DR. COOKEY D.

 INTRODUCTION
 EPIDEMIOLOGY
 AETIOLOGY
 CLINICAL PRESENTATION
 PATHOLOGICAL FEATURES
 INVESTIGATIONS
 MANAGEMENT
 COMPLICATIONS
 FOLLOW-UP
 Severe acute malnutrition is defined as the presence of
severe wasting and bilateral edema or weight for height
below -3Z score or mid-upper arm circumference
<115mm) in a child up to the age of 5 years

 It is a life threatening condition requiring urgent treatment.

 SAM remains a major cause of childhood mortality

worldwide.
 Current estimates by WHO in 2012 showed that 17.3m
children were affected with SAM.

 Here in Nigeria, the Federal Ministry of Health in 2016

reported that 244,000 under 5 children suffered SAM in
Bornu State.

 A study carried out by Ogunlesi et al in 2015 in Olabisi

Onabanjo University Teaching Hospital amongst 208
under 5 children showed that 64.9% had normal nutrition
while 18.3% had SAM.
 Another study carried out in the South East(Abakaliki) in
2014 by Pius et al amongst 606 under 5 children showed
that 27(4.4%) had SAM.
 Inadequate food intake
◦ Feeding child with poor quality staple food
◦ Infrequent feeding of the child

 Disease conditions
◦ Measles
◦ Whooping cought
◦ HIV/AIDS
◦ Repeated diarrhea
◦ Intestinal parasitosis
  Frequent upper respiratory tract infection
 Malaria

 Insufficient household food security

◦ Poverty
◦ unemployment
 Inappropriate care for mothers
◦ Mothers nutritional status during pregnancy
◦ Physical, mental and educational status of the mother
◦ Her knowledge, beliefs and superstitions about food
◦ Her hygienic, feeding and weaning practices
◦ Her health care seeking behaviour
 Inappropriate care for the child
◦ Being born as a LBW baby
◦ Being one of a set of multiple births
◦ Lack of exclusive breastfeeding in first 6 months of life
◦ High in the birth order
◦ Being cared for by other children
◦ Orphaned or a child of another marriage
◦ Child happen to be an unfortunate victim of congenital defect
◦ Circumstance where the lion-share of the meal is reserved for
breadwinner of the family
 Inadequate health care service
◦ Lack of provision of adequate health care services
• Weight loss
• Poor growth
• Edema
• Muscle wasting
• Mental changes- Apathy, irritability, dullness, miserable and
unhappiness.
• Skin changes- Flaky paint dermatosis, dyspigmentation
 Hair changes- easy pluckability, change in colour to brown,
appearance of stripes referred to as flag sign
 Moon face
 They can have signs of micronutrient deficiencies
 Intractable diarrhea
 Hepatomegaly
 All tissues/organs of the body are affected in SAM.

 LIVER – fatty liver, enlarged liver with both structural and

functional derangement.
 GIT – Atrophy of the intestinal mucosa Flattening
of the villous process Disaccharidase(lactase)
deficiency Severe diarrhea

 HEART- Wasting of cardiac muscle decr. Cardiac

output cardiac failure.
 KIDNEYS – Impaired renal clearance, impaired
concentrating ability of the kidney(due to poor circulation
& perfusion)

 NEUROLOGICAL SYSTEM- Cognitive dysfunction

 BASAL METABOLISM- there is depressed basal

metabolic rate
 ENDOCRINE
◦ Increased growth hormone lipolysis ↑fatty acids
◦ ↑circulatory cortisone

 BODY FLUID & ELECTROLYTES

◦ ↓intracellular water
◦ ↓K+, ↓Ca2+, ↓PO42-, ↓Mg2+, ↓Zn, ↓Cu, ↓Fe, ↓Mn
 IMMUNE DEFENCE SYSTEM-
◦ Innate immunity, humoral and cell immunity are all lost.
◦
 FBC – PCV, WBC + DIFFERENTIALS
 Blood smear for malaria parasite
 Blood glucose level
 Urinalysis + M/C/S
 Stool microscopy for ova, parasites, leucocytes, test for
occult blood
 Urine culture
 Swabs for skin ulcers
 Tuberculin skin test for Tuberculosis (however, may be
negative in SAM)
 Chest X-ray
 HIV screening
 Serum proteins and electrolytes
 It is based on 3 phases:
◦ Stabilization phase
◦ Transition phase
◦ Rehabilitation phase
◦ Follow up

 Management of SAM patients can be done on an outpatient

or inpatient basis
APPETITE TEST:
 A reliable test known as the appetite test is used to
differentiate between complicated from uncomplicated
cases of SAM.

 It is also used in inpatient setting to assess if a child who is

in stabilization phase can transit from the inpatient care to
the outpatient care.
PROCEDURES FOR CONDUCTING THE APPETITE
TEST:
1. Provide 20-25mls of medicine cup
2. Wash child’s hands
3. Feed child with ready to use therapeutic food (RTUF)
using the graduated medicine cup
4. If child refuses initially, quietly encourage the child, do
not force the child
5. Sometimes child may refuse because she is frightened,
distressed or fearful of the environment, she can be taken
to a quiet place.
6. Give with plenty of water
PASS APPETITE TEST FAILED APPETITE TEST
 Consumes at least  Did not consume at least
moderate amount of moderate amount of
RUTF RUTF
STABILIZATION PHASE:
 It takes 3-7 days
 Here life threatening complications such as hypoglycaemia,
hypothermia, dehydration are identified and treated
 Correction of electrolyte imbalance and micronutrients
without iron
 Treat infections
 Initiate feeding
 Begin stimulation of emotional and sensorial development.
HYPOGLYCAEMIA- Blood Glucose <3mmols or
<54mg/dl
 Commence feeding orally if possible 2-3 hourly.

 If feeding is not possible, give 50mls of 10% dextrose or

sucrose solution (1 heap teaspoonful of granulated sugar
into 3 ½) by mouth or NG tube.

 If child is unconscious give 5mls/kg of 10% dextrose

water intravenously.
HYPOTHERMIA – Rectal temp. <35.5°C or
axillary temp. <35°C

 Dress child in warm clothings

 Keep child warm using the Kangaroo method

 Keep child away from drought by closing windows and

doors mostly at night
DEHYDRATION:
 In SAM, assessment of dehydration is very difficult

 Generally assumed that some form of dehydration is present at the

time of presentation.

 Give Resomal 5mls/kg every 30mins for the 1st 2 hours then 5-
10mls/kg/hr over the next 4-10 hours.

 If child is in septic shock, rehydrate intravenously with ½ strength

darrors + 5% dextrose OR ringers lactate + 5% dextrose OR
0.45 Saline+5% dextrose.
DEHYDRATION CONT’D:
 Give fluid at 15mls/kg over 1hour and reassess. If child is
still in shock, this can be repeated.

 At the same time pass an NG tube and give resomal at

10mls/kg/hr
ELECTROLYTE IMBALANCE/MINERAL
DEFICIENCIES:
 There are body deficits of (K+, Mg2+) and minerals (zinc,
copper and iron)

 These are already provided in the resomal solution.

INFECTIONS:
 All children with SAM are prone to infections such as respiratory
infections, UTI, malaria, measles, skin infections and septicaemia.

 Give broad spectrum antibiotics

 Immunize the child against measles

 Give antihelminthic therapy with oral mebendazole 100mg daily

X 3 days

 Give antimalarial in malaria endemic regions

INITIATE FEEDING:
 Feed child with F75 (starter feed) – it is a high energy milk
fed via NG tube or orally.

 Give at 100kcal/kg/day in 8 divided doses

 Continue breastfeeding

 Daily weighing and charting

 During this period, the child is out of stabilization phase
and is being prepared to move to rehabilitation phase.

 In this phase, diet is changed fro F-75 to ready-to-use

therapeutic food (RUTF) or to F-100

 It also prepares the child for exiting to outpatient care

 It takes about 3-5 days

 This phase promotes rapid weight gain and catch-up
growth

 It takes 2-6 wks

 Feed child with F-100 which provides 100kcal of CH20

and 2.9g of protein/100mls

 Aim at feeding at 150-220kcal/kg/day of CH20 and 4.6g

of protein/kg/day
 Increase successive feeds by about 10mls as appetite
improves.

 Continue breastfeeding

 Continue psychomotor stimulation

 The milk based food is gradually replaced with locally

available stable foods

 Educate parents on how to feed child

TREATMENT OF ASSOCIATED CONDITIONS:
 Xerophthalmia - treat with Vit. A, Tetracycline, Atropine eye drops
and eye pads soaked in normal saline to cover affected eye.

 Severe anaemia – transfuse child with caution

 Congestive Cardiac Failure

◦ Causes – Fluid overload, electrolyte imbalance or severe anaemia
◦ Treat accordingly
◦ **Do not give digoxin because of associate myocardial atrophy
TREATMENT OF ASSOCIATED CONDITIONS
CONT’D:
 Dermatosis – Give Zinc supplementation, 0.01% potassium
parmaganate solution, barrier creams like zinc and castor oil
ointment
 This takes 7-26 wks – after discharge, child should be
followed up at the Nutrition Rehabilitation Clinic

 At each visit, child’s weight is taken and plotted on a chart.

 During visits, health and nutrition education sessions will

be given to caregivers until the child is discharged from
out-patient care.
 Dehydration  Vitamin A def.
 Shock  Dermatoses
 Septic(toxic)shock  Scabies
 Hypoglycaemia  Tuberculosis
 Hypothermia  HIV
 Infection  Persistent
 Severe Anaemia diarrhea/dysentry
 Heart failure
 Micronutrient def.
 Primary prevention
SAM is a major global health problem, contributing to
childhood morbidity, impaired intellectual development, poor
school achievement, sub-optimal adult work capacity and
increased risk of non-communicable disease.

Prompt Diagnosis and treatment will reduce the burden in our

society
 APPETITE TEST
◦ Is a reliable test done to differentiate complicated
from uncomplicated cases of SAM. A poor appetite
test is an indication for care in an inpatient facility.

◦ It is an indication of significant infection or major

metabolic abnormality and an immediate risk of death.
It is also used in inpatient setting to assess if the child
in the stabilization phase can transit from the inpatient
facility(IPF) to outpatient program(OTP)
 Explain to the caregiver the purpose of appetite test
and how it is carried out.
 Let the mother wash her hands properly with soap and
water.
 Let the mother wash the hand and face of the child
with soap and water.
 Open the ready to use therapeutic food and give the
child to eat directly or put a small amount on the
mother’s finger and give it to the child.
Pre-prepare graduated 20-25ml medicine cups before the
start of the appetite test. The Pkt of the RUTF
contain 100g of the paste, it is easier to judge the
amount taken from a graduated medicine cup then
from the packet itself.
 The mother or care giver should not consume any of
RUTF
 If the child refuses, continue to quietly encourage the
child. Do not face the child. Let the mother pretend to
take some, seeing the mother eat some, this may
encourage the child
 Sometime the child may still not eat b/c she is
frightened, distressed or fearful of the environment
or the staff. So she should be taken to a quiet place
to do the test and the child may be initially allowed
to play with the RUTF Pkt and become familiar
with the environment.
 It must be given with plenty of water to drink.
 The caregiver must not face the child.
 PASS APPETITE TEST
◦ A child that takes at least the moderate amount of
RUTF shown in the appetite test table passes the
appetite test.

 FAILED APPETITE TABLE

◦ A child that does not take at least the moderate amount
of RUTF fails the test. Even if the child is not taking
b/c he does not like it or is frightened, the child did not
pass the test.
 STABILIZATION PHASE
◦ It takes 3-5days
◦ Life threatening problems are identified
◦ Specific deficiencies are corrected
◦ Metabolic abnormalities are reversed
◦ Feeding is begun
 DEHYDRATION
◦ The classical signs of dehydration – sunken eye balls,
skin turgor are unreliable in patients with SAM
◦ Pass NG-tube or Orally
◦ Rehydrate child with Resomal(rehydration solution
for malnourished child) at 5mls/kg every 30mins for
the first 2hours. Then hourly for the next 4-10hours.
◦ If Resomal is not available, give half strength low
osmolarity WHO oral rehydration solution with
potassium/glucose.
◦ Give 30mls of Resomal for each watery loose
stool that is lost
◦ Continue breastfeeding. Start F75 as soon as
possible orally or via NG-tube
◦ Alternate Resomal and F75 hourly if there is still
some dehydration and continuing diarrhea
◦ If child is in shock OR severely dehydrated and
cannot be rehydrated orally or by NG-tube, give
IV fluid, either Ringers lactate solution with 5%
dextrose 15mls/kg over the1st hour and reassess
 If none is available then, give 0.45% Saline + 5%
Dextrose.
 Do not stop breastfeeding while rehydrating.
 Weigh the child
 Note liver edge
 Record RR & PR
SIGNS OVER-REHYDRATION
1. Fast weight gain
2. Incr. respiratory rate
3. Incr. PR
4. Puffy eyelid
5. Enlarging liver size on palpation.
 Its common in areas with a very dry
atmosphere(deserts) particularly if there is a high
temperature
 It occur in children that have been carried for long
distance in the sun without the mother stopping to
give child a drink.
 It also occur when the feeds are over-concentrated
 Its important that those arriving at the clinics are
given water/glucose-water to drink.
DIAGNOSIS
1. Doughy skin
2. Sunken eyes
3. Scaphoid abdomen
4. Fever
5. Drowsiness and unconsciousness
6. Convulsion unresponsive to phenobarbitone,
diazepam
7. Death
 INVESTIGATION
◦ Incr. Na+ >150mmol/L

TREATMENT
For inpatients hypernatremic child i.e. conscious child
◦ Breastfeed child
◦ Give 10mls/kg/hr of 10% Dextrose water in
sips over several hours until thirst of the child is
satisfied for developed Hypernatremic
dehydration
◦ The aim is to reduce serum Na+ at about
12mmol/24hrs OR correct over 48hrs
◦ Treat slowly, measure serum Na+
 SHOCK
SIGNS AND SYMPTOMS
1. Semiconsciouness
2. Weak and fast pulse ≥160beat/min for children 2-
12months, ≥140beats/min for children 1-5years
3. Absent radial and femoral pulse
4. Cold clammy hands and feet
5. Poor capillary refill in the nailbed(>3sec.)
 TREATMENT
 Give Oxygen
 Give 10% DW 5mls/kg
 Give 15mls/kg IV over the 1st hour and reassess using
either 1/2strength Ringer’s lactate with 5% dextrose
OR ½ strength N/S with 5% dextrose.
If there are signs of improvement (↓PR & ↓RR)
Repeat the 15mls/kg IV over another 1hour
Then stop the drip & switch over to oral or NG-tube
rehydration with Resomal at 10mls/kg.
If no improvement i.e. PR and RR still ↑ and child has
gained weight,
 Consider Toxic, septic or cardiogenic shock.
 Stop rehydration.

DIAGNOSIS OF SEPTIC SHOCK

 A fast weak pulse
 Cold peripheries
 Slow capillary refill in the nailbeds(>3sec)
 Altered consciousness
 Absence of signs of heart failure
 TREATMENT
◦ Give broad spectrum antibiotics – cefotaxime +
ciprofloxacin or gentamicin + Flagyl. You can add
cloxacillin. If no improvement in 24hrs, then add
fluconazole
◦ Keep child warm to prevent hypothermia
◦ Whole blood – 10mls/kg over 3hours
◦ ½ N/S with 5% glucose
 HEART FAILURE
 Give IV Lasix
 Give digoxin
 ELECTROLYTE IMBALANCE

◦ All severely malnourished children have deficiencies of

K+ and Mg2+, which may take about 2wks to
correct.
◦ These are contained in sufficient quantity in F-75 and
Resomal, so the child does not require additional
intake.
 Usually 20 to bacteremia, severe malaria, hookworm
infestation, HIV infection, micronutrient deficiency
 Do PCV for all SAM patient.

TREATMENT
 Transfuse if PCV <12%
 Transfuse if PCV 12-18% + signs of Respiratory
distress
 Give whole blood 10mls/kg slowly over 3hours under
iv lasix.
 HYPOGLYCEMIA(RBS<3mmol/L)
 All SAM Patients are at risk of hypoglycemia and
immediately on admission should be given 10% glucose
 3-4 hourly feeding.
SYMPTOMS OF HYPOGLYCEMIA
 Usually no signs at all
 They do not sweat or have raised hair on their arms or
so pale
 They become less responsive, slip into coma and often
present with hypothermia
 Eyelid retraction(usually noticed at sleep)
TREATMENT
 If conscious and able to drink, give 50mls of sugar
water(5-10mls/kg) or F-75 by mouth
 If imminent unconsciousness, 50mls of sugar water by
NG-tube, if fully conscious F-75 frequently.
 If unconscious, give IV 10% Dextrose water 5mls/kg
or pass NG-tube and give sugar water.
MONITORING
 If the initial blood glucose was low, repeat
measurement after 30mins.
 If blood glucose <3mmol/L repeat 10% glucose or
oral sugar solution.
 HYPOTHERMIA
SAM children are highly susceptible to hypothermia and
indicates coexisting hypoglycemia or serious infection.

DIAGNOSIS
◦ Axillary temp. - <35oC
◦ Rectal temp. < 35.5oC
 TREATMENT
◦ Keep child warm using kangaroo technique
◦ Cover child with warm clothing and caps
◦ Give hot drinks to mother so her skin gets warm
◦ Keep child away from drought, windows and doors
closed at night.
◦ Feed child immediately and then 3-4hourly unless they
have abdominal distension, if dehydrated rehydrate also
◦ Monitor body temp. every 30min.
◦ Change wet nappies, clothing and beddings
 INFECTIONS
 Signs of infection such as fever is usually absent and
infections are usually hidden.
 Give broad spectrum antibiotics
If child does not have complication and is on inpatient
management
◦ Give oral Amoxil 15mg/kg/12hrly × 5/7
If child is ill(lethargic) OR has complications, give IV
antibiotics.
 First line IV Amoxil 50mg/kg/day every 12hrly for 1/52
 IV cefotaxime 50mg/kg 12hrly × 5/7 + IV genticin +
IV Flagyl 10mg/kg 12hrly ×1/52.
 2nd Line : IV Ciprofloxacin 10mg/kg/dose every
12hrs for 72hrs, then continue for 1/52 OR IV
ceftriaxone 50-100mg/kg/day daily × 5/7
Vit. A, Zn, Folic acid, Cu, are present in F-75, F-100
and RUFT, So should not be given in solution.
 Give Fe from the 2nd week.
 If there are signs of Vit. A def. or child has measles,
then give Vit. A on day 1.
◦ <6months – 50,000IU
◦ 6-12months -100,000IU
◦ >12months – 200, 000I
 If child is not on F-75, F-100 or RUTF, give
multivitamins syrups dly for 2/52
REHABILITATION PHASE
Provide sensory stimulation/emotional support
1. Provide tender loving care
2. Provide a cheerful, stimulating environment
3. Structured play therapy for 15-30minutes/day
4. Teach mother how to make simple toys and
emphasize the importance of regular play sessions at
home.
 Transferred patients to the out-patient clinic
continue to receive nutritional care with and
medical care on weekly basis.
 During visits, health and nutrition education
sessions will be given to caregivers until the child is
discharged from out-patient care.
 SAM is a major global health problem, contributing to
childhood morbidity, impaired intellectual development,
poor school achievement, sub-optimal adult work capacity
and increased risk of non-communicable disease.
Prompt Diagnosis and treatment will reduce the burden
in our society
THANKS FOR
LISTENING