool-age children are suffering from severe wasting .

 Of the 7.6 million deaths annually among under 5 years of age;

 ~35% are due to nutrition-related factors and 4.4% of deaths due to severe wasting.

 Severe acute malnutrition remains a major cause of child mortality worldwide.

 While pneumonia and diarrhoea are often the final steps in the pathway, severe wasting is estim
ated to account for around 400 000 child deaths each year.

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 Major challenges remain to implementation of effective use of growth monitoring in primary h
ealth-care settings

 Low W-for-H,or MUAC are highly associated with a 5–20 fold increased risk of mortality.

 Malnutrition in children typically develops during the period from 6 to 18 months of age

 The nutritional status of children can also be affected by chronic infections such as HIV.

 Higher HIV prevalence, i.e. up to 50%, has been reported among children with SAM

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 If intensive refeeding is initiated before metabolic and electrolyte imbalances have been correct
ed, mortality rates are high.

 For this reason, WHO developed clinical guidance on the management of the child with SAM.

 Increasingly, SAM is being documented among infants who are less than 6 mo of age.

 However,there are few data describing to what extent of pathophysiology in this population is t
he same as that in older children and how to approach therapeutic feeding

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 38 % of children under 5 stunted (below -2 S
D),EDHS 2016

 18 % are severely stunted (below -3 SD).

 There are some regional variations;

 Stunting ranges from a high of 46 % in the A

mhara region to a low of 15 % in AA

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 10% of children in Ethiopia are wasted, and
3% are severely wasted (below -3 SD). (EDHS
2016)

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What is Malnutrition ?

 Malnutrition refers to all deviations from adequate nutrition and can exist in two forms: over nu
trition and undernutrition of Macronutrients and/ or Micronutrients

 Malnutrition is common in Ethiopia and can be manifested as:

Stunting

Wasting

Underweight AND Micronutrient deficiencies

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"the cellular imbalance between the supply of nutrients and energy and the body's
demand for them to ensure growth, maintenance, and specific functions."(WHO)

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Causes of Malnutrition
I. Immediate Causes:
 Inadequate dietary intake and repeated infectious diseases
II. Underlying Causes:
 Food insecurity;
 Defective maternal and child caring practices;and
 Unsafe water,poor sanitation,and inadequate health services.
III. Basic Causes:
limited education,poverty,and marginalization.

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 Lethargy and irritability
Long term effects on Impaired cortisol and growth
development?
Decreased appetite
Impaired cardiac function?
Impaired hepatic synthetic
function and
hepatobilliary function
Reduced b.cell function
Impaired pancreatic
exocrine function
Impaired glomerular and
tubular function?
Impaired thyroid function
hormone response
Respiratory tract
infections
Altered immune functions
Impaired
macronuitrentabsorption
Intestinal infections
changes to microbiomes
Chronic inflammation?
Loss of skinn integrity 12
Potassium decreased due to:
Reduction in muscle protein and increased urinary and fecal losses
CVS:
•Cardiac output and stroke volume are reduced
•Any increase in blood volume can easily produce acute heart failure;any decrease will further co
mpromise tissue perfusion
• Blood pressure is low
•Renal perfusion and circulation time are reduce

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Genitourinary system
•Glomerular filtration is reduced
•Capacity of kidney to excrete excess acid
•Urinary phosphate output is low
•Sodium excretion is reduced
•Urinary tract infection is common
Liver
•Synthesis of all proteins is reduced
•Abnormal metabolites of aminoacids are prod
uced
•Capacity to take up,metabolize and excrete to
xins is severely reduced
•Energy production from substrates such as gal
actose and fructose is much slower than norm
al
•Gluconeogenes is reduced
•Bile secretion is reduced
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Gastrointestinal system
•Production of gastric acidis reduced
•Intestinal motility is reduced
•Pancreas is atrophied and production of digestive enzymes is reduced
•Small intestinal mucosa is atrophied;activities of digestive enzymes are reduced
Endocrine system
• Insulin levels are reduced and the child has impaired glucose tolerance
• Insulin growthfactor1(IGF-1)levels are reduced,although growth hormone levels are increased
• Cortisol levels are usually increased

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Circulatory system
•Basic metabolic rate is reduced by about 30%
•Energy expenditure due to activity is very low
•Both heat generation and heat loss are impaired (hypo/hyperthermic)
Skin,muscles and glands
•The skin and subcutaneous fat are atrophied
•Many signs of dehydration are unreliable
•Many glands,including the sweat,tear and salivary glands,are atrophied
•Respiratory muscles are easilyfatigued

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•How does Reductive adaptation affect care of child?

•Three important implications for care:

Presume and treat infections

Do not give Iron early in treatment?

Provide potasium and Restrict sodium

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Recognize Signs of SAM
Visible Severe wasting

Bilateral oedema

Dermatosis

Eye signs

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Management Principles
 Children with severe malnutrition are often seriously ill when they first present for treatment
.

 Wasting, anorexia and infections are common.

 Severely malnourished children should be referred to hospital.

 Careful clinical evaluation and anticipation of common problems.

 The physiology of malnourished children is seriously abnormal;

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 Recently admitted children should be kept in a special area
 Isolated from other patients.
 The child should not be kept near a window or in a draught, and windows should be closed at
night.
 Properly covered with clothes, including a hat, and blankets.
 Involvement of care givers and family
 The room temperature should be kept at 28–32°C
 Intravenous infusions should be avoided except when essential

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Activity Initial treatment Rehabilitation Follow-up
Days 1—2 Days 2—7 Weeks 2—6 Weeks 7--26
Treat or prevent
Hypoglycemia
Hypothermia
Dehydration
Correct electrolyte
imbalance

Treat infection
Correct micronutrient With out iron
deficiencies Whithout IRON With Iron

Begin feeding
Increase feeding

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Activity Initial treatment Rehabilitation Follow-up
Days 1—2 Days 2—7 Weeks 2—6 Weeks 7—26
Stimulate
emotional,
sensorial
development

Prepare for
discharge

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WHO
WHOREVISION AREAS
REVISION AREAS
 Admission and discharge criteria for children
who are 6–59 months of age with SAM
 Where to manage children with SAM who ha
ve oedema
 Use of antibiotics in the management of chil
dren with SAM in outpatient care
 Vitamin A supplementation in the treatme
nt of children with SAM
 Therapeutic feeding approaches in the mana
gement of SAM in children who are 6–59 mo
nths of age
 Fluid management of children with SAM
 Management of HIV-infected children with
severe acute malnutrition
 Identifying and managing infants who are <
6 months of age with SAM
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1.Admission and Discharge criteria (6–59 moof age)

 A systematic review was conducted to examine admission and discharge criteria for SAM in ch
ildren who are 6–59mon of age

 The guideline group noted that percentage weight gain should no longer be used as a cri
terion for discharge from treatment.

 Weight-for-height ≤–3 Z-score, or

 MUAC <115 mm, or

 Presence of bilateral oedema;

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 Visible severe wasting is not included as a diagnostic criterion.

 Children with SAM with medical complications or failed appetite test should be admitted to hos
pital for inpatient care

 Admission may also be warranted if there are significant mitigating circumstances such as disab
ility or social issues, or there are difficulties with access to care;

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 Criteria for Inpatient or Outpatient care

 First assess medical complications and appetite.

Inpatient:

Medical complications, OR

Severe oedema (+++), OR

Poor appetite OR

Present with one or more IMCI danger signs

 Children who have appetite and are clinically well and alert should be treated as outpatients.
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 Transfer to outpatient care when:

 Their medical complications, including oedema, are resolving and

 Good appetite, and

 Clinically well and alert

 The decision to transfer should be determined by their clinical condition

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Criteria For Discharging From Treatment
 W-for-H is ≥–2 Z-score and no oedema for at least 2 weeks, or

 MUAC is ≥125  mm and no oedema for at least 2 weeks.

 The anthropometric indicator that is used to confirm SAM should also be used to assess nutritio
nal recovery

 Children admitted with only bilateral pitting oedema should be discharged from treatment based
on whichever anthropometric indicator used .

 Percentage weight gain should not be used as a discharge criterion.

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2. Where to Manage children with SAM who have oedema
 + or ++ bilateral pitting oedema but with medical complications or have no appetite should be a
dmitted for inpatient care

 Severe bilateral oedema +++,even if they present with no medical complications and have appeti
te, should be admitted for inpatient care.

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 3. Use of antibiotics in SAM , Outpatient care

 The choices of antibiotic influenced by cost, availability, ease of administration and local suscep
tibility profiles

 Amoxicillin is relatively safe in malnourished children; it has been proven to improve outcomes
in children with SAM

 Dose of 80  mg/kg/day in two divided doses for 7  days. This should also be the regimen for chi
ldren with complicated SAM after they have stabilised.

The rationale for a 7-day course of gentamicin in children with complicated SAM, who commonl
y have dehydration and compromised renal function?

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In case of sepsis or septic shock:

Im cefotaxime (for children or infants aged beyond 1mo:50mg/kg every 8 to 12 hours)+
oral ciprofloxacin (5 to 15 mg/kg:twice a day)

if suspected staphylococcal infections:

Add cloxacillin(12.5 to 50mg/kg/dose:4 times daily,depending on severity of infection

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If: Give

No complications Amoxicillin oral:25mg/kg every 12 hours for 5 days or until

referal for outpatient care

Complications (Shock,hypoglycemia, Gentamicin**IV or IM(7.5mg/kg),once daily for 7 days

dermatosis*,Resp/UTI,lethargic/sick appearance) plus
Ampicillin IV or IM(50mg/kg),every 6 hour for 2
days,followed by amoxicillin oral 25 mg/kg,every 12 hours
for 5 days

If resistance to amoxicillin and ampicillin and presence of Sepsis and septic shock:Im cefotaxime (>1mo:50mg/kg 8
medical complications to 12 hours)+oral ciprofloxacin (5-15mg/kg BID)
If staphlococcus suspected add cloxacillin
(12.5mg/kg/dose 4 times daily

If specific infections Specific antibiotics

**If child is not passing urine,dont give second dose

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4. Vitamin A supplementation in SAM

 Globally, 100 -140 million children are vitamin A deficient, 4.4 million of whom are estimate
d to have xerophthalmia

 Many children living in low-resource settings have a marginal deficiency:

 Essential to maintain mucosal barriers and for normal humoral and cellular immune responses.

 Commercially available therapeutic formulas (F-75 and F-100 and RUTF)that complies with th
e WHO specifications are fortified with vitamin A

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Vitamin A supplementation trials
 Two trials in sub-Saharan Africa aimed to compare low-dose (5000 IU) vs high-dose (2

00 000 IU for children >1 year; 100 000 IU children <1 year) vitamin A supplementation
in severely malnourished children .

 In Senegal, hospitalized children with SAM received either the high-dose vitamin A sup

plement at admission or low-dose supplements daily until discharge

 Incidence and duration of respiratory infection were reduced in the low-dose group com

pared to the high-dose group.

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 In a subgroup analysis, the low-dose course was protective against mortality in children
with oedema (AOR 0.21, 95% CI 0.05–0.99). No differences were detected for diarrhoea
morbidity or mortality.

 These findings suggest that SAM children with oedema may benefit by a low-dose cour
se of vitamin A supplementation during hospitalization (mortality and incidence of severe d
iarrhoea).

 low-dose vitamin A supplementation (5000 IU) is more effective for reducing mortality
for children with oedema, incidence of severe diarrhoea and respiratory infection than a s
ingle high dose vitamin A supplementation
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 There is no clear rationale for giving a single high-dose vitamin A supplement, unless children
have:

SAM and eye signs of vitamin A deficiency

SAM with recent measles

 Children with SAM should be provided with about 5000 IU vitamin A daily

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WHO recommendations
1. Children with SAM should receive the daily recommended nutrient intake of vitamin A throug
hout the treatment period. 5000 IU vitamin A daily, either as an integral part of therapeutic foods
or as part of a multi-micronutrient formulation.

2. Children with SAM do not require a high dose of vitamin A as a supplement if they are receivi
ng F-75, F-100 or RUTF that comply with WHO specifications, or vitamin A is part of other dail
y supplements.

3. Children with SAM should be given a high dose of vitamin A on admission, only if they are gi
ven therapeutic foods that are not fortified as recommended in WHO specifications and vitamin
A is not part of other daily supplements.

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4.A high dose of vitamin A should be given to all children with SAM and eye signs of vitamin A d
eficiency on day 1, with a second and a third dose on day 2 and day 15 (or at discharge from the p
rogramme), irrespective of the type of therapeutic food they are receiving;

5.To all children with SAM with recent measles on day 1, with a second and a third dose on day 2
and day 15 (or at discharge from the programme), irrespective of the type of therapeutic food they
are receiving.

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 Care for eyes

If the child has:Bitots spots only(no other eye signs)

No eye drop needed

If the child has:pus or inflammation

Give tetracycline (1%) or gentamycin(0.3%) eye drops or TTC eye ointment(1%)

If the child has:corneal clouding or corneal ulceration

Give both
Tetracycline(1%) or gentamycin (0.3%) eye drops or Tetracycline eye ointment (1%)
1 drop
4 times
1 drop
Atropine(0.1%) eye drops TID

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5. Therapeutic Feeding Approaches

1. SAM and acute diarrhoea treated as outpatients;

2. SAM and Persistent diarrhoea;

3. During the transition period from initial stabilization to nutritional rehabilitation .

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5.1.Therapeutic Feeding , SAM and AGE treated as OTP
 The relationship between SAM and acute diarrhoea is bidirectional –

 Vitamin A and zinc, together with other vitamins, are adequate in WHO Therapeutic feedings an
d RESOMAL to correct deficiencies

 The amounts of zinc included in these therapeutic foods are beyond the 10–20  mg of zinc per d
ay

 Children managed as outpatients who develop a serious complication or fail to respond to treatm
ent should be transferred for inpatient care.

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5.2 Therapeutic Feeding SAM and Persistent Diarrhoea
 The possible causes of Persistent Diarrhoea in children with SAM include all those that give ris
e to “malabsorption syndrome” in all children

 Management of persistent diarrhoea involves:

 Nutritional interventions,

 Restricting disaccharides (e.g. low-lactose feeds)),

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 Treating bacterial overgrowth, and, when appropriate,

 Excluding enteric or other systemic infections.

 Start therapeutic feeding as soon as possible in the initial phase of treatment

 10–20  mg of zinc daily for 10 to 14 days recommended in the 2005 WHO guidelines for diarrh
oea treatments less the amount already included in either F-75 or RUTF.

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6. Fluid management of children with SAM

 Profound disturbances of normal physiology, including electrolyte imbalances and altered fluid
distribution

 Children with bilateral pitting oedema typically have high intracellular sodium and are therefore
inclined to retain fluids.

 By comparison, intracellular potassium is lost to the extracellular space and total body potassiu
m is often very low.

 These changes at cellular level are part of the overall adaptive responses to repeated infections a
nd damage to cell membranes by free radicals.

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6.1 SAM And Dehydration Without Shock
 Low-osmolarity ORS may put these children at risk of sodium, and thereby f
luid, overload.
 The WHO recommended the use of ReSoMal, which contains 45  mmol/L s
odium and 40  mmol/L potassium .
 ReSoMal is not, however, appropriate for dehydrated children with SAM wit
h cholera or profuse watery diarrhoea.
 In the context of feeding with F-75 or RUTF , adding K+, zinc and mg to Re
SoMal may be less important.

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48
Monitoring algorithm for a child on Resomal

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6.2 .Fluid management of children with SAM and Shock

 IV therapy is reserved for children with shock who are lethargic or unconscious

 Iv Fluid options:

 Half-strength Darrow’s solution with 5% dextrose, or

 Ringer’s lactate solution with 5% dextrose or

 0.45% saline with 5% dextrose

 Initially 15  mL/kg/h, while observing for signs of overhydration and CHF

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 All children with SAM with signs of shock with lethargy or unconsciousness should be treated
for septic shock.

 15 mL/kg/h of one of the recommended fluids; it is carefully monitored every 5–10  min for si
gns of overhydration

 If signs of overhydration and CHF develop, IV therapy should be stopped immediately;

 If a child with SAM presenting with shock does not improve after 1  h of IV therapy, a blood tr
ansfusion (10 mL/kg slowly over at least 3 h) should be given;

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Management of Septic shock
 All patients with signs of septic shock should immediately:

1. Given broad-spectrum antibiotics

 Second line and first line antibiotics together;
 Consider third line antibiotics, antifungal treatment and anti-staphylococcal treatment.

2. Be physically disturbed as little as possible (no washing, excess examination, etc..)

3. Never be transported to another facility

4. Give maintenance IV fluids (4 ml/kg/hour) while waiting for blood transfusion.

 Transfuse whole fresh blood at 10 ml/kg slowly over three hours. If there are signs of heart failure, gi
ve packed cells instead of whole blood as these are smaller in volume.
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Management of Severe Anemia
 What is Very severe Anemia?
a hemoglobin concentration of < 4 g/dl (or hematocrit <12%).

Bacteraemia,

Frequent bouts of malaria,

Hookworm infection, HIV infection and

Micronutrient deficiency

Dilutional anemia -

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Blood transfusion recommended :

 Haemoglobin (Hb) levels <4  g/dL, or

 <6 g/dL if the child has respiratory distress,or

 Septic shock does not improve after 1  h of intravenous fluid therapy.

 Whole-blood transfusion is recommended within the first 24  h of admission

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7. Management of HIV-infected children with SAM

 Multifactorial causes of wasting :

 Altered glucose and lipid metabolism,

 Raised basal metabolic rate,

 Multiple micronutrient deficiencies,

 Higher rates of diarrhoea and malabsorption,

 Frequent co-infections and higher rates of food insecurity and poverty.

 Higher rates of persistent diarrhoea and opportunistic infections

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 Children living with HIV who have any one of symptom complex of TB ,should be eval
uated for TB and other conditions.

 Start on ART as soon as possible after stabilization of metabolic complications and sep
sis.

 HIV-infected children with SAM should be given the same antiretroviral drug treatmen
t regimens, in the same doses, as children with HIV who do not have

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 High dose of vitamin A on admission ,zinc for management of diarrhoea as indicated for other c
hildren with SAM, unless they are already receiving F-75, F-100 or RUTF.

 HIV-infected children with SAM in whom persistent diarrhoea does not resolve with standard m
anagement should be investigated to exclude carbohydrate intolerance and infective causes

 Should be managed with the same therapeutic feeding approaches as children with SAM who ar
e not HIV infected.

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8.Identifying and Managing infants who are less than 6 mon
ths of age with SAM
Infants less 6mo become malnourished if they have:

• Never been breast feed or suboptimal practice

•Inappropriate complementary introduced too early

•Recurrent Infections

•A medical complications

•Dead or sick ,absent mother

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Special cares
 Pay attention to any of signs:
 General danger signs

 Failure to gain weight or recent weight loss

 Failure to feed effectively (directly observed) and

 The presence of any pitting bilateral oedema

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 Management of SAM in this age group has focused on :

 Establishing,or re-establishing exclusive breastfeeding,and,

 Where this has not been possible, there are some reports of using formula feeds and early introd
uction of complementary foods

 What are the criteria for defining SAM in infants who are less than 6  months of age?

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Criteria to define SAM in Under 6mo
Defined as:

W-for-L < –3 Z-score, or

Presence of bilateral pitting oedema;

 Poor weight gain and poor response to nutrition counselling and support (IMCI) sho
uld be admitted

 General danger sign as defined by the IMCI should be admitted for urgent treatment
and care.

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 Inpatient care:

 Any serious clinical condition or medical complication

 Recent weight loss or failure to gain weight;

 Ineffective feeding (attachment, positioning and suckling) directly observed for 15–20 mi
n, ideally in a supervised separated area;

 Any pitting oedema;

 Any medical or social issue needing more detailed assessment or intensive support.

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 Given parenteral antibiotics to treat possible sepsis

 Should be breastfed where possible and the mothers or female caregivers should be sup
ported to breastfeed the infants.

 If an infant is not breastfed, support should be given to the mother or female caregiver t
o re-lactate.

 If this is not possible, wet nursing should be encouraged;

Should also be provided a supplementary feed:

 Should not be given undiluted F-100 at any time

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•During the initial phase of treatment,breastfeeding must be supplemented as:

•Between half an hour and an hour after normal breastfeeding session ,give maintenance ammou
nt of milk supplement 130ml/kg/day,8 feeds daily

•Infant without oedema should be supplemented with EBM,or,infant formula or F-75

•Infants with oedema should be supplemented with EBM,OR,F-75,infant formula, until oedema h
as resolved

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Transition if infants recieves
F-75
•When infant begin to gain weight (at least 20 g per day) for 2 to 3 days:

•Gradually decrease F-75 by one third,maintain this amount for 2 to 3 days

•If the baby gain satisfactory weight, further reduce until not giving anymore

•If weight gain is not satisfactory when reducing volume of milk,increase volume to previous level
for 2 days and try again

•Infant does not receive anymore milk during rehabilitation phase

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Feeding in case there is no brea
stfeeding
•Generic infant formula or F-75 130 mL/kg during stabilization phase
•when the child show sign of recovery in transition phase taking Formula/F-75
•Increase the volume by 30% or F-100 diluted 150-170mL/kg per day
Criteria for further increasing:
a good appetite(90%)
complete loss of oedema or
The child has been talking this amount for 2 days
No other medical problems

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Micronutrients supplementation
Vitamin A
Give a dose of 50,000IU to every infant at the time of discharge from inpatient care/admission
to outpatient care
Iron
should be given when the infant starts to gain on weight.
Give 3mg/kg/day in 2 divided doses

67
Transfer to outpatient care when:?

 All medical complications, including oedema, are resolved, and

 The infant has good appetite, is clinically well and alert, and

 Weight gain on either exclusive breastfeeding or replacement feeding is satisfactory ,a

nd

 Immunizations and other routine interventions, and

 The mothers or caregivers are linked with needed community-based follow-up and support

68
When to Discharge from all care?
 Are breastfeeding effectively or feeding well with replacement feeds, and

 Have adequate weight gain, and have a weight-for-length ≥–2 Z-score.

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The objective of the SAM ward should be to achieve case
fatality rate of less than 5%
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 Common incorrect practices in initial treatment that may cause death

Child not Fed at Night Standard ORS used instead of ReSOMAL

Iv Fluids given even though child is not

in shock Child left uncoverd at night

Diuretics given to treat oedema Anaemia treated with iron from admission

High protein diet given immediately Whole 12 hour rehydration is tried with
ReSOMAL alone

Antibiotics not given because no clinical

signs of infections

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OTP management of SAM
Components:
•community mobilisation and case findings
•Outpatient therapeutic care for SAM whithout complications
•Inpatient therapeutic care for SAM With complications
•Management of MAM

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Advanced elements making CMAM PO
SSIBLE
Advent of RUTF
The new classification of acute malnutrition
Screening and admission by MUAC
Community mobilisation
Timely detection of cases in community
Simplified management of cases at health center

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 References
 Guidelines for the Management of Acute Malnutrition Guidelines Government of Ethiopia Federal
ministry of health April 2016.

 Nelson TEXTBOOK of PEDIATRICS 20th edition

 WHO GUIDLINE UPDATES ON THE MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS

AND CHILDREN

 UPTODATE 21.6

UNICEF programme guidance document, 2015

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