4. 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.
8. WHO recommends exclusive inpatient management of
children with SAM.
History : Breastfeeding, diarrhea, vomiting, appetite,
contact with tuberculosis, cough
Examination
Anthropometry – MUAC
Clinical features
9. 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
10. 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
11. 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.
12. Ten steps in two phases :
Stabilization phase – restoring homeostasis(2-7days)
Rehabilitation phase – rebuilding wasted tissue
13.
14. < 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.
15. 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
16. 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.
17. 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.
18. 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
19. 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.
20. 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.
.
21. 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.
22. 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
23. 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.
24. 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
26. 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
27. 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
28. At family level: Exclusive breast feeding
Complementary feeds
Vaccination
Adequate time between pregnancies
29. Children <6 yrs
Provided at Anganwadi
Six services : Supplementary nutrition
Immunization
Nonformal preschool education
Health checkup
Referral services
Nutritional and health education
30. Midday meal of 450 kcal and 12 g of protein for
primary stage
700 kcal and 20 g protein for upper primary stage.
31. 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%
