Severe Acute Malnutrition

By ULY CLINIC Staff,

Acute Malnutrition

Acute Malnutrition (wasting) is a rapid decline of weight while height remains unchanged. It is a reflection of inadequate dietary intake or acute infection.

It is classified into severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the degree of wasting and the presence or absence of oedema.

It is defined as oedema of both feet and visible severe wasting.

Diagnostic Criteria

Visible severe wasting
Oedema of both feet
Weight for length/height <-3SD
MUAC < 11.5 cm

Investigations:

RBG
BS for MPS
Septic screening; Urine culture, Blood culture, Swab cultures
FBP
HIV screening
Chest X ray

Treatment of Severe Acute Malnutrition

The management of severe malnutrition involves 10 steps in three
Phases: stabilization, transition and rehabilitation.

Stabilization

This is the initial phase in the management of SAM where by acute complications and metabolic derangements are addressed.

Treat/Prevent Hypoglycaemia

Give 50 ml 10% glucose by mouth or NGT if unable to feed OR 50mls of sugar water (1 rounded tea spoon sugar in 3 table spoons of water)
Give bolus of 10% glucose IV 5ml/kg if RBG <3mmol/L or 54 mg/dL followed by 50ml of 10%glucose or sugar water by NGT for unconscious, lethargic or convulsing child.
Give F-75 half an hour after giving glucose, feed 2 hourly. Give ¼ of the 2 hourly amount of F-75 every half-hour during the first 2 hours to an unconscious child.
Treat/Prevent Hypothermia (Axillary temperature<35ºC or Rectal temperature<35.5ºC)
Change wet clothes and beddings promptly.
Cover the child including the head and feet with a warm blanket, and place a heater (not pointing directly at the child) or lamp nearby
Keep room temperature at 28 to 32 °C.

Note:

Do not use hot-water bottles to warm the child.

Treat/Prevent Dehydration

Assume dehydration if there is a recent history of diarrhoea and/or vomiting
Give Rehydrating Solution for Malnutrition (ReSoMal) 5ml/kg every 30 minutes for 2 hours, then 10ml/kg/hr alternating hourly with F-75 for the next 4-10 hours
If ReSoMal is unavailable give half strength ORS.
Give Zinc PO 20mg (children six months or older) or 10mg (children less than six months) once a day for ten days.
Continue breast feeding throughout treatment.

Note:

Do not give IV fluids in severely malnourished children except in shock.
Do not give ReSoMal in case of profuse watery diarrhoea (e.g. Cholera), instead give ORS without changing the amount and frequency.

Prevention of dehydration

Give ReSoMal after every watery stool as follows:
For children <2years, give 50-100 ml after each watery stool.
For children >2years, give 100-200 ml after each watery stool.

Correct Electrolyte imbalance.

Give extra Potassium 3 mmol/kg/d.
Give extra Magnesium 0.4 mmol/kg/d.
When rehydrating, give ReSoMal.
Prepare food without salt.

Note:

Commercially prepared F-75/F-100 contains micronutrients thus do not require extra micronutrient supplements.

Treatment of Infections

Give Ampicillin IV 50mg/kg 6 hourly for 2 days then Amoxycilin DT PO 40 mg/kg/dose 12 hourly for 5 days AND
Gentamicin IV 7.5mg/kg once daily for 7 days.

Micronutrients Supplementation

Folic acid 5 mg on Day 1 then 1mg daily for 3 months
Give Iron 3mg/kg once a day for 3 months to be given during

Rehabilitation

Note:

Commercially prepared F-75/F-100/ Ready to Use therapeutic Food (RUFT) contains micronutrients thus do not require extra micronutrient supplements.

Dietary management

Give F-75 11mls/kg 2 hourly (12 feeds/day) OR For stable children F-75 16mls/kg 3hourly (8 feeds/day).
If a child has severe oedema, give F-75 8.5mls/kg 2 hourly OR
For stable children F-75 12.5mls/kg 3 hourly

Note

Do not give food other than F75 and breast milk

Transition Phase

A short period between stabilization and rehabilitation phase to assess if the child can tolerate F-100.

Criteria to move from Stabilization Phase to Transition Phase see explanation below:

Appetite has improved
Loss of, or minimal oedema
Treatment of medical complications has commenced and patient has improved.
IV fluids and NGT feeding completed.
Child can take feeds orally.

Dietary Management

Replace F-75 feeds with the same amount of F-100 for the first 2 days.
On the third day, increase amount of F100 given by 10mls in each successive feed as long as child finishes feeds.

Rehabilitation Phase

This phase is associated with full recovery and rapid catch up of lost weight. In this phase use either F 100 or Ready to Use Therapeutic Food (RUTF).

Dietary Management

• Give 25mls/kg of F-100 3 hourly.

RUTF