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SAM

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Severe Acute Malnutrition Management

Publicado en: Educación
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SAM

  1. 1. Can be UNDERNUTRITION or OVERNUTRITION Susceptible to infections like sepsis, pneumonia and gastroenteritis.
  2. 2. Diarrhoea (neonatal)… Tetanus 1% AIDS 1% Measles 1% Pneumonia (neonatal) 3% Other neonatal 3% Meningitis and Pertussis 3% Congenital abnormalities 5% Malaria 5% Injuries 6% Sepsis 7% Diarrhoea (post- neonatal) 9% Intrapartum- related complications 11% Pneumoni a (post- neonatal) 13% Pre-term birth complications 16% Other 17% Malnutrition is the underlying cause of 45% of all child deaths
  3. 3.  In children of 6 to 59 months defined as any of the following :  i) wt for height < -3 SD of WHO growth reference  ii) visible severe wasting  iii) bipedal edema  iv) MUAC < 11.5 cm under 6 year age.
  4. 4. Immediate determinan t Underlying determinant Basic determinant
  5. 5.  WHO recommends exclusive inpatient management of children with SAM.  History : Breastfeeding, diarrhea, vomiting, appetite, contact with tuberculosis, cough  Examination Anthropometry – MUAC Clinical features
  6. 6.  SAM-children are immune-compromised, and hence show limited or no signs of infection and inflammation.  Assess ABC, temperature, Weight, Height  MUAC (use WHO “MOYO” charts)  Hypothermia (common) or fever (rare)  Signs of dehydration-loss of elsticity of skin,weak pulse,oligouria  Pallor ,shock –weak rapid pulse, cold hand, slow capillay refill  Oedema (+ up to ankle, ++ up to knee, +++ generalised oedema)  Liver size (many kwashiorkor children have this as ‘sign’ of SAM)  Abdominal distension (small bowel bacterial overgrowth)  Skin changes  Look for changes in the eye for Vit. A deficiency
  7. 7. Associated with marasmus or kwashiorkor or both Marasmus : acute starvation over borderline nutritional status.  Main sign is severe wasting  Monkey face and baggy pants  Alert child  No edema
  8. 8. Kwashiorkor  Main sign is pitting edema  Fat sugar baby appearance  Muscle wasting – hypotonic and weak child  Skin changes: enamel spots and flaky paint  Hair : flag sign ; loss of lustre; easily pluckable  Anemia ,mental changes, decreased renal fn etc.
  9. 9. Ten steps in two phases :  Stabilization phase – restoring homeostasis(2-7days)  Rehabilitation phase – rebuilding wasted tissue
  10. 10.  < 54 mg/ dl or 3 mmol/l of glucose.  Blood glucose measured immediately  Symptomatic and asymptomatic  Hypoglycemia , Hypothermia and Infection generally occur as a triad.
  11. 11.  50 ml of 10% glucose orally or Nasogastric tube by first feed  Feed with starter of F-75 every 2 hr day and night  Blood glucose monitoring every 30 min until normal
  12. 12.  5 mL/kg of 10% dextrose IV. Followed by  50 ml 10% dextrose or sucrose by Nasogastric tube.  First feed of F-75 2 hourly day and night after stable.  Blood glucose monitoring every 30 min until normal.  Start appropriate antibiotics.  Prevention : 2 hourly feed started immediately. Prevent Hypothermia.
  13. 13.  Rectal temp < 35.5ᵒ C or < 95.9ᵒ F  Rewarmed by Conduction by skin contact Convection Heat converter Radiation overhead heaters  Head covered  Feed immediately  Temp monitored every 2 hrs.
  14. 14.  Treated over 12 hrs  Reduced osmolarity ORS with K supplements  Amt depends on child’s need  5mL/ kg every 30 min for first 2 hrs and then 5-10 mL/kg every hour for next 4-10 hrs and 5-10 mL/kg after each watery stool  Breastfeeding continued  After signs of hydration, ORS must stop
  15. 15.  Supplementary K : 3-4 mEq/kg/day for 2 weeks.  50 % MgSO4(4mEq/ml) i.m. on first day, then 0.8 to 1.2 mEq/kg daily.  Excess body sodium exists even plasma sodium may be low so decrease salt in diet.
  16. 16.  Investigations are done : Hb, TLC, DLC, peripheral smear. Urine analysis and culture blood culture, chest xray, periphweral smear for malaria, mantoux, CSF examination.  Majority of bloodstream infections are due to gram- negative bacteria.  Hypoglycemia and hypothermia are markers of severe infection. .
  17. 17.  Broad Spectrum Antibotics  Parenteral ampicillin 50mg/kg/dose for at least 2 days followed by amoxicillin 15mg/kg 8 hourly for 5 days.  If no improvement occurs within 48hr, cefotaxine 100-150mg/kg/day 6-8 hourly.
  18. 18.  Twice recommended daily allowance of vitamin and minerals  Fe added only in rehabilitation phase  Day one : Vit A < 6 months 50000 IU  6 -12 months 1,00,000 IU  >1 yr 2,00,000 IU  Folic acid : 1mg/day(give 5mg on 1 day)  Zn: 2 mg/kg/day  Cu: 0.2 -0.3 mg/kg/day  Iron 3 mg/kg/day
  19. 19.  Osm < 350 mOsm/L, lactose <2-3 kg/day  5 % cal from proteins, renal solute load  Low viscosity , adequate bioavailiability of micronutrients.  Easily prepared, socially acceptable.  Cautious feeding : 80 kcal/kg/day to 100 kcal/kg/day.
  20. 20.  F-75 replaced with F-100  Increases calories to 150-200 kcal/kg/day and proteins to 4-6g/kg/day.  Frequency decrease and volume increased  Breastfeeding continued.  Ready to use therapeutic food (RUTF) : oil based paste ; can be stored (3-4.9kg:130gm, 5-6.9:260, 7-9.9:400, 10-14.9: 460)  Similar nutrient profile but high energy density
  21. 21.  Cheerful environment  Structured play therapy 15 to 30 min/day.
  22. 22.  Criteria for discharge : wt for ht is 90% of NCHS median and no edema, 15% of weight gain  In severely malnourished ready for discharge when Alert, active, eating 120-130kcal/kg/day with weight gain of 5g/kg/day for consecutive days. Free from infection, completed immunization, receiving micronutrients
  23. 23.  At national level: nutritional supplementation nutritional surveillance nutritional planning  At community level: Health and nutritional education Promotion of education and literacy Growth monitoring Integrated health package Family planning
  24. 24.  At family level: Exclusive breast feeding Complementary feeds Vaccination Adequate time between pregnancies
  25. 25.  Children <6 yrs  Provided at Anganwadi  Six services : Supplementary nutrition Immunization Nonformal preschool education Health checkup Referral services Nutritional and health education
  26. 26.  Midday meal of 450 kcal and 12 g of protein for primary stage  700 kcal and 20 g protein for upper primary stage.
  27. 27.  Stunting TARGET: 40% reduction in the number of children under-5 who are stunted  Anaemia TARGET: 50% reduction of anaemia in women of reproductive age  Low birth weight TARGET: 30% reduction in low birth weight  Childhood overweight TARGET: No increase in childhood overweight  Breastfeeding TARGET: Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%  Wasting TARGET: Reduce and maintain childhood wasting to less than 5%

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