1. SEVERE ACUTE MALNUTRITION
Dr Rameela Sanya

2. Malnutrition (‘mal’- bad) refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.
The term malnutrition covers 2 broad groups of conditions. One is ‘under nutrition’—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals).
The other is overweight, obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and cancer)¹

3. Malnutrition in children typically develops during the period from 6 to 18 months of age, when growth velocity and brain development are especially high.
Young children are particularly susceptible to malnutrition if complementary foods are of low nutrient density and have low bioavailability of micronutrients.
In addition, children’s nutritional status will be further compromised if complementary foods are introduced too early or too late, or are contaminated.

4. Severe acute malnutrition is the most extreme and visible form of under nutrition.
Severe acute malnutrition (SAM) is defined by very low weight for height (below -3SD scores of the median WHO growth standards), a mid-upper arm circumference <115mm or by the presence of nutritional oedema(3).
Children with severe acute malnutrition have very low weight for their height and severe muscle wasting.
They may also have nutritional edema – characterized by swollen feet, face and limbs.

5. It is estimated that 19 million preschool-age children, mostly from the WHO African Region and South-East Asia Region, are suffering from severe wasting
Childhood undernutrition is a major global health problem, contributing to childhood morbidity, mortality, impaired intellectual development, suboptimal adult work capacity, and increased risk of diseases in adulthood
Of the 7.6 million deaths annually among children who are under 5 years of age (1), approximately 35% are due to nutrition-related factors and 4.4% of deaths have been shown to be specifically attributable to severe wasting
The median case fatality rate is approximately 23.5% in severe malnutrition, reaching 50% in edematous malnutrition(2).

6. These deaths are the direct result of malnutrition itself, as well as the indirect result of childhood illnesses like diarrhoea and pneumonia that malnourished children are too weak to survive.
These settings are worsened by chronic poverty, lack of education, poor hygiene, limited access to food and poor diets. The result is significant barriers to sustainable development in these nations.
Children who are <-3SD weight-for-age may be stunted (short stature) but not severely wasted.
Stunted children who are not severely wasted do not require hospital admission unless they have a serious illness.(4)

7. DIAGNOSIS In children between ages of 6 months- 5 years, SAM is when:
1)weight-for-length/height < -3SD , using the WHO Growth Chart or
2) Presence of visible severe wasting or
3) Presence of bipedal edema of nutritional origin or
4) mid-upper arm circumference (MUAC) < 115 mm
Children with severe acute malnutrition should first be assessed with a full clinical examination to confirm whether they have any general danger sign, medical complications and an appetite.

8. IDENTIFICATION AND MANAGEMENT OF SAM
Initial Assessment
(4) Appetite Test
(2) Danger signs
(1) 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)
- loss of appetite
- family circumstances
- cough > 2 weeks
-contact with TB
- recent contact with measles
-known or suspected HIV infection/ exposure.
(3)Signs of infection
(5) Lab Investigations

9. (2) Danger signs
shock: lethargic or unconscious; with cold hands, slow capillary refill (> 3 s), or weak (low volume), rapid pulse and low blood pressure
signs of dehydration
severe palmar pallor
bilateral pitting oedema
eye signs of vitamin A deficiency: dry conjunctiva or cornea, Bitot spots, corneal ulceration, keratomalacia
Children with vitamin A deficiency are likely to be photophobic and will keep their eyes closed. It is important to examine the eyes very gently to prevent corneal rupture.
(3) Signs of infection
localizing signs of infection, including ear and throat infections, skin infection or pneumonia
signs of HIV infection
fever (temperature ≥ 37.5 °C or ≥ 99.5 °F) or hypothermia (rectal temperature < 35.5 °C or < 95.9 °F)
mouth ulcers
skin changes of kwashiorkor:
– hypo or hyper pigmentation
– desquamation
– ulceration (spreading over limbs, thighs, genitalia, groin and behind
the ears)
– exudative lesions (resembling severe burns) often with secondary infection (including Candida).

11. (4)Appetite Test
Appetite test is an important criterion to differentiate a complicated from an uncomplicated case of SAM and decide if a patient should be sent for in-patient or out- patient management.
Children with SAM who have poor appetite are at immediate risk of death and they will not take sufficient amounts of the diet at home to prevent deterioration and death.
Body weight (kg)
Minimum amount of RUTF to be consumed for passing the Appetite Test (mL or grams)
<4 15
4-6.9 25
7-9.9 35 50
TABLE 1

12. In African setting, a child not consuming the minimum recommended amount of RUTF, is labelled as ‘failed’ Appetite Test and referred for inpatient care.
Appetite test has not been standardized in Indian settings with different types of therapeutic foods, but this may be extrapolated to the therapeutic food used in Indian setting
To be carried out at each visit for patients, particularly those who don’t show a steady weight gain.

13. 5) Lab Investigations
Hb, TC, DC, peripheral smear
Urine analysis and urine culture
Blood culture
X-ray chest
Mantoux test
Gastric aspirate for AFB
Peripheral smear for malaria (in endemic areas)
CSF examination (if meningitis suspected)

14. TRIAGE FOR INPATIENT CARE:
In the community/ any facility where child is initially brought to find out if children identified with SAM need facility care.
Indications for Inpatient care are:
Presence of medical complication
Reduced appetite (‘failed’ appetite test)
Presence of bipedal pitting edema
Age less than or equal to 6 months
Children who have a good appetite and no medical complications can be managed as outpatients(4).

15. FIGURE 1
Identification and management of children with severe acute malnutrition (SAM)

16. ACTIVE DETECTION OF CHILDREN WITH SAM
To ensure these children are identified before they develop medical complications and manage them before prognosis worsens as well as reduce the need for hospitalization.
Health professionals and health care providers- to detect SAM at every opportunity, be it for a medical complaint or for health promotional measures( growth monitoring, immunization)
Can be undertaken at every health facility( PHCs, Sub centres, hospitals, day care centres etc) and even in the community and Anganwadis.
Management of SAM should constitute an important component of IMNCI program(Integrated Management of Neonatal and Childhood Illnesses).

17. OUTPATIENT CARE
Therapeutic food as per WHO and UNICEF specifications based on sound scientific principles with a balanced composition of type-1 and type-2 nutrients for consumption by children with SAM who are managed at home/ in the community.
One form of therapeutic food is RUTF(Ready-to-use Therapeutic Food) high energy food, available in a ready-to-use form with long shelf-life and requiring no preparation at the point of use.
The prescribed amount of RUTF to be given in 2-3 hourly feeds along with plenty of water ( Table 2).

18. AMOUNT OF THERAPEUTIC FOOD TO BE CONSUMED
WEIGHT(kg)
AMOUNT OF RUTF PER DAY(g/day)
3-4.9
5-6.9
7 – 9.9
260 – 400
10 – 14.9
400 – 460
TABLE 2

19. OUTPATIENT CARE (continued)
Breast feeeding should be continued.
Other foods may be given if child has good appetite and has no diarrhoea.
It should be emphasised to families and society that RUTF is not to be used as a supplementary food for other children or as a part of regular diet.
Appropriate notifications to ensure availability and accessibility to target population and distribution through appropriate channels( Nutritional Rehabilitation Centres(NRCs), Anganwadis etc.
Mother/ caretaker – counselled about breast feeding, supplementary care hygiene, optimal food intake, immunisation etc.

20. OUTCOME OF TREATMENT
Non-responder/ Primary Failure (i) Failure to gain any weight for 21 days, or (ii) Weight loss since
admission to program for 14 days.
Secondary Failure or Relapse (i) Failure of Appetite
test at any visit or (ii) Weight loss of 5% body weight at any visit.
Non-responders and children who develop a danger sign at any time during first 4 weeks should be referred to a hospital.
Defaulters: Not traceable for at least 2 visits.

21. CRITERIA FOR DISCHARGE
(a) Children admitted to SAM program on the basis of weight for height criteria should be discharged from the program (end therapeutic feeding) when weight for height becomes greater than or equal to -2SD of WHO reference and there is no edema. (b) Children admitted on the basis of MUAC criteria or presence of bilateral edema should be discharged (end therapeutic feeding) when MUAC becomes greater than or equal to 125 mm and there is no edema. Thereafter, the child can be referred for usual health care program and growth promotion activities can be ensured by Anganwadi workers (AWW), health care workers and health care providers.

22. INPATIENT CARE
Admission in a warm area separate from other children with infection
Prevent, look for and manage: Hypoglycemia,
Hypothermia, Dehydration, Electrolyte disturbances, Infection and sepsis, Micronutrient-Deficiency; using IAP Guidelines 2006.
A. Children above 6 months of age
Early initiation of appropriate feeding is an important
step in the management of SAM. Therapeutic feeding
conforming to F-75 composition can be used as an
initial starting formula in the acute phase, followed by
F-100 composition in the rehabilitation phase.

23. B. Infants less than 6 months
Prospect of continuing or re-initiating breastfeeding:
Breastfeeding should be encouraged in children with SAM. Supplemental suckling technique can be used to support and enhance breastfeeding. These children should be monitored by measuring weight gain and amount of supplemental feed taken. The supplemental feeding can be slowly withdrawn as the breast milk output increases and baby shows weight gain. A baby showing consistent weight gain on exclusive breastfeeding can be discharged from the inpatient care and then monitored on outpatient basis.
No prospect of continuing or re-initiating breastfeeding: These babies should be treated with F-75 composition therapeutic food in the acute phase and response monitored.

24. Continuation of breastfeeding should be encouraged.
Sensory stimulation in the form of tender loving care, cheerful stimulating environment, structured play therapy, initiation of physical activity as soon as the child is well and maternal involvement in comforting, feeding and play.

25. SUPPLEMENTARY SUCKLING TECHNIQUE(SST)
The supplementation is given using tube feedings: the same size as 8NGT (5NGT can be used and is better for the infant, but the milk should be strained to remove any small particles that block the tube). The appropriate amount of supplemental suckling milk is put in a cup. The mother or assistant holds it.
The end of the tube is put in the cup. The tip of the tube is plastered over the breast at the nipple and the infant is offered the breast in the normal way so that the infant attaches properly.
At first, cup should be placed about 5 cm to 10 cm below the level of the nipples so the SS-milk can be taken with little effort by a weak infant. It must NEVER be placed above the level of nipple, as it may flow quickly into infant’s mouth and cause risk of inhalation.

26. As the infant becomes stronger the cup should be lowered progressively to about 30 cm below the breast. It may take a day or two for the infants to get used to the tube and the taste of the mixture of milks, but it is important to persevere.
FIGURE 2

27. INPATIENT MANAGEMENT OF CHILDREN WITH SAM
FIGURE 3

28. 1) Treat or prevent Hypoglycemia:
Blood glucose level <54 mg/dL is defined as hypoglycemia in a severely malnourished child. If blood glucose cannot be measured, assume hypoglycemia
Hypothermia, infection and hypoglycemia generally occur as a triad.

29. 2) Treat/ Prevent Hypothermia:
All severely malnourished children are at risk of hypothermia due to a lowered metabolic rate and decreased body fat.
Children with marasmus, concurrent infections, denuded skin and infants are at a greater risk.
Hypothermia is diagnosed if the rectal temperature is less than <35.5ºC or 95.5ºF. If axillary temperature is less than 35ºC or 95ºF or does not register on a normal thermometer assume hypothermia. Use a low reading thermometer (range 29ºC-42ºC), if available.

30. Treat/ Prevent Dehydration:
It is difficult to estimate dehydration status accurately in the severely malnourished child using clinical signs alone.
However, it is safe to assume that all severely malnourished children with watery diarrhea may
have some dehydration.
Treatment:
Do not use the IV route for rehydration except in
cases of shock.

31. IAP recommends the use of reduced osmolarity ORS with potassium supplements given additionally
Composition of Reduced Osmolarity ORS
Component Concentration (mmol/L)
Sodium 75
Chloride 65
Potassium 20
Citrate 10
Glucose 75
Osmolarity 245

32. Add 20 mmol/L of additional potassium as syrup
potassium chloride (15 mL of the syrup provides 20 mmol/L of potassium).
Give the reduced osmolarity ORS, orally or by nasogastric tube, much more slowly than you would
when rehydrating a well-nourished child:
Give 5 mL/kg every 30 minutes for the first 2 hours,
then give 5-10 mL/kg/hour for the next hours.
Feeding must be initiated within two to three hours of starting rehydration.
Then continue feeding with starter F-75 feeds

33. SEVERE DEHYDRATION WITH SHOCK:
Management is targeted at replenishment of the intravascular volume by use of intravenous fluids to improve the perfusion to the vital organs.
Ideally, Ringer’s lactate with 5% dextrose should be used as rehydrating fluid. If not available, use half normal (N/2) saline with 5% dextrose. The other alternative is to use Ringer’s lactate solution.
Give oxygen.
Give rehydrating fluid at slower infusion rates of 15 mL/kg over the first hour with continuous monitoring.
Administer Intravenous antibiotics.

34. 4)Correct Electrolyte Imbalance
Excess body sodium exists even though the
plasma sodium may be low in severely malnourished children.
Giving high amounts of sodium could kill the child.
In addition, all severely malnourished children have deficiencies of potassium and magnesium; these may take two weeks or more to correct.
Edema may partly be due to these deficiencies.
Do not treat edema with a diuretic.

35. Supplemental potassium at 3-4 mmol/kg/day for at least 2 weeks.
Potassium can be given as syrup potassium chloride;most common preparation available has 20 mmol/15 mL.
On day 1, give 50% magnesium sulphate(equivalent to 2 mmol/mL) Intra Muscular once (0.3mL/kg up to a maximum of 2 mL)
Then give extra magnesium ( mmol/kg daily) orally. Injection magnesium sulphate can be
given orally as a magnesium supplement mixed
with feeds.
Prepare food without adding salt.

36. 5) Treat/ Prevent Infection:
multiple infections are common.
But usual signs of infection such as fever are often absent.
Investigations done.
All severely malnourished children should receive broad-spectrum antibiotics- parentral route
(a) Ampicillin 50 mg/kg/dose 6 hourly I.M. or I.V. for at least 2 days; followed by oral Amoxycillin15 mg/kg 8 hourly for five days (once the child starts improving) and

37. Gentamicin 7.5 mg/kg or
Amikacin mg/kg I.M or I.V once daily for seven days.
If the child fails to improve within 48 hours, change to IV Cefotaxime ( mg/kg/day 6-8 hourly)/Ceftriaxone (50-75 mg/kg/day 12 hourly).
In case of malaria or Tubeculosis or pneumonia etc, give appropriate antibiotics.
Delay any vaccination if the child is in shock.
The child’s activity, interaction with parents and appetite should improve. If there is no improvement or deterioration of the symptoms/ signs of infection, the child should be screened for infection with resistant bacterial pathogens,tuberculosis, HIV and unusual enteric pathogens

38. 6) Correct Micronutrient Deficiencies:
Up to twice the recommended daily allowance of various vitamins and minerals should be used.
Although anemia is common, do not give iron
initially. Wait until the child has a good appetite and starts gaining weight (usually by week 2). Giving iron may make infections worse.
Vitamin A orally on day 1 (if age >1 year give 2lakh IU; age months give 1lakh IU; age 0- 5 months give 50,000 IU)
Daily: Multivitamin supplement containing (mg/1000 cal): Thiamin 0.5, Riboflavin 0.6 and Nicotinic acid (niacin equivalents)

39. Folic acid 1 mg/d (give 5 mg on day 1).
Zinc 2 mg/kg/d (can be provided using zinc syrups/ zinc dispersible tablets).
Copper mg/kg/d (will have to use a multivitamin/ mineral commercial preparation).
Iron 3 mg/kg/d, only once child starts gaining weight; after the stabilization phase.

40. 7) Initiate re-feeding:
Start feeding as soon as possible with a diet which has,
-Osmolarity less than <350 mosm/L.
-Lactose not more than 2-3 g/kg/day.
- Appropriate renal solute load (urinary osmolarity <600 mosm/L).
- Initial percentage of calories from protein of 5%
-Adequate bioavailability of micronutrients.
-Low viscosity, easy to prepare and socially acceptable.
- Adequate storage, cooking and refrigeration.

41. Cautious feeding-frequent small feeds.
Initiate nasogastric feeds if the child is not being able to take orally, or takes <80% of the target intake.
Recommended daily energy and protein intake from initial feeds is 100 kcal/kg and g/kg respectively.
Total fluid recommended is 130 mL/kg/day; reduce to 100 mL/kg/day if there is severe, generalized edema.
Continue breast feeding.

42. Starter diets (adapted from WHO guidelines) recommended in severe malnutrition
F-75 Composition

43. 8) Achieve Catch up Growth:
Once appetite returns which usually happens
in 2-3 days higher intakes should be encouraged.
The frequency of feeds should be gradually decreased and the volume offered at each feed should be increased.
Breast feeding should be continued.
Gradually change from F-75 diet to F-100 diet. The starter F-75 diet should be replaced with F- 100 diet in equal amount in 2 days- contain 100 kcal/100 mL with g protein/100 mL.

44. F-100 composition

45. 9)Provide sensory stimulation and emotional support:
A cheerful, stimulating environment.
Age appropriate structured play therapy for atleast min/day.
Age appropriate physical activity as soon as the child is well enough.
Tender loving care.

46. 10)Prepare for follow-up after recovery:
Primary Failure to respond is indicated by:
• Failure to regain appetite by day 4.
• Failure to start losing edema by day 4.
• Presence of edema on day 10.
• Failure to gain at least 5.g/kg/day by day 10.
Secondary failure to respond is indicated by:
Failure to gain at least 5 g/kg/day for 3 consecutive days during the rehabilitation phase.

47. Poor weight gain?
• Good weight gain is >10 g/kg/day and indicates a good response. It is recommended to continue with the same treatment.
• Moderate weight gain is 5-10 g/kg/day; food intake should be checked and the children should be screened for systemic infection.
Poor weight gain is <5 g/kg/day and screening for inadequate feeding, untreated infection, tuberculosis and psychological problems is recommended

48. Criteria for discharge
Severely malnourished children are ready for discharge when the following criteria have been fulfilled:
• Absence of infection.
• The child is eating at least cal/kg/day and receiving adequate micronutrients.
• There is consistent weight gain (of at least 5 g/kg/day for 3 consecutive days) on exclusive oral feeding.
• W/H is 90% of NCHS median; The child is still likely to have a low weight-for-age because of stunting.
• Absence of edema.
• Completed immunization appropriate for age.
• Caretakers are sensitized to home care.

49. Advise caregiver to:
• Bring child back for regular follow-up checks.
• Ensure booster immunizations are given.
• Ensure vitamin A is given every six months.
• Feed frequently with energy-and nutrient dense foods.
• Give structured play therapy.

50. NUTRITIONAL REHABILITATION CENTERS
After treating the life-threatening problems in a hospital, the child with acute malnutrition will be transferred to NRC for:
intensive feeding to recover lost weight
development of emotional & physical stimulation
capacity building of the primary caregivers of the child with acute malnutrition through sustained counseling and continuous behavioral change activities
NRC  function as a bridge between hospital & home care
A short stay home for children with acute malnutrition along with the primary care givers

51. Objectives:
a. To provide institutional care for children with acute malnutrition.
b. To promote physical, mental & social growth of children with acute malnutrition.
c. To build capacity of primary care givers in the home based management of malnourished children.
d. Sick children with malnutrition are managed in hospitals where as children without any disease are given feeding advise and regularly monitored in community by FHWs and AWWs.

52. The services and care provided for the in-patient management of SAM children:
1. 24 hour care and monitoring of the child.
2. Treatment of medical complications.
3. Therapeutic feeding.
4. Providing sensory stimulation and emotional care.
5. Social assessment of the family to identify and address contributing factors.
6. Counseling on appropriate feeding, care and hygiene.

53. 7. Demonstration and practice - by - doing on the preparation of energy dense child foods using locally available, culturally acceptable and affordable food items.
8. Follow up of children discharged from the facility
NRCs in India:
There are 966 NRCs in 25 states/Union Territories in India.
3 NRCs situated in Kerala- Palakkad, Calicut, Trivandrum.

54. Estimated that around 93.4 lakhs children with SAM as per NFHS-4, out of this 10% of SAM with medical complications may require admission to NRCs.
Around 1.7 lakh children were enrolled at NRCs during
During the year , out of 1,72,902 children enrolled in these NRCs, a total of 92,760 children have been able to successfully recover from the above mentioned conditions.

55. REFERENCES
1)Severe malnutrition. In: Pocket Book of Hospital care for children. World Health Organization
2) WHO Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children. A joint statement by WHO and UNICEF, Accessed from http : // n t /nutrition/publications/severemalnutrition/ )
3) Sachdev HP, Kapil U, Vir S. Consensus statement: National Consensus workshop on management of SAM children through medical nutrition therapy. Indian Pediatrics Aug 1;47(8):661-5.
4) Hossain MM, Hassan MQ, Rahman MH, Kabir AR, Hannan AH, Rahman AK. Hospital management of severely malnourished children: comparison of locally adapted protocol with WHO protocol. Indian pediatrics Mar 1;46(3)

56. THANK YOU