MODERATE AND

SEVERE ACUTE
MALNUTRITION
MEENAKSHY A R
MEGHA KIRAN
 MODERATE ACUTE
MALNUTRITION
 Moderate malnutrition make up the greatest portion of malnourished
children and account for >80% of malnutrition associated deaths.
 It is, therefore, vital to intervene in children with mild and moderate
malnutrition at the community level before they develop complications.
 The mainstay of treatment is provision of adequate amounts of protein
and energy; at least 150 kcal/kg/day should be given.
 In order to achieve these high energy intakes, frequent feeding (up to
seven times a day) is often necessary. Because energy is so important
and because carbohydrate energy sources are bulky, oil is usually used
to increase the energy in therapeutic diets.
 It is recognized increasingly that a relatively small increase over
normal protein requirements is sufficient for rapid catchup growth,
provided energy intake is high.

 A protein intake of 3 g/kg/day is sufficient. Milk is the most frequent

source of the protein used in therapeutic diets, though other
sources, including vegetable protein mixtures, have been used
successfully.

 Adequate minerals and vitamins should be provided for the

appropriate duration. The best measure of the efficacy of treatment
of mild and moderate malnutrition is weight gain
DEFINITION
Severe acute malnutrition (SAM) among children 6-59 months of age
is defined by World Health Organization (WHO) and UNICEF as any of
the following:
 Weight for-height below -3 standard deviation (SD or Z scores) of
the

 Visible severe wasting

 Presence of bipedal edema; or

 Mid upper arm circumference below 11.5 cm.

Click icon to add picture
 WHO CLASSIFICATION
 The assessment of nutritional status is done according to weight-for-
height (or length), height (or length)-for-age and presence of edema.

 The SD score is defined as the deviation of the value for an individual

from the median value of the reference population, divided by the
standard deviation of the reference population.
CLINICAL FEATURES
 It is divided into MARASMUS and KWASHIORKOR
MARASMUS

 It is characterized by marked wasting of fat and muscle as these tissues are

consumed to make energy.
 The main sign is severe wasting. The child appears very thin (skin and bones)
and has no fat. There is severe wasting of the shoulders, arms, buttocks and
thighs.
 The loss of buccal pad of fat creates the aged or wrinkled appearance that has
been 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 be alert in spite of their condition.
 KWASHIORKOR
 It usually affects children aged 1-4 yr. The main sign is pitting edema, usually
starting in the legs and feet and spreading, in more advanced cases, to the hands
and face.

 Child may have a fat sugar baby appearance.

 Muscle wasting. It is always present. The child is often weak, hypotonic and unable to
stand or walk.

 Skin changes Increased pigmentation, desquamation and dyspigmentation.

Pigmentation may be confluent resembling flaky paint or in individual enamel spots.
The distribution is typically on buttocks, perineum and upper thigh. Petechiae may be
seen over abdomen. Outer layers of skin may peel off and ulceration may occur.
 Mucous membrane lesions include Smooth tongue, cheilosis and
angular stomatitis are common.

 Hair Changes include dyspigmentation, loss of characteristic curls

and sparseness over temple and occipital regions. Hairs also lose
their lustre and are easily pluckable. A flag sign which is the
alternate bands of hypopigmented and normally pigmented hair
pattern is seen when the growth of child occurs in spurts.

 Mental changes Includes unhappiness, apathy or irritability with

sad, intermittent cry. They show no signs of hunger and it is difficult
to feed them.

 Neurological changes - These are seen during recovery

 Gastrointestinal system- Anorexia, sometimes with
vomiting, is the rule. Abdominal distension is
characteristic. Stools may be watery or semisolid, bulky
with a low pH and may contain unabsorbed sugars.

 Anemia- It may also be seen, as in mild PEM, but with

greater severity.

 Cardiovascular system- The findings include cold, pale

extremities due to circulatory insufficiency and are
associated with prolonged circulation time, bradycardia,
diminished cardiac output and hypotension.

 Renal function- Glomerular filtration and renal plasma flow

are diminished. There is aminoaciduria and inefficient
excretion of acid load
COMMUNITY BASED
MANAGEMENT OF SAM

 Community Mobilization
 Outpatient Therapeutic Programme (OTP)
 Inpatient Care (Stabilization Centres)
 Supplementary Feeding Programmes (SFP)
 Follow-up and Prevention
 STABILIZATION
MNEMONIC – ‘HIDE’

◦ Hypoglycaemia: Blood glucose <54 mg/dL is hypoglycaemia in SAM

◦ For conscious child: 50 mL 10% glucose or 1 tsp of sugar in 50 mL of

water is given.
◦ Then give F75, every half hour for the first 2 hrs and then 2 hourly.

◦ For unconscious or convulsing child: IV 10% glucose 5 mL/kg, then

consider 50 mL 10% glucose or 1 tsp of sugar in 50 mL of water via
nasogastric tube.
Repeat blood sugar estimation
◦ Hypothermia (axillary temperature <35°C or rectal temperature
warmer or in contact with the mother's body (kangaroo mother care).
Start feeding. Monitor temperature 2 h

◦ Infections: Presumptive antibiotic is indicated in all hospitalized

severe PEM cases (ampicillin 50 mg/kg every 6 hrs and gentamicin 7.5
mg/kg once daily). All SAM babies >6 months must be given measles
vaccine, with a repeat dose of MR vaccine at the routine time of 9
months.

◦ Dehydration: ORS mainly. IV fluid only if the child is in shock (Ringer

lactate with 5% dextrose)
◦ Electrolytes: Hypokalaemia: Potassium 3-4 mEq/kg/day

orally; Hypomagnesemia: Magnesium 0.5 mEq/kg/day (inj or

oral).

◦ Micronutrients: Iron is given only after stabilization stage.

Other micronutrients to be supplemented are folic acid, zinc,
vitamin A, etc. Vitamin D is started once the child starts
growing.
 Management of
uncomplicated SAM
1. Identification & Admission Criteria
Uncomplicated SAM is defined by:

 Weight-for-height/length < –3 SD or mid–upper arm circumference (MUAC) < 11.5 cm,

 With no medical complications (e.g. no oedema, no serious infections, ability to eat, alert,
well‑perfused).
 Children meeting these criteria are suited for outpatient therapeutic care.

2. Therapeutic Feeding: Ready-to-Use Therapeutic Food (RUTF)

3. Medical & Micronutrient Support
 Routine medications: Amoxicillin for 5–7 days, Deworming (albendazole/mebendazole),
 Vitamin A (according to WHO schedule),
 A zinc course for diarrhea,
 Iron usually deferred until after stabilization to avoid free radical risk in active infection.
4. Discharge Criteria
Discharge once:
 Weight-for-height ≥ –2 SD or MUAC ≥ 12.5 cm for at least two consecutive
visits,
 No oedema, and clinically stable.

5. Follow up, regular monitoring

Primary and Secondary
failure
 According to the IAP Guidelines

 Primary failure (non‑response):

 No weight gain for 21 days or
 Weight loss for 14 days since admission

 Secondary failure (relapse):

 Loss of appetite during the course or
 Weight loss of ≥ 5% body weight at any point
 Management
1. Prompt Recognition
 Primary failure: suspected when no improvement by Day 10–21.
 Secondary failure: recognized through vigilant MUAC/weight checks during outpatient follow-
ups.
2. Refer for Inpatient Care if:
 Primary/secondary failure occurs or
 Danger signs emerge: loss of appetite, persistent fever, infections, signs of dehydration,
edema, etc.
3. Inpatient Management Includes:
 Stabilization phase (F-75 therapeutic milk):
 Treat hypoglycaemia, hypothermia, dehydration, infection, and electrolyte/micronutrient
deficiencies.
 wait for appetite, clinical status, and metabolic conditions to improve.
 Transition phase with F-100
5. Monitor Response in Hospital:

 Daily weight gain target: ≥ 5 g/kg/day.

 Watch for appetite return, resolution of edema/infection, and clinical

improvement.
 Failure to meet targets signals need to reassess for underlying problems

or escalate care.

6. Discharge & Follow-Up

CRITERIA FOR DISCHARGE
◦ Ideally 6-8 weeks of hospitalization is required for complete recovery. The child
is said to have recovered when his weight for height is 90% of the NCHS median or
has 15% weight gain, and he has no edema.
◦ Severely malnourished children are ready for discharge when the child:
◦ Is alert and active, eating atleast 120-130 kcal/kg/day with a consistent weight
gain (of at least 5 g/kg/day for 3 consecutive days) on exclusive oral feeding.
◦ Is receiving adequate micronutrients free from infection
◦ Has completed immunization appropriate for age
◦ The caretaker has been sensitized to home care.
◦ The caregiver should be advised to bring child back for regular follow up checks,
ensure booster immunizations, make sure that vitamin A is given every six
months, feed frequently with energy and nutrient dense food
 Criteria for discharge before
recovery is complete
For some children, earlier discharge may be considered if effective alternative
supervision is available.
◦ Is aged >12 months
◦ Has a good appetite with satisfactory weight gain
◦ Has completed antibiotic treatment
◦ Has taken 2 weeks of potassium/magnesium/mineral/vitamin supplement
◦ It is important to be sure that the mother/caretaker has the financial resource to feed
the child, is specifically trained to give appropriate feeding (types, amount, frequency),
lives within easy reach of the hospital, is trained to give structured play therapy and is
motivated to follow advice given
REHABILITATION
◦ The various stages are feeding, monitoring catch up growth,
provision of stimulating environment and follow-up. Feeding will
promote growth with stimulation and follow-up (mnemonic)
FEEDING
◦ Phase 1 of feeding: Start F-75 diet as soon as possible after the
initial steps of stabilization.
◦ F-75: Full cream milk 30 mL + Sugar 2 tsp (10 g) + MCT oil
½ tsp + water to make it 100 mL. This provides 75 calories
and 1 g protein. F-75 given at volumes to provide 100
cal/kg/day aims at recovery of normal metabolic functions
and not growth (higher calories and proteins at this stage
precipitate metabolic disequilibrium).
◦ Transition phase of feeding: Replace starter F-75 with the same
amount of F-100 for 48 hrs (frequent small quantity leeds).
Kwashiorkor patients should remain in transition phase until the
oedema starts subsiding
◦ Phase II of feeding: Start this phase with the return of
appetite, and loss of oedema.
◦ The options are:
◦ F-100: Full cream milk 90 mL + sugar 1 tsp (5 g) + MCT
oil ½ tsp + water to make it 100 mL. This provides 100
calories and 3 g protein.
◦ RUTF Ready to Use Therapeutic Food: 100 g provides 500
cal & 15 g protein. It is commercially available or can be locally
prepared using available and acceptable foods.
◦ Home available solid foods. Examples are banana, chappatti,
dosa, etc.
◦ In phase II, the amount of calorie is increased to 150-200
kcal/kg/day and protein to 4-6 g/kg/day as per tolerance.
RUTF
◦ This is an energy dense, mineral and vitamin enriched ready to use
therapeutic food with a similar nutrient profile but greater energy and
nutrient density than F-100 has greatly improved cost effectiveness of
treating severe malnutrition.
◦ F-100, although extremely effective during rehabilitation phase in inpatient
centers, is very vulnerable to bacterial contamination and must be used
within a couple of hours of being made
◦ RUTF is an oil-based paste and as such can be stored at home unrefrigerated with
little risk of microbial contamination for several months. The daily amount of RUTF to
be consumed varies according to body weight as follows:
◦ 3-4.9 kg: 105-130 g
◦ 5-6.9 kg: 200-260 g
◦ 7-9.9 kg: 260-400 g
◦ and 10-14.9 kg: 400-460 g.
◦ This amount is to be given along with plenty of water in 2-3 hourly feeds. The child
should continue to receive other foods and breastfeeding during medical nutrition
therapy with RUTF.
◦ Complementary foods should be added as soon as possible to prepare the child for
home foods at discharge
◦ They should have comparable energy and protein concentrations once the catchup
diets are well tolerated
◦ Catch up growth expected is >10 g/kg/day with the
above feeding.

◦ Stimulation: A stimulating environment and structured

play therapy should be provided.

◦ Follow-up: For weight gain, immunization, health

education (how to avoid recurrence of PEM, care during
diarrhea and other illnesses), etc.

◦ Follow-up is best planned with the local Anganwadi.