SEVERE ACUTE MALNUTRITION - PowerPoint Presentation

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SEVERE ACUTE MALNUTRITION Dr Farogh Hassan Senior residentDepartment of PaediatricsJ.N. Medical College, AMU, Aligarh

DEMONSTRATION CLASS (MBBS 2016 BATCH)

SATURDAY

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SEMINAR ON Guidline Management of SAM childernPresented By: Dr. Farogh HassanModerator : Dr . A. K. PatwariOBJECTIVE:Definition ApproachCriteria for admission Clinical featureLaboratory testManagement

Principles

of management

10

steps of routine

care

Discharge criteria

Follow up

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WHAT IS SAM ??In children between the ages of 6 and 59 months, Severe acute malnutrition (SAM) is defined as: (i)Weight/height or Weight/length < -3 Z score, using the WHO Growth Charts; OR(ii) Presence of bipedal edema of nutritional origin; OR(iii) mid- upper arm circumference (MUAC) < 115 mm.

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Indications for inpatient care include the following: (i) Presence of a medical complication; (ii) Reduced appetite (as judged on the basis of a failed appetite test); (iii) Presence of bilateral pitting edema (iv) Age ≤ 6 months.

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ADMISSION CRITERIA: Criteria for admission for inpatient treatment (Children 6-59 months) any of the following:MUAC <115mm with or without any grade of oedema; ORWFH < -3 SD with or without any grade of oedema; ORBilateral pitting oedema +/++ (children with oedema +++ always need inpatient care)

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Cont...WITH Any of the following complications:Anorexia (Loss of appetite)Fever (39 degree C) or Hypothermia (<35 C)Persistent vomitingSevere dehydration based on history and clinical examinationNot alert, very weak, apathetic, unconscious, convulsionsHypoglycaemiaSevere Anaemia (severe palmar pallor)Severe pneumoniaExtensive superficial infection requiring IM medicationsAny other general sign that a clinician thinks requires admission for further assessment or care.

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APPROACH TO CHILD WITH SEVERE ACUTE MALNUTRITION Severe Acute Malnutrition in children 6 to 59 months of agePresence of Weight-for-height <-3SD on the WHO growth standard; orPresence of bipedal edema; orMid-upper arm circumference (MUAC) below 11.5 cm (age 6 months or more)

Assess for the following complications

Severe edema

Low appetite

( failed appetite test), or

Medical complications, or

One or more danger signs as per IMNCI

UNCOMPLICATED

SAM

COMPLICATED

SAM

Supervised home management

Inpatient management in a facility

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CLINICAL FEATUREPersistent vomiting Fever (Axillary temperature >38.5 degree Celsius).Children with fast breathing /chest indrawing /cyanosis).Extensive skin lesions, eye lesions, post measles states.Diarrhoea with dehydration based on history and clinical signs.Severe pallorHypothermia (Axillary temperature <350C).

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Clinical signs of SAMFace: Moon face (kwashiorkor), simian facies (marasmus)Eye: Dry eyes, pale conjunctiva, Bitot spots (vitamin A)Mouth: Angular stomatitis, cheilitis, glossitisTeeth: Enamel mottling, delayed eruptionHair: Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating bands of light and normal color), broomstick eyelashes, alopeciaSkin: Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry, follicular hyperkeratosis, crazy paving or flaky paint dermatoses

, poor

wound healing

Nails:

Koilonychia

, thin and soft nail plates, fissures,

or ridges

Musculature:

Muscle wasting, particularly buttocks and

thighs

Abdomen:

Distended: hepatomegaly with fatty liver;

ascites

Cardiovascular:

Bradycardia, hypotension, reduced cardiac

output

Neurologic:

Global developmental delay, loss of knee

and ankle

reflexes, impaired memory

Hematologic: Pallor, petechiae, bleeding diathesis

Behavior: Lethargic, apathetic, irritable on handling

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To check oedema, grasp the foot so that foot rest in your hand with thumb on top of the foot. Press your thumb gently for few seconds (approximately 10 seconds).the child has oedema if a pit(dent) remains in foot when you lift your thumb.The extent of oedema is commonly rated in the following way :1+ mild : both feet2+ moderate : both feet, plus lower legs, hands, or lower arms.3+ severe : generalised oedema including feet, legs, hands, arms and face.

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MARASMUS

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KWASHIORKOR

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LABORATORY TESTSAll children with SAM admitted as inpatient should undergo the following basic investigations :Haemoglobin or packed cell volume in children with severe palmer pallor.Blood glucoseSerum electrolytesScreening for infections:TLC and DLC, blood cultureUrine cultureStool R/MChest X- rayMantoux testScreening for HIV after counsellingAny other specific test required based on geographical location or clinical presentation eg. Celiac disease, malaria etc.

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Principles of hospital-based managementThe principles of management of SAM are based on 3 phases: Stabilization PhaseTransition Phase andRehabilitative Phase.

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Guidelines for ManagementA. General principles of routine care (the 10 steps)B. Emergency treatment of shock and severe anaemiaC. Treatment of associated conditionsD. Failure to respond to treatmentE. Discharge before recovery is complete

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CRITERIA FOR FAILURE TO RESPOND TO TREATMENTPRIMARY FAILUREFailure to regains appetite Day 4 Failure to start to loose oedema Day 4Oedema still persists

Day 10

Failure to gain at least 5 gm/kg/day body weight.

Day 10

SECONDARY FAILURE

Failure to gain at least 5 gm/kg/day body weight during rehabilitation during 3 successive days

.

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CRITERIA FOR DISCHARGE FROM INPATIENT CARECHILDAchieved weight gain of >= 15% and has satisfactory weight gain for 3 consecutive days (>5 gm/kg/day).Oedema has resolved.

Child eating an adequate amount of nutritious food that the mother can prepare at home.

All infections and medical complications have been treated.

Child is provide with micronutrients.

Immunization is updated

.

MOTHER/CAREGIVER

Able to take care of the child.

Able to prepare appropriate foods and feed the child.

Is trained to give structured play therapy and sensory stimulation.

Knows how to give home treatment for common problems and recognises danger warning immediate medical assistance

.

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DISCHARGE AND FOLLOW UP (Contd..)Follow-up regularly at 1,2,4 weeks, then monthly for 6 months and subsequently every 6-months for 2 years.Criteria for early discharge :Child

Has a

good appetite

, eating at least

120-130 kcal/kg/day

receiving adequate micronutrients.

Has

lost oedema

Consistent weight gain (

at least 5 gm/kg/day for 3 consecutive days

).

Completed antibiotic treatment .

Completed immunization appropriate for age.

Mother

or

Caregiver

Trained

on appropriate feeding.

Has financial resources to feed child.

Motivated to follow the advise given.

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Flow chart: Screening and management of SAM

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THANK YOU..