Management of SAM

1. SEVERE ACUTE
MALNUTRITION
DR. ADITYA
GUPTA

2. DIAGNOSIS

4. MAGNITUDE OF THE PROBLEM
• NFHS- 4 DATA

6. ASSESEMENT

7. HISTORY
Recent intake of food and fluids
Usual diet (before the current illness)
Breastfeeding
Duration and frequency of diarrhoea and vomiting
Type of diarrhoea (watery/ bloody)
Chronic cough
Loss of appetite
Family circumstances (to understand the child’s social background)
Contact with tuberculosis
Recent contact with measles
Known or suspected HIV infection
Immunizations

8. EXAMINATION
Anthropometry- weight,
height/length, mid arm
circumference
Oedema
Pulse, heart rate,
respiratory rate
Signs of dehydration
Shock (cold hands, slow
capillary refill, weak and
rapid pulse)
Palmar pallor
Eye signs of vitamin A
deficiency: Dry
conjunctiva or cornea,
Bitot’s spots ,corneal
ulceration, Keratomalacia

9. EXAMINATION
LOCALIZING SIGNS
OF INFECTION
MOUTH ULCERS SKIN CHANGES OF
KWASHIORKOR

10. CRITERIA FOR ADMISSION
Anorexia (Loss of
appetite)
Fever (39 degree c) or
Hypothermia (<35 c)
Persistent vomiting
Severe dehydration based
on history and clinical
examination
not alert, very weak,
apathetic, unconscious,
convulsions
Hypoglycaemia
Severe Anaemia (severe
palmar pallor)
Severe pneumonia
Extensive superficial
infection requiring I.M.
medications
Any other general sign
that a clinician thinks
requires admission for
further assessment or
care

11. APPETITE TEST

12. LAB TESTS

13. INPATIENT MANAGEMENT

15. HYPOGLYCAEMIA
• . HYPOGLYCAEMIA
• Blood glucose < 54 mg/dl
(if blood glucose cannot be measured, hypoglycaemia is assumed)
CONSCIOUS CHILD UNCONSCIOUS CHILD
• Always give correction orally or via NG
50 ml bolus of 10% glucose or
sucrose solution (1 tsp of sugar in 3 1/2
tbsp water);
• then start diet Q 30 min X 2 hrs (1/4th
feed each time
Intravenous 10% dextrose (5 ml/kg),
followed by 50 ml of 10% glucose by
N/G tube
then starter diet once child regains
consciousness

16. MONITORING
Blood glucose: repeat RBS after 2 hrs.
If low, then repeat 5ml/kg of 10% glucose/sucrose solution.
Continue feeding q30 min till blood glucose level is stable.
Repeat blood glucose level if,
-Rectal temperature <35.5°c;
-Deterioration of level of consciousness.

17. HYPOTHERMIA
• AXILLARY TEMPERATURE <35°C OR RECTAL TEMP. <35.5 °C.
FEED RIGHT AWAY/ REHYDRATE IF REQUIRED
• REWARM:
• CLOTHE THE CHILD INCLUDING HEAD
• COVER WITH PRE-WARMED BLANKET
• PROVIDE HEAT WITH AN OVERHEAD WARMER/ INCANDESCENT LAMP/ RADIANT
HEATER
• PLACE BED IN WARM DRAUGHT FREE AREA
• PLACE ON MOTHER’S BARE CHEST (KANGAROO MOTHER CARE)

18. MONITOR
• blood glucose level: check for hypoglycaemia whenever hypothermia is
found
• body temperature: during rewarming take rectal temperature two-
hourly until it rises to >36.5oC (take half-hourly if heater is used)
• ensure the child is covered at all times, especially at night
• feel for warmth

19. IF RECTAL TEMPERATURE < 32°C
TREAT FOR SEVERE HYPOTHERMIA
• Give warm humidified oxygen.
• Give 5ml/kg of 10% dextrose iv immediately or 50ml of10% dextrose by
nasogastric route, provide heat using radiation (overhead warmer), or
conduction (skin contact) or convection (heat convector). Avoid rapid
rewarming , monitor temperature every 30 minutes
• Give warm feeds immediately, if clinical condition allows the child to take
orally, else administer the feeds through a nasogastric tube. Start
maintenance iv fluids (prewarmed), if there is feed intolerance/
contraindication for nasogastric feeding.
• Rehydrate using warm fluids immediately, when there is a history of
diarrhea or there is evidence of dehydration.
• Start intravenous antibiotics

20. DEHYDRATION

23. • Signs of over hydration:
• Increased respiratory rate and pulse.(Both must
increase to consider it a problem–increase of
pulse by15 & respiratory rate by 5)
• Jugular veins engorged
• Puffiness of eye
• Stop ORS if any of the above mentioned signs
appear.

25. ELECTROLY
TE
IMBALANCE
:
Potassium
3-4 mmol/kg/day for at least 2 week
Severe hypokalemia- potassium < 2 mmol/ l or 3.5 mmol/l with ECG
changes - correct at 0.3 to 0.5 mmol/ kg/ hr infusion of potassium
chloride in IV fluid with continuous ECG monitoring
2. Magnesium - on day 1 give 50 % magnesium sulphate IM once ( 0.3
ml/ kg max upto 2 ml) following this 0.4-0.6 mmol/kg of magnesium
can be given orally for 7 days
3. Food should be prepared without added salt

26. INFECTIONS
SCREENING
•HB , TLC, DLC, PS
•URINE ANALYSIS AND URINE CULTURE
•BLOOD CULTURE
•X-RAY CHEST
•MANTOUX TEST
•GASTRIC ASPIRATE FOR AFB
•PERIPHERAL SMEAR FOR MALARIA (IF INDICATED)
•CSF EXAMINATION (IF MENINGITIS SUSPECTED)

27. • All severely malnourished children should receive broad
spectrum antibiotics
• Ampicillin 50 mg/kg/ dose 6 hourly I.M with
• Gentamycin 7.5 mg/kg or Amikacin 15 to 20 mg/ kg I.M
or I.V 24 hourly for 7 days
If no improvement in 2 days
• IV Cefotaxime 100 mg/ kg/ day 6-8 hourly or
• IV Ceftriaxone 50-75 mg/kg/day 12 hourly

28. MENINGITIS IS SUSPECTED, LP SHOULD BE DONE AND
CEFOTAXIME ( 200 MG/KG 6 HOURLY ) AND AMIKACIN ( 15
MG/ KG 8 HOURLY ) IS TO BE GIVEN FOR 14 TO 21 DAYS
 IF STAPHYLOCOCCAL INFECTIONS ARE SUSPECTED IV
CLOXACILLIN IS GIVEN AT 100 MG/KG/DAY 6 HOURLY
 ADD ANTIMALARIAL TREATMENT / ANTI TB TREATMENT IF
DIAGNOSED

29. MICRONUTRIENT SUPPLEMENTATION

30. • Multivitamin supplement (should contain vitamin A, C, D,
E and B12 and not just vitamin b-complex): twice
recommended daily allowance
• Folic acid: 5 mg on day 1, then 1 mg/day
• Elemental zinc: 2 mg/kg/day
• Copper: 0.3 mg/kg/day
• Iron: start daily iron supplementation after two days of the
child being on catch up diet. Give elemental iron in the
dose of 3 mg/kg/day in two divided doses, preferably
between meals. (Do not give iron in stabilization phase.)

31. MEDICAL NUTRITION THERAPY
• Feeding is a critical part
• To be started cautiously and in frequent small amounts
• Nutrients should be well titrated-
Stabilisation phase- low protein low sodium , moderate fat
and high digestible carbohydrate in the diet
Transition phase- transitioning through close monitoring
Rehabilitation phase gradual shifting to normal diet
• Maintain 24 hour food intake chart

32. STABALISATIO
N PHASE
F-75 starter diet is used initially – contains 75 kcals of energy and 0.9
gram of protein per 100 ml to be started at 130 ml /kg/day (
100ml/kg/day if there is edema)
1. Determine frequency of feeds
day 1 – feeds given every 2 hours.
If child is hypoglycaemic ¼’th the 2 hourly amount can be given every
½ hour for 1’st 2 hours or till child is euglycemic
Night feeds
After 1’st day, increase volume per feed and as child starts accepting
larger volumes decrease the frequency to every 3 to 4 hours

34. Best to feed the child with a cup, with the child seated in the
mothers lap and sitting straight . child should never be force
fed.
NG feeds
• If child is not accepting orally
• Oral ulcers,
• Cannot consume 80 % of starter diet by mouth for 2 or 3
consecutive feeds
SAM children are prone to develop aspiration pneumonia as they
have weak muscles and swallow slowly
NG tube can be removed when child consumes 80 % of the days
amount orally or consumes 2 consecutive feeds fully by mouth
Never stop breastfeeding and number of starter feeds should not

35. TRANSITION
• Usually takes 3 to 7 days
• Signs of readiness for transition
1) return of appetite- easily finishes 4 hourly feeds of F-75
2) reduced edema or minimal edema
• First 48 hours : give catch up F-100 diet every 4 hours in the same
amount as the last F-75 diet
• On 3rd day : increase feed by 10 ml as long as child is finishing
feeds. If not offer same amount at next feed. Increase the amount
till 30 ml/ kg/ feed is reached
• Protein – 3gm/kg/day

36. REHABILITATION PHASE
• Encourage child to eat as much as he wants
• Child should be able to feed freely on F-100 diet to an upper limit
of 220 kcal /kg/day and 4-6 gm/kg/day of protein
Rehabilitation also includes
• Daily care – feeding, weighing, giving antibiotics, monitoring and
recording
• Sensory stimulation – loving care, stimulating environment, play
therapy
• Maternal involvement in care

37. CRITERIA FOR DISCHARGE
•Absence of infection
•Eating at least 120-130 cal/kg/day & receiving adequate
micronutrients
•Consistent weight gain (of at least 5 g/kg/day for 3 consecutive
days) on exclusive oral feeding
•No edema
•Completed immunization appropriate for age
•Caretakers should be sensitized for home care

38. FOLLOW UP
Failure to respond
1. Primary –
• Failure to regain appetite or start losing edema by day 4,
• Presence of edema on day 10,
• Failure to gain at least 5 g/ kg/ day by day 10
2. Secondary –
• Failure to gain at least 5 g/ kg/ day for 3 consecutive days during
rehabilitation phase

39. 1.Inadequate feeding – check if night feeds are given,
target energy and protein levels are actually being
recorded, is proper feeding techniques followed, feed
preparation etc
2. Specific nutrition deficiencies
3. Untreated infections – repeat urinalysis , stool
examination, CXR. Commonly overlooked infections
include UTI, otitis media, TB and giardiasis
4. HIV/AIDS
5. Psychological problems – look for abnormal

40. • RECOVERY: CHILD IS 90% WEIGHT-FOR-LENGTH
• RECOVERED CHILD MAY STILL HAVE A LOW WEIGHT-FOR-AGE
• ADVISE PARENT OR CARE-GIVER TO:
• FEED FREQUENTLY WITH ENERGY AND NUTRIENT DENSE FOODS
• BRING CHILD BACK FOR REGULAR FOLLOW-UP-CHECKS
• ENSURE BOOSTER IMMUNIZATIONS GIVEN
• ENSURE VITAMIN A IS GIVEN EVERY SIX MONTHS