Des Hydra Tai On

MANAGEMENT OF SEVERE ACUTE
MALNUTRITION
Dr DJOMALEU Rollin
1a
PLAN
Introduction
Background
Hospital management of SAM
Ambulatory(outpatient) management of SAM
Conclusion
2
INTRODUCTION
3
INTRODUCTION
DEFINITION
Nutrition = general term referring to the processes adopted by living things
including feeding, digestion and the body's use of food for growth, development,
reproduction, physical activity and the maintenance of health.
4
INTRODUCTION
DEFINITION
Malnutrition: Pathological condition resulting from the deficiency or excess of
calories or one or more nutrients.
Malnutrition consists
Obesity = excess of nutrients or calories
Undernutrition= deficiency of nutrients or calories
5
INTRODUCTION
DEFINITION
Undernutrition
Underweight W/A
Acute malnutrition, W/H (Moderate, severe)
Chronic malnutrition H/A
6
INTRODUCTION
DEFINITION
SAM = W/H<-3 SD and/or MUAC < 115 mm with or without œdema
Marasmus = SAM without œdema
Kwashiorkor = SAM+ œdema 3+++
Formes mixte = W/H<-3 SD and/or MUAC < 115 mm with œdema 2+
MAM = 115 mm <MUAC≤ 125 mm and /or -3ZS<W/H ≤-2 ZS
7
INTRODUCTION
INTEREST
 Important public health problem in developing countries
 More than 170 million cases worldwide, 90% of which are in developing
countries
In Cameroon: 30.4% of children under 5 suffer from chronic malnutrition,

including 12.6% in the severe form. (MICS 2006)
Severe disease/forms; High lethality (20 to 25%)
 Better understanding of physiopathology = codification of management.

8
BACKGROUND
9
BACKGROUND
NOTION OF REDUCTIVE ADAPTABILITY

 Adaptation mechanism during malnutrition
Corresponds to a slowdown in body functions and activities
in response calorie and nutrient deficiency.
10
BACKGROUND
NOTION OF REDUCTIVE ADAPTABILITY

 Consequences
 Signs of infection are often absent
 Fever
 Inflammation
 Loss of equilibrium Na+/K+ (loss of K+ and Na+)
 Decrease in Hb level and accumulation of Fe2+
 Formation of free radicals
 Promotes growth of bacteria
11
BACKGROUND
ETIOLOGICAL FACTORS
 Three main groups of factors :
Factors related to insufficient available food;
Infectious factors;
 Sociocultural and psychoaffective factors.
12
BACKGROUND
ETIOLOGICAL FACTORS
Factors related to insufficient food available;

Shortage of food production; Welding
Lack of financial means of the parents;
Other factors: famine, floods, displacement of populations (conflicts, war, etc.),
insufficient breastfeeding of infants under 6 months).
13
BACKGROUND
ETIOLOGICAL FACTORS
 Infectious factors = infectious and parasitic diseases:
Viral diseases: measles, HIV/AIDS…
 Bacterial diseases: whooping cough, tuberculosis, acute bacterial gastroenteritis
/ shigellosis, salmonellosis, etc.
 Parasitic diseases: malaria, helminthiasis and intestinal protozoosis, digestive
candidiasis...
14
INFECTIONS
UNDERNUTRITI
ON
VICIOUS CYCLE- UNDERNUTRITION
BACKGROUND
RISK FACTORS
 Sociocultural and psychoaffective factors:
 Lack of information from parents;
 Bad eating habits linked to beliefs, customs, taboos
 Poor weaning behavior;
 Large families ;
 Abandonment of young children;
 Maternal deaths.
16
BACKGROUND
SIGNS OF SAM
 Marasmus
 Old look
 Etiolated muscles
 Normal or brittle hair
 No edema
 Prominent ribs
 Loose skin
17
BACKGROUND
SIGNS OF SAM
 Marasmus
 Old look
 Etiolated muscles
 Normal or brittle hair
 No edema
 Prominent ribs
 Loose skin
18
BACKGROUND
SIGNS OF SAM
 Kwashiorkor
Etiolated muscles
 Red hair
 Skin lesions
Crybaby
Edema
19
BACKGROUND
SIGNS OF SAM
 Kwashiorkor
 The severity of the edema is classified as follows :
 + mild : both feet;
 ++ moderate : both feet, plus lower legs, hands, or lower arms;
 +++ severe : generalized edema affecting both feet, legs, hands, arms and
face.
20
HOSPITAL MANAGEMENT OF SAM
21
HOSPITAL MANAGEMENT OF SAM(CNTI)
ADMISSION CRITERIA
Neonate less than 6 months:
With severe emaciation or visible edema of both lower limbs or severe

difficulties to breastfeed despite maternal support.
Infants aged 6 months and above:
 MUAC < 115 mm
 or W/H<-3 Ecart-Type
 With or without edema of both feet
 And Poor appetite with or without medical complications. 22
BASIC PRINCIPLES OF MANAGEMENT
Patient is in danger whenever there is or in blood volume:

 ReSoMal or F-75 in case of dehydration
No IV fluid except patient is in shock.
Minimise the use of drugs that are eliminated by the liver.
Systematically give broad spectrum antibiotics.
Keep patient warm to prevent hypothermia.
 Tepid sponge in case of fever.
23
BASIC PRINCIPLES OF MANAGEMENT
TRAITEMENT SYSTEMATIQUE
TRAITEMENT NUTRITIONNEL
TRAITEMENT DES
COMPLICATIONS
STIMULATION EMOTIONNELLE
24
SYSTEMATIC MEDICAL MANAGEMENT
Systematic antibiotherapy:
 Amoxicilline 50 – 100mg/kg/d
 If amoxicilline resistance :
 Ceftriaxone 50 mg/kg/d for 2days or combination amoxicillin clavulanic acid
 2nd line
 Add gentamicine IM (5mg/kg/d) (without stopping amoxicillin or change to ampicillin)
 Change to Ceftriaxone (50mg/kg) and ciprofloxacine (10 mg/kg/ q 8h)
 suspicion of staphylococcus, add cloxacilline (100 – 200 mg/kg/d, thrice a day)

25
SYSTEMATIC MEDICAL MANAGEMENT
Malaria (if TDR + ou MP +)

 Arthemether-Lumefantrine ; 1tb initially, 1tb after 8hr, then D2 to D3 1tb morning and evening
(adjust posology to age of child).
 Artesunate 3 mg/kg or 2,4 mg/kg H0 H12 H24 H48 if P< 20 kg or p˃20 kg respectively, in
case of severe malaria.
Vaccination against measles

 From 9 months upward, serve on admission at CNT1 or at the hospital if no proof of prior
vaccination.
 2nd dose of vaccine to be given at the 4th week of treatment(CNAS) 26
DRUGS GIVEN ONLY UNDER SPECIFIC CIRCUMSTANCES
Vitamine A
When child presents signs of vitamin A deficiency.
Children more than 9months, during MEASLES EPIDEMIC if the child has not
been vacccinated against measles.
Folic acid
If clinical anemia, to give 1dose of folic acid (5mg) on the day of admission.
27
Vitamine A
28
Anti-helminthics
Delay antihelmithic treatment until patient admitted at CNAS.
Other nutrients
F75 (and F100, F100 diluted, RUTF) already contains all the nutrients required
for the treatment of patients with SAM.
29
NUTRITIONAL MANAGEMENT
Phase 1 or Stabilisation Phase

 Product used is F75 (130ml = 100kcal); 130 ml/kg /d
 Patient should receive at least 8 feeds per day
 Follow-up should indicate: quantity and anomalies during feeding.
 NGT
 If the patient does not take at least 75Kcal/kg/d
 Oral malformations, painful lesions inside the mouth.
 Coma, respiratory distress

30
Phase 1 or Stabilisation Phase

Criteria to move patients from the acute phase to the transitional phase
 Regaining of appetite
 Reduction of edema
 Patient clinically improved
31
Transitional Phase
The only difference with acute phase is the change in diet :
From F75 to RUTF – or to F100, if RUTF is not tolerated by patient.
It is better to use RUTF during the transitional Phase. Patients to continue
ambulatory treatment should be used to RUTF before discharge home.
32
Criteria to move back form transitional phase to acute phase

New onset edema
New onset Abdominal distension
 New onset Diarrhea with weightloss
 Complications requiring IV fluids
Worsening general state of patient
33
Criteria to transfer from transitional phase to CNAS or to phase 2

 Good appetite (at least 90% of portion);
 Complete resolution of edema for patient with kwashiorkor ;
 Absence of NGT and other medical problem;
 If transitional phase starts with F100, and patient succeed appetite test for RUTF.
 enough quantity of RUTF should be found at CNAS;
 CNAS Not far from patient’s house.
34
 Phase 2
Dietetic treatment in phase 2 is preferentially done with RUTF
Principle of phase 2 is to feed patients with balanced diet rich in calories
 1 sachet RUTF/3kg.
Breastfeeding is encouraged and maintained throughout the treatment
Breastfed infants should be breastfed prior to RUTF or to F100.
35
MANAGEMENT OF COMPLICATIONS
Hypoglycemia
Hypoglycemia with poor clinical signs should be prevented by feeding frequently.
For conscious patients: 50 ml sweet water 10% (5g or 1 coffeespoon of sugar

in 50 ml water) or F-75 per os ;
Obnibulated patient : 50 ml sweet water at 10% through NGT
Comatose patient : sweet water through NGT and glucose IV single shot
( 5ml/kg of glucose 10%)
36
 Hypothermia
 Very frequent in malnourished chid
 Rectal Temperature < à 35,5°C or
 Axillary Temperature < à 35°
 Treatment
 keep child warm
 Feed child every 2hrs
 Treat infections
 Correct hypoglycemia
37
 Severe anemia
T Hb< 40g/l (or hématocrite< 12%)
Clinical signs: palor of palms of hands and soles of feet, gingiva, lips, with
tachypnea and tachycardia
Treatment
Blood Transfusion of packed red blood cells ( 5- 7ml/kg) pendant 3heures
Monitor for signs of heart failure

38
 Hyperthermia
 Continue systematic treatment;
 Uncover the child
 Keep in well ventilated environment ;
 Give drinks ;
 Rule out malaria and other infections
 Cover with moist towel if temperature is markedly elevated
39
 Septic shock
Put child on oxygen
Give Dextrose 10%: 5 ml/kg IV
Administer IV Ringer Lactate solution in SG 5% + 20 mmol/l of potassium

chloride at a rate of 15ml/kg over 1hr
Monitoring
Pulse and respiratory rate every 10 mn
40
 Dehydration
Diagnosis
 History of recent fluid loss
 Recent change in last hours to days.
 History of recent change in physical appearence.
 Sunken eyes: mother should confirm that eyes have changed since diarrhea started.
41
 Dehydration
Diagnosis
shock = dehydratation +
 Semi conscious or unconscious and
 Rapid pulse and
 Cold extremities
 Delay capillary refill time
42
 Dehydration
Diagnosis Trap
Do not use classical signs of dehydration. They are not reliable.
Do not confuse faeces of undernutrition with diarrhea
Do not use the standard protocole for dehydration .
ORS and RESomal should not be left available to patients nor carers.
All IV treatments are very dangerous

43
 Dehydration
Management
 Accurate weight gain is the best measure of fluid balance.
 BEFORE starting the t3 of dehydration, you must :
 Weigh the child and determine the target rehydration weight (at most 5%)
 Mark the edges of the liver and the costal edges on the skin with an indelible pen
 Take and record respiratory rate
44
 Dehydration
Management
Start giving 10 ml/kg/hour for the first 2 hours orally or by NG tube
 Weigh the child every hour and assess the size of the liver
 Adapt the hydration protocol according to the evolution
45
 Dehydration
46
 Dehydration
Management of shock
Give 15 ml/kg mixture RL+ SG5% 50% IV for 1 hour and reassess the effect
 If weight loss continues Continue at 15 ml/kg IV the next H
If no improvement and the patient is gaining weight Stop rehydration therapy and
look for other causes of loss of consciousness
47
 Dehydration
Management of shock
As soon as the patient regains consciousness or the heartbeat slows down to
normal:
Stop the infusion and treat the patient orally or by NG tube at a rate of 10ml/kg/h
of ReSoMal.
Continue with the protocol described above
48
 Dehydration
Surveillance
Stop all rehydration t3 immediately, if one of the following signs is observed:

 The target weight of reh2O is reached (give F75),
 The visible veins are turgid,
 Edema develops (give F75),
 The size of the liver increases by more than one centimeter*,
 The liver is sensitive to palpation*,
 RR increases by 5 or more breaths per min

49
 Dehydration
Surveillance
 An expiratory grunting develops (this noise is only on the exhalation and not on the
inspiration),
 Presence of crackles on auscultation of the lungs,
 Presence of a galloping sound on cardiac auscultation
50
AMBULATORY MANAGEMENT
OF SAM(CNAS)
51
AMBULATORY MANAGEMENT DE LA SAM
ADMISSION CRITERIA
 6 to 59 months
 W/H < -3 z-score
 and/or
 MUAC < 115mm
 And/or
 Bilateral Œdema + and ++
 Without medical complications and with good appetite
52
AMBULATORY MANAGEMENT OF SAM
NUTRITIONAL TREATMENT
Ready-to-Use Therapeutic Foods (RUTF) are staple foods of treatment.
 Nutritional composition is similar to F100.
The quantity of RUTF to be given to each beneficiary must ensure an energy

intake of 170 kcal/kg/day.
53
SYATEMATIC TRAITEMENT
54
SURVEILLANCE
Children in the CNAS are followed up on a weekly basis
Perform the following actions at each visit:
 Check if the patient does not meet the criteria for treatment failure,
 Carry out the medical consultation and question the accompanying person if
symptoms of medical complications have been observed;
Administer routine treatment according to protocol;
55
SURVEILLANCE
Actions Frequency
Oedema check Every visit, all patients
MUAC measurement Every visit, all patients
Weight check Every visit, all patients
Calculation of W/H On admission, then tracking the target weight at
each visit
Height measurement On admission and when suspected child
substitution (sudden change in the weight)
Temperature check Every visit, all patients
Appetite test Every week except in case of adequate weight gain
56
CNAS CURE CRITERION
W/H ≥ -1,5 z-scores after 2 consecutive visits
or
MUAC ≥ 125mm after 2 consecutive visits
And
Absence of bilateral oedema since 2 weeks(for those admitted with Kwash
57
TRANSFER CRITERIA FROM CNAS TO CNTI
Transfer to the CNTI any patient treated at the CNAS who develops one of the
following criteria:
Patients treated at the CNAS who develop signs of serious medical

complications (pneumonia, dehydration)
Failed appetite test;
 Increase/development of nutritional edema;
Appearance of refeeding diarrhea leading to weight loss;

58

Presence of one of the “treatment failure” criteria:
Weight loss during 2 consecutive weigh-ins
Weight loss of more than 5% of body weight during any visit.
 Thesame weight during 3 consecutive weigh-ins
Failed appetite test
No reduction of edema after 2 weeks of treatment
No reduction of edema after 3 weeks
No satisfactory weight gain after total resolution of the edemas
59
Presence of one of the “treatment failure” criteria:
 Weight loss during 2 consecutive weigh-ins
 Weight loss of more than 5% of body weight at any visit.
 Stagnant weight for 3 consecutive weigh-ins
60
CONCLUSION
61
CONCLUSION
Malnutrition = major public health problem /DC
Often late diagnosis
Serious condition: highly lethal /severe acute forms
Need for appropriate PEC + early screening + adapted management
PREVENTION +++
62

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MANAGEMENT OF SEVERE ACUTE

Hospital management of SAM

Ambulatory(outpatient) management of SAM

Undernutrition= deficiency of nutrients or calories

Acute malnutrition, W/H (Moderate, severe)

Chronic malnutrition H/A

Kwashiorkor = SAM+ œdema 3+++

Formes mixte = W/H<-3 SD and/or MUAC < 115 mm with œdema 2+

MAM = 115 mm <MUAC≤ 125 mm and /or -3ZS<W/H ≤-2 ZS

 Important public health problem in developing countries

In Cameroon: 30.4% of children under 5 suffer from chronic malnutrition,

Severe disease/forms; High lethality (20 to 25%)

 Better understanding of physiopathology = codification of management.

NOTION OF REDUCTIVE ADAPTABILITY

Corresponds to a slowdown in body functions and activities

in response calorie and nutrient deficiency.

NOTION OF REDUCTIVE ADAPTABILITY

Factors related to insufficient food available;

Neonate less than 6 months:

With severe emaciation or visible edema of both lower limbs or severe

BASIC PRINCIPLES OF MANAGEMENT

Patient is in danger whenever there is or in blood volume:

BASIC PRINCIPLES OF MANAGEMENT

SYSTEMATIC MEDICAL MANAGEMENT

 Change to Ceftriaxone (50mg/kg) and ciprofloxacine (10 mg/kg/ q 8h)

 suspicion of staphylococcus, add cloxacilline (100 – 200 mg/kg/d, thrice a day)

SYSTEMATIC MEDICAL MANAGEMENT

Malaria (if TDR + ou MP +)

Vaccination against measles

DRUGS GIVEN ONLY UNDER SPECIFIC CIRCUMSTANCES

DRUGS GIVEN ONLY UNDER SPECIFIC CIRCUMSTANCES

DRUGS GIVEN ONLY UNDER SPECIFIC CIRCUMSTANCES

Delay antihelmithic treatment until patient admitted at CNAS.

Phase 1 or Stabilisation Phase

 Patient should receive at least 8 feeds per day

 Follow-up should indicate: quantity and anomalies during feeding.

 Oral malformations, painful lesions inside the mouth.

 Coma, respiratory distress

Phase 1 or Stabilisation Phase

 Patient clinically improved

The only difference with acute phase is the change in diet :

From F75 to RUTF – or to F100, if RUTF is not tolerated by patient.

Criteria to move back form transitional phase to acute phase

New onset Abdominal distension

 New onset Diarrhea with weightloss

 Complications requiring IV fluids

Worsening general state of patient

Criteria to transfer from transitional phase to CNAS or to phase 2

 Complete resolution of edema for patient with kwashiorkor ;

 Absence of NGT and other medical problem;

 enough quantity of RUTF should be found at CNAS;

 CNAS Not far from patient’s house.

Principle of phase 2 is to feed patients with balanced diet rich in calories

Breastfeeding is encouraged and maintained throughout the treatment

Breastfed infants should be breastfed prior to RUTF or to F100.

For conscious patients: 50 ml sweet water 10% (5g or 1 coffeespoon of sugar

 Axillary Temperature < à 35°

 Feed child every 2hrs

Blood Transfusion of packed red blood cells ( 5- 7ml/kg) pendant 3heures

Monitor for signs of heart failure

 Uncover the child

 Keep in well ventilated environment ;

 Rule out malaria and other infections

 Cover with moist towel if temperature is markedly elevated