SEVERE ACUTE

MALNUTRITION

- Amirdha V
Theertha P
141and 140
 Objective

PE 10.1

- Define Malnutrition as per WHO

- Etiopathogenesis, Classification and clinical features

of SAM
 Definition as per WHO

Malnutrition refers to deficiencies

or excesses in nutrient intake,
imbalance of essential nutrients or
impaired nutrient utilization(1).
 Malnutrition -
Classification
2. Overweight, obesity and
1. Undernutrition
diet-related non-
communicable diseases
A. Stunting
A. Heart disease
B. Wasting
B. Stroke
C. Underweight
C. Diabetes mellitus
D. Micronutrient deficiency or
insufficiency
D. Cancer
 SAM - Definition
Severe acute malnutrition (SAM) among children 6-59
months of age is defined by WHO and UNICEF as any of
the following three criteria:

i. Weight-for-height below -3 standard deviation score

(<3 SDS) on the WHO Growth Standard; or

ii. Presence of bipedal edema; or

iii. Mid-upper arm circumference (MUAC) below 11.5 cm.

In a child below 6 months of age, the MUAC is not used as
a criterion(3).
Undernourished
Children
 ETIOPATHOGENESIS
1. Inadequate food intake:
Poverty, Delayed complementary feed, insufficient food intake means less energy
and protein available for growth. This underlies about 55% of childhood
undernutrition.

2. Infections:
Diarrhea, pneumonia and other infections increase energy expenditure and hamper
growth.

3. Maternal factors:
Low birth weight (about 20% childhood under-nutrition is attributable to feta, growth
restriction), poor breastfeeding, Maternal malnutrition during pregnancy

4. Socioeconomic and environmental factors:

Poor sanitation → repeated infections, Lack of access to health care, delayed
introduction of complementary feeding(3).
Determinants of child’s nutrition
status (3)
 CLASSIFICATION
a) Classification according to weight for

i) Wellcome Trust Classification ii) IAP classification

iii) WATERLOW’S CLASSIFICATION

Two key anthropometric indices are used :

1. Wasting (acute malnutrition) - Based on weight‑for‑height (W/H %) compared to
reference standards:
Normal: ≥ 90%
Mild wasting: 80–89%
Moderate wasting: 70–79%
Severe wasting: < 70%

2. Stunting (chronic malnutrition) - Based on height‑for‑age (H/A %):

Normal: ≥ 95%
Mild stunting: 87.5–94%
Moderate stunting: 80–87.5%
Severe stunting: < 80%
iv) Gomez Classification
 continuation

b) WHO classification of malnutrition

MUAC CLASSIFICATION

Severe Acute
Malnutrition
 Clinical Features of SAM
Marasmus
1. The main sign is severe wasting. The child appears very thin and has
no fat. There is wasting of shoulders, arms, buttocks, and thighs.

2. The loss of buccal pad of fat creates aged or wrinkled appearance

referred to as monkey facies.

3. Baggy pants, appearance refers to loose skin of the buttocks hanging

down, and axillary pad of fat may also be diminished.

4. There is no edema.
Kwashiorkor
1. General appearance: child may have fat, sugar baby appearance.

2. Edema: mild to gross and may represent up to 5 to 20% of the body

weight.

3. Muscle wasting: child is often weak, hypotonic and unable to stand or

walk.

4. Skin changes: Increased pigmentation, desquamation, and

depigmentation. Petechia seen over abdomen. Outer layers of skin
may peel off and ulceration occurs. The lesions may resemble burns.

5. Mucus membrane lesions: smooth tongue, cheilosis and angular

stomatitis are common.
6. Hair: Easily pluckable and loss of curls and sparseness over temple
and occipital regions. A flag sign is the alternate bands of hypo-
pigmented and normally pigmented hair pattern, seen when the growth
of child occurs in spurts.

7. Mental changes: unhappiness, irritability with sad, intermittent cry.

They show no signs of hunger, and it’s difficult to feed them.

8. Neurological changes: Tremors are seen during recovery.

9. GI system: anorexia, sometimes with vomiting, is the rule. Abdominal

distension is characteristic. Stools may be watery or semi solid, bulky
with a low pH and may contain unabsorbed sugars.

10. CVS: cold, pale extremities due to circulatory insufficiency,

bradycardia anaemia, diminished cardiac output, and hypotension.
Flag
Baggy pants
sign
 SAM Children 6 to 59 Months

Once a child, 6 months or older, is diagnosed as SAM, she /he should be

assessed by a physician for complications by;

1. severe edema (+++)

2. lack of appetite

3. medical complications (e.g. severe anemia, pneumonia, diarrhoea,

dehydration, cerebral palsy, tuberculosis, HIV, heart disease)

4. danger signs according to IMNCI algorithm

If any of these are present, it’s complicated SAM, and inpatient management is
required. If the above-mentioned signs are absent, then child has uncomplicated
SAM and outpatient setting with care at home is done.
IMNCI (4)
SAM - Approach (3)
 Home management
1.Family is counseled and fully engaged.

2.Community health worker(s) and peer counselors are involved to

support the family.

3.There is supply of adequate home food

4.Periodic monitoring for growth and medical condition can be

ensured.adequate

5.Foods prepared from locally available cereals and pulses ensuring 175
kcal/kg body weight/day.

6.Breastfeeding should be continued, if the child is breastfed.

7. Optimum home management of a child with SAM needs
facilitation and guidance by the health worker (ASHA, AWW). A
home contact every day initially, and then twice a week is
essential.

8. In addition, sensory stimulation should be given (play, physical

activity, laughter, exposure to colors and shapes, storytelling, etc)
 IN-PATIENT MANAGEMENT
The general treatment involves 10 steps in two phases:

1.Stabilisation phase (restoring homeostasis and treating medical

complications)

2. Rehabilitation phase (focuses on rebuilding wasted tissues)

STEP 1: HYPOGLYCAEMIA

Definition: Blood glucose <54 mg/dL or 3 mmol/L

Triad: Hypoglycemia, hypothermia, infection

Treatment:

Asymptomatic: 50 mL 10% dextrose/sucrose orally → F-75 feed every 2 hrs

Symptomatic: 10% dextrose IV (5 mL/kg) or via NG tube → F-75 feed every 2 hrs

Prevention: Feed every 2 hrs, start antibiotics, prevent hypothermia

STEP 2 : Hypothermia Definition: Rectal temp <35.5°C or axillary <35°C

Treatment: Warm clothes + head cover, Rewarm with skin-to-skin/mother’s chest, Avoid rapid rewarming,
Immediate feeding + antibiotics

Prevention: Draught-free area, keep child warm and covered, 2-hourly feeds immediately after admission
STEP -3 : Dehydration
• Assume present in all SAM children with diarrhea
• Treatment:
◦ Use reduced osmolarity ORS + potassium, Feed with F-75 within 2–3 hrs of rehydration, Monitor for dehydration
signs
• Prevention:
◦ ORS (5–10 mL/kg) after each stool, Continue breastfeeding, Start F-75
STEP - 4 : Electrolytes
Treatment:
• Day 1: MgSO₄ IM (0.3 mL/kg), then extra Mg (0.8–1.2 mEq/kg/day), K supplementation: 3–4 mEq/kg/day x 2 weeks,
Avoid excess Na (even if plasma Na low), salt restricted diet
STEP - 5: Infection
• Assume serious infection; often asymptomatic
• Commonly gram-negative bacteria
• Treatment:
◦ Ampicillin 50 mg/kg/dose 6hrly + Gentamicin 7.5 mg/kg/day for 7 days, If no response in 48 hrs → IV
Cefotaxime/Ceftriaxone, If other infections identified, Start appropriate antibiotics.
Prevention:
• Standard hygiene, MR vaccine: 6 mo & not immunized ; >9 mo, if vaccinated before 9 mo
STEP- 6 : Micronutrients (Up to 2× RDA)

STEP - 7 : Initiate Feeding

• Small-frequent feeds, NG feeds, if not oral
• Fluids: 130 mL/kg/day (reduce to 100 if severe edema)
• Breastfeeding ad libitum, Starter feeds 2-hourly
• If Persistent diarrhea → low lactose diet
STEP - 8: Catch-Up Growth
• Start after 2–3 days of higher intakes (once appetite returns)
• ↑ Volume, ↓ frequency to 6 feeds/day
• Calories: 150–200 kcal/kg/day, Proteins: 4–6 g/kg/day
• Add complementary foods pre-discharge
STEP - 9 : Sensory Stimulation
• Cheerful environment, Play therapy: 15–30 min/day, Physical activity as tolerated, Tender loving care
STEP - 10 : Prepare for Follow-Up
Primary Failure (by Day 10):
• No appetite/weight gain by Day 4, Edema present by Day 10, <5 g/kg/day weight gain by Day 10
Secondary Failure:
• <5 g/kg/day gain for ≥3 consecutive days during rehabilitation phase
MODERATE ACUTE
MALNUTRITION
●Weight for height standard deviation score
between -2 and -3

●Mid upper arm circumference of 11.5-12.5 cm

●The mainstay of treatment is provision of adequate amount of
protein and energy , atleast 150 kcal per kg per day or additional
25 kcal per kcal per day should be given.

●In order to achieve these high energy intakes , frequent feeding

( upto 7 times a day ) is often necessary.

●Nutrients deserve foods enable children to consume and maximise

the absorption of nutrients in order to fulfill their requirements of
energy and all essential nutrients.
MANAGEMENT AND TREATMENT OF MAM

●Counseling caregivers on breastfeeding and nutrient-

dense complementary foods

●Provide extra ~25 kcal/kg/day over baseline needs

●Emphasize on animal-source proteins and

micronutrients like Fe and Zn
 References

1. https://www.who.int/health-topics/malnutrition

2. Nutrition and Child Development by KE Elizabeth 7th edition

2024

3. GHAI essential Pediatrics 10th edition

4. https://nhm.gov.in/images/pdf/programmes/child-health/guidelin
es/imnci_chart_booklet.pdf
THANK YOU