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Emmanuel Ameyaw Department of Child Health Kath, Kumasi


About 20 million children are affected by severe acute malnutrition globally, Leading cause of death in children in developing countries, contributes to 5060% of all child deaths, Mortality rates for children with SAM are 5 to 20 times higher compared to well-nourished children

1 million to 2 million preventable child deaths each year Only about 15% get hospital admission 28% of children under 5 years of age are underweight.

Malnutrition is defined as the failure of cells to perform their physiological functions due to inability receive and use the energy and nutrients needed, (in terms of amounts, mix and timeliness). Severe malnutrition is characterized by

Severe wasting ( weight for height < 70% or <3SD), and/or, Edema (of both feet).

Primary malnutrition refers to malnutrition resulting from inadequate food intake Secondary malnutrition refers to malnutrition resulting from increased nutrient needs, decreased nutrient absorption, and or increased nutrient losses. Micronutrient malnutrition Macronutrient malnutrition

Weight for height of <-1SD :mild

Weight for height of <-2SD :moderate Weight for height of <-3SD :severe

Syndromic classification
Kwashiokor Marasmus Marasmic Kwashiokor

1st degree .. .. Wgt between 90% and 75% 2nd drgree .. .. 75% and 60% 3rd degree.. Below 60%

Weight between 80% and 60% (expected weight)
EdemaKwashiokor No edemaundernutrition

Weight below 60%

Edema marasmic kwashiokor No edema marasmus

1st degree wgt between 90 and 80% (expected wgt) 2nd degree wgt between 80 and 70% (expected wgt) 3rd degree wgt between 70 and 60% (expected wgt) 4th degree below 60% (expected wgt)

Mild: wgt between 90 and 80% (expected) Moderate: wgt between 80 and 70% (expected) Severe: wgt below 70% (expected)

Acute: wasted but not stunted
Wgt for height is low, height for age is normal

Chronic: wasted and stunted

Wgt for height low, height for age low


Severe wasting:
Loss of fat and muscle (skin and bones) Front view: ribs easily seen and skin of upper arm and thighs look loose. Back view: ribs and shoulder bones easily seen, flesh missing from the buttocks, folds of skins on buttocks and thighs (wearing baggy pants)

2. Oedema of both feet: The retained added to the weight therefore weight for height > 3SD. Rating of oedema: + mild: both feet ++ moderate: both feet + lower legs + hand or lower arms +++ severe: generalised (moderate + face)

3. Dermatosis
Occurs in oedematous malnutrition than wasted child. Range from patches of abnormal pigmented skin (light and dark) to shedding, ulceration and weeping lesion. Affects perineum, groin, nappy areas, limbs, behind ears, armpit and face

4. Eye Signs: Vit. A deficiency


Night blindness Conjunctivitis xerosis Bitot spot Corneal xerosis Cornea ulceration Cornea scar

In severe malnutrition, the systems almost shut down or slow down in order to allow for survival on the barest minimum energy requirements. Almost all the major organs are affected

HISTORY Frequency of feeding Recent appetite Usual diet before current illness When last child ate normally Breastfeeding history Birth history Social/Family history

MEDICAL HISTORY Vomiting & diarrhea Episodes of fever Chronic cough Birth weight Birth rank and intervals Immunizations Milestones reached before current illness

Typical signs of malnutrition Signs of shock Signs of infections or heart failure Temperature, pulse, and respiratory rate Eye signs, Mouth; sore tongue, thrush etc Skin lesions ENT, Chest Organomegaly, especially the liver, spleen Lymph nodes

Blood film for Mps Full blood count Chest x-ray Urine RE & Culture Stool RE & Culture VCT-where the suspicion is there

Weight for height of <-3SD

Edematous malnutrition

Prevent or Treat Hypoglycemia Prevent or Treat Hypothermia Prevent or Treat Dehydration Correct Electrolyte Imbalance Treat and Prevent Infections Correct Micronutrient deficiencies Start Cautious feeding Give Catch-up diet Provide TLC and play and stimulation Prepare for Follow-up and discharge

Phases Initial phase

Stabilization phase(1-2) Transition phase (3-7)

Rehabilitation phase(2-6wks) Follow ups (7-26 wks)

MINERALS Potassium Magnesium Zinc Copper Iodine Selenium

2340mg 146mg 40mg 5.6g 154mcg 94mcg

Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin

A D E C B1 B2 B6 B12

3000mcg 60mcg 44mg 200mg 1.4mg 4mg 1.4mg 2mcg

Vitamin K Biotin Folic acid Patothenic acid Niacin

80mcg 0.2mg 700mg 6mg 20mg

F 75 F 100 Suji RUTF

Treat infections and other medical problems Provide sufficient energy and nutrients to stop further loss of muscle and fat Revive the cells and organs that are almost dormant

Provide extra energy and nutrients for rapid weight gain Start stimulating the child to improve mental and motor development Start educating carer on how to continue caring for the child after discharge

Starter formula (F 75 here) Must contain milk, sugar and oil Must be low in sodium and protein and high in sugar Must be fed in small amounts every 3 hours day and night. Feed very ill children 2hrly.

Feed by NGT if a child; Is lethargic and refuses to eat Has refused or vomited the last 2 consecutive feeds Is taking <70% of the prescribed volume

Child is active and smiling Edema resolving or resolved Increased appetite Continue with F 100 or RUTF

Catch-up diets are high in energy and protein and some micronutrients It contains more milk and oil and less sugar than starter formula Rapid weight gain Give high energy snacks such as bread and margarine, banana between feeds Avoid salty foods Weight gain should be aimed at 10g/kg/day

In severe malnutrition, theres delayed behavioral and mental development. These can be improved by giving; TLC A cheerful stimulating environment Structured play therapy,15-30min/day Physical activities as soon as well enough Maternal involvement as much as possible

Counselling Bringing child back for regular follow-up checks Ensure they complete immunization schedules

HYPOGLYCAEMIA Blood sugar <3mmol/l Hypothermia is a sign of hypoglycemia Other signs include lethargy, loss of consciousness, or convulsions If RBS stick or glucometer unavailable, assume child has hypoglcemia and treat Start feeding as soon as possible

When axillary temperature <35.0 Examine the child quickly and keep the child covered as much as possible Keep the child warm at all times, including the head Start feeding and at regular intervals, as soon as possible

Difficult to rely on usual signs to tell severity of dehydration Assume all children with watery diarrhea may have some dehydration No IV fluids except in shock ReSoMal-ideal solution in malnutrition; give orally or by NGT.

ReSoMal: 5ml/kg every 30mins for the 1st 2 hours, then 5-10ml/kg/hr for the next 4-10 hours Start starter feeds after 4 hours Continue breastfeeding

Look out for signs of over hydration Puffy face Engorged jugular vein Pulse Respiratory rate HR Crackles

Assume all malnourished children have an infection Hypoglycemia & hypothermia are signs of severe infections Give broad-spectrum antibiotics Keep warm Check RTHC for at least measles vaccine,

All severely malnourished children have vitamin & mineral deficiencies Do not give iron within the first 2 weeks Give; Vitamin A Multivitamin supplement Folic acid Zinc Copper

Haemotransfusion required if Hb <4g/dl Hb 4-6g/dl and child has respiratory distress Packed cells;10ml/kg slowly over 3hours IV lasix 1mg/kg Be cautious with hemotransfusing after 4872 hours after admission

Common causes Misdiagnosis of dehydration with consequent inappropriate hydration Very severe anemia Overloading due to blood transfusion High Na diet using conventional ORS or excess ReSoMal Inappropriate treatment of refeeding diarrhea with rehydration solutions

First fast breathing 2-12 months: RR>50 cpm 1-5years: RR>40cpm Later Cyanosis or pulse oximetry,SaO2 <94% Cold hands and feet Liver enlarged by >2cm Engorged jugular veins Increased pulse rate Lung crepitations Respiratory distress

Stop all oral intake and IV fluid No fluid should be given until cardiac function improves A diuretic-IV lasix,1mg/kg stat

TB can be a cause of failure to gain weight Signs are often non-specific Asymmetric chest signs or lymph nodes are usually TB The mantoux test can be negative Take a chest x-ray To treat as soon as the suspicion is there

Nutritional treatment of HIV/HIV-suspected patients is the same as for any severely malnourished patient They require the same dietary and medical treatment HIV-positive patients usually respond well to the nutritional treatment and gain weight

Children can be allowed to go home if they; Have completed the transition to catch-up diets and are eating well Have no edema Have completed antibiotic treatment Have received extra electrolytes and micronutrients for at least 2 weeks Have been gaining weight well for at least 1week Are up to date with their immunizations W-f-h of >85%,if theres good follow-up services; w-f-h of >95% without good follow-up services

MONTH January February March April May June July August September October November December TOTAL

KWASHIOKOR 7 0 1 1 5 2 0 3 4 1 10 10 44

MARASMUS 15 15 13 20 20 18 15 16 12 14 20 17 195

MK 2 2 1 3 4 3 4 3 0 3 8 4 37

TOTAL 24 17 15 24 29 23 19 22 16 18 38 31 276

FATALITY 2 3 4 0 5 1 4 4 2 3 9 2 39


































14.13% for 2008 11.11% for 2009 Both primary and secondary WHO accepts between 5-10% Resources available: 1-5%

Part of Ward B4 Four nutritionist 3 pediatricians 1 resident 3/4 house officers Nurses Health care assistants

Over crowding Nocturnal feedings No office and store for feeds Funds for alternate feeds Hospital bill

Case management practices suitable for the non malnourished child may be highly dangerous for the PEM child A malnourished child can be likened to a premature neonate Very delicate and fragile, but when given the necessary care and treatment, can surprise even you

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