Management of Severe

Acute Malnutrition
Roll no. 30 and 31
• The management differs from mild to moderate to severe cases
• The mainstay of treatment adequate amounts of protein and energy needs to be given to the child at
least 150 kcal/kg
• Protein intake of 3g/kg/day is sufficient
• Milk is the most frequent source of proteins including other sources like vegetable sources of
proteins needs to be given
• For age 6 to 59 months old child assess for any medical complications like pneumonia ,
tuberculosis ,HIV,
• Check for danger signs according to IMNCI (Integrated Management for Neonatal and Childhood
Illness).
 Assess for the following:
• Severe Edema(+++)
Presence of SAM: • Low appetite (failed
• Weight-for-Height <-3SD appetite test)
• Presence of Bipedal Edema • Medical Complications
• MUAC <11.5cm for age of 6 • 1 Or more complications
months as per IMNCI

If NO : If YES:
Uncomplicated Complicated
SAM SAM

Supervised Home Management Inpatient Management at a facility

Management of SAM:
1.Hypoglycemia
Blood glucose level <54mg/dL or 3 mmol/L.If blood glucose cannot be measured,
assume hypoglycemia.Hypoglycemia, hypothermia and infection generally occur as
a triad.
Treatment :
Asymptomatic Hypoglycemia:50ml 10℅ glucose or sucrose solution orally or by NG tube followed by first
feed. Feed with starter F-75 every 2 hourly day and night.
Symptomatic Hypoglycemia:10℅dextrose IV 5ml/kg.Follow with 50ml 10℅dextrose or sucrose solution by
NG tube. Feed with starter F-75 every 2 hourly day and night. Start appropriate antibiotics.
Prevention:
Feed 2 hourly starting immediately. Prevent Hypothermia.

2.Hypothermia
Rectal temperature <35.5°C Or Axillary temperature <35°C.Always measure blood glucose and screen for
infections in the presence of Hypothermia.
Treatment:
Clothe the child with warm clothes and cover the head with a scarf or cap. Provide heat using overhead
warmer, skin contact or heat convector. Avoid rapid rewarding as it may cause disequilibrium. Feed the
child immediately. Give antibiotics.
Prevention:
Always keep the child we’ll covered;ensure that head is also covered we’ll. Skin to skin contact-keeping the
child in contact with the mother’s bare chest or abdomen. Feed the child 2-hourly starting immediately
3.Dehydration
Difficult to estimate dehydration status in a severely malnourished child. Assume that all severely malnourished children with watery diarrhoea have
some dehydration. Low blood volume (Hypovolemia) can coexist with edema.
Treatment:
Use reduced osmolarity ORS with potassium supplements for rehydration and maintenance. Amount depends on how much the child needs, volume
of stool loss and whether the child is vomiting. Initiate feeding within 2-3 hours of starting rehydration;use F-75 formula on alternate hours along
with reduced osmolarity ORS. Be alert for signs of overhydration.
Prevention:
Give reduced osmolarity ORS at 5-10mL/kg after each watery stool, to replace stool losses. If breastfed, continue breastfeeding. Initiate refeeding
with starter F-75 formula.
4.Electrolytes
Give supplemental potassium at 3-4mEq/kg/day for at least 2 weeks. On day 1,give 50% MgSO4 (equivalent to 4mEq/mL) IM once (0.3
mL/kg;maximum of 2mL).Therafter, give extra Mg(0.8-1.2mEq/kg daily). Excess body Na exits even though the plasma Na may be low; decrease the
salt in diet.
5.Infection
Multiple infections are common;assume serious infection and treat. Usual signs of infection like fever are absent. Majority of bloodstream infections
are due to Gram –ve bacteria. Hypoglycemia and Hypothermia are markers of severe infection.
Treatment:
Parentetal Ampicillin 50 mg/kg/dose 6 hourly for at least 2 days followed by oral Amoxicillin 15mg/kg 8hourly for 5 days ;and Gentamicin 7.5mg/kg
or Amikacin 15-20mg/kg IM Or IV once daily for 7 days. If there’s no improvement in 48h , change to IV cefotaxime (100-150mg/kg//day 6-8hourly)
Or Ceftriaxone (50-75mg/kg/day 12hourly).If other specific infections are identified, give appropriate antibiotics.
Prevention:
Follow hang hygiene, give measles vaccine, if child >6 months and not immunized or if child is>9 months and has been vaacinated before the age
of 9 months
6.Micronutrients
Use up to 2× the daily requirements of various vitamins and minerals. On day 1 give Vitamin A orally (if age>1yr,
give 2lakh IU;age 6-12 months, give 1lakh IU;age 0-5 months, give 50,000 IU) Folic acid 1mg/day (give 5mg on day
1).Zinc 2mg/kg/day.Copper 0.2-0.3 mg/kg/day iron 3mg/kg/day, once child starts gaining weight after the
stabilization phase.

7.InitiateFeeding
Start feeding ASAP as frequent small feeds. Initiate Ng feeds if unable to take orally. Total fluid recommended is
130ml/kg/day, reduce this to 100ml/kg/day in case of edema. Continuous breastfeeding ad libitum. Make a
gradual transformation feed from F-75 to F-100. Diet. Increase intake of calories to 150-200kcal/kg/day and
proteins to 4-6 g/kg/day.Add complementary foods ASAP to prepare the child for home food immediately after the
discharge.

8.Catch-Up Growth
Once appetite returns in 2-3days, Encourage higher intakes. Increase volume offered at each feed and decrease
the frequency of feeds to 6 feeds per day. Continue breastfeeding ad libitum. Make a gradual transition from F-75
to F-100 diet. Increase calories to 150-200 kcal/kg/day, and proteins to 4-6g/kg/day.Add complementary foods
ASAP to prepare the child for home food at discharge.

9.Sensory Stimulation
A cheerful stimulating environment, Age-appropriate structured play therapy for at least 15-30min/day.Age-
appropriate physical activity as soon as the child is well enough. Tender, loving care.
10.Prepare for Follow-up
Primary failure to respond indications:
Failure to regain appetite by day -4
Failure to start losing edeam but day -4
Presence of edema on day 10
Failure to gain at least 5g/kg/day by day 10
Secondary failure to respond indications:
Failure to gain at least 5g/kg/day for consecutive days during the rehab
phase.
Clinical approach to child with SAM
• At home the family needs to be counselled and fully engaged
• Community health worker survey needs to be done
• Supply of adequate home food and ready to use therapeutic food
• Periodic monitoring for fast growth and medical condition can be ensured
• In hospital initial stabilisation should be done to restore homeostasis and treatment medical
complications 2-7 days of and symptoms of fever , hypothermia needs to be assessed of HIV
infection ,mouth ulcers and skin changes
• The rehabilitation phase focuses on rebuilding of tissues and may take several weeks
 Clinical approach for child with
MAM (Moderate Acute
Malnutrition)
• A mainstay diet of 150 Kcal/day needs to be given
• Nutritious home food need to be included
• Animal food sources to meet amino acid requirement
like milk ,eggs ,meat and plant source proteins like
pulses , cereals need to be given to the child.
 Treatment of patients with SAM
• Symptoms of hypoglycaemia is seen 50 ml of 10% GLUCOSE needs to
be given orally or through nasogastric tube
• For dehydration ORS needs to be given orally or through Nasogastric
tube for every 30 min for 1st 2 hours
• For any infection patients need to be given ampicillin 50mg/kg/dose
band IV gentamicin /amikacin for 7 days . Cloxacillin if any
staphylococcal infection is suspected.
Supplementation of micronutrients
• Vitamin A orally on days 1,2 and 4 if xeropthalmia dose -5000 IU for
less than 6 months 1 lakh IU for 6 months 1 year 2 lakhs
• Multivitamin like folic acid 1mg/ kg/day and Iron 3mg/kg/day given
once daily
• Vitamin k 2.5mg IM needs to be started .