Management of Severe Acute Malnutrition

The 10 steps in the management of children with SAM and are divided into two parts. 

1. Initial stabilization phase (containing 7 steps) 

2. Rehabilitation phase (containing 3 steps) 

Initial Stabilization Phase: There are seven steps in initial stabilization phase, where life-threatening conditions are identified and treated and specific deficiency is corrected and which is usually achieved in 1st week. 

Seven steps are the following:- 

Step 1: Treat/prevent Hypoglycaemia  

Step 2: Treat/prevent Hypothermia  

Step 3: Treat/prevent Dehydration  

Step 4: Correct electrolyte imbalance  

Step 5: Treat/prevent Infection  

Step 6: Correct Micronutrient deficiency Step 

7: Start cautious feeding including breast feeding Rehabilitation phase:  Usually achieved in 2–6 weeks. 

Three stages of rehabilitation are following:-

Step 8: Achieve catch up growth  

Step 9: Provide sensory stimulation and emotional support  

Step 10: Prepare for discharge and follow up regularly. 

STEPS OF MANAGEMENT:-

Initial Stabilization Phase Step 

step1: Hypoglycaemia 

 • Blood glucose Less than 3 mmol/L or 54 mg/dL

 Clinical features: 

 Lethargy, hypothermia, altered level of consciousness 

 •Management 

–If the baby is conscious 

    -50 mL of 10% glucose orally or by nasogastric (NG) tube 

    -F-75 diet half hourly for 2 hours (giving one-quarter of 2 hourly feed) 

    -Keeping the child warm 

    -Antibiotics 

    -Two hourly feed, day and night 

–If the child is unconscious 

   -Intravenous 10% glucose (10 mL/kg) followed by 10% glucose 50 mL by NG tube, followed by F-75 diet as mentioned above.

    Blood sugar should be carefully monitored. If blood sugar is persistently less than 3 mmol/L, in spite of above management more severe underlying cause including septicemia should be considered and appropriate management and if possible, referral to a higher facility should be done

Step 2: Hypothermia 

 •Rectal temperature less than 35.5°C, axillary less than 35°C 

 •Co-exists with hypothermia and sepsis 

 •Re-warm the child  

   –Cover the child with warm blanket and increase the ambient temperature with safe heat source, or put the baby on mother’s bare chest (skin to skin) and cover them, the Kangaroo mother care 

   –Start antibiotics and 2 hourly feed

Step 3: Diarrhea and Dehydration

It is difficult to estimate dehydration in severely malnourished children as positive skin pinch sign and sunken eye may occur due to loss of fat and muscle wasting without dehydration.

Similarly dehydration may be overestimated in oedematous malnutrition. Therefore, it is assumed that malnourished children with diarrhea have dehydration.

Dehydration correction oral solution for malnourished children called ReSoMal contains low sodium and high potassium

Correction of dehydration is done in the following manner: 

 •Give ReSoMal 5 mL/kg every 30 minutes for 2 hours. Then 5–10 mL/kg/hour every alternate hour for 4–6 hours

 • F-75 in alternate hour 

 • If diarrhea is severe modifi ed/ Hypo-osmolar WHO ORS, containing more sodium (75 mmol sodium/L) than of ReSoMal (sodium 45 mmol/L) may be used to prevent symptomatic hyponatremia.

 Signs of overhydration (due to injudicious use of fluid resuscitation) 

 • Increasing pulse rate 

 • Increase respiratory rate 

 • Edema (puff y face) 

 • Distended neck veins. A positive skin pinch sign may be found in malnourished child due to loss of subcutaneous fat, even without dehydration. So a full thickness skin pinch (Figs 12 and 13) is required to assess dehydration.

Step 4: Correct Electrolyte Imbalance

 Severe acute malnutrition children have excess body sodium with low tissue potassium and magnesium. Serum electrolytes do not reliably reflect tissue electrolytes contents rather it may act as supporting role of clinical dyselectrolytemia.

  Treatment Until stabilization introduce: 

 •Extra potassium 3–4 mmol/kg/day 

 •Extra magnesium 0.4–0.6 mmol/kg/day when rehydrating, give low sodium rehydration fluid (ReSoMal) 

 •Prepare food with less salt 

 •Do not treat edema with diuretics

Symptomatic tissue potassium deficiency may be associated with ileus and abdominal distension, which aggravates feeding difficulty. Intramuscular magnesium injection help improving body potassium utilization, thereby improving abdominal distension and feeding difficulty.

Step 5: Treat and Prevent Infection 

Signs of infection such as fever are absent and subacute bacterial infections are common in malnourished children which may be asymptomatic. Therefore, routine broad-spectrum antibiotics are used on admission. Early use of antibiotics also: 

 • Improves nutritional response to feeding 

 • Prevents shock 

 • Reduce mortality.

 First-line treatment: With no complication (WHO guidelines) oral amoxicillin 15 mg/kg 8 hourly for 5 days. If the child is severely sick with lethargy or complication IV/IM ampicillin (50 mg/kg) 6 hourly for 2 days, then oral amoxicillin 15 mg/kg 8 hourly for 5 days and IV/IM gentamicin 7–8 mg/kg once daily for 7 days.

 Second-line treatment: If the child does not improve with first-line of treatment within 48 hours or deteriorates after 24 hours or if the child present with septic shock or meningitis, then inject IV/IM Ceftriaxone injection 100 mg/kg/day along with injection Gentamicin (IV/ IM) for 5 days

 Injection 50% magnesium sulphate 0.3mL/ kg intramuscular (IM) should be given on 1st day and 0.1 mL/kg on 2nd and 3rd day

Step 6: Correct Vitamin A and other Micronutrient Deficiency

 Severely malnourished children are at high-risk of blindness due to Vitamin A deficiency. Thus vitamin A should be given to all severely malnourished children on Day 1, unless there is definite evidence that a dose has been given in the past month. Additional doses are given if: 

• The child has visible clinical signs of vitamin A deficiency like Bitot’s spots, corneal opacity or corneal ulceration 

• The child has signs of eye infection (pus, inflammation) that may hide the signs of vitamin A deficiency or 

• The child has measles now or has had measles in the past 3 months the addition doses are given on D2 and at least 2 weeks later on D14. Other vitamin deficiencies either occult or showing their clinical feature like angular stomatitis are frequently associated with severe malnutrition. Therefore multivitamins (not containing iron initially) in the form of drops containing water soluble and fat soluble vitamins should be given daily. Vitamins and minerals for malnourished children if available as combined mineral and vitamin (CMV) can be used in preparing food. Other micronutrient including folic acid, zinc, cooper and later iron should also be given in appropriate dose. Appropriate timing and doses of vitamin A and other micronutrients are mentioned in Table 11.  Calcium is also added in therapeutic food. Although calcium and vitamin D deficiency are also associated with severe malnutrition, clinical rickets is very unusual. This is because rickets occurs due to mineral deficiency in growing bone. Calcium and vitamin D supplement are essential during rehabilitation phase of malnutrition when the child grows rapidly.

 WHO recommended therapeutic diet?

 • F-75 (100 mL containing 0.9 g protein and 75 kcal energy) 

 • F-100 (100 mL containing 2.9 g protein and 100 kcal energy) 

 • Prepared from milk powder, sugar, soybean oil 

 • Combined minerals and vitamins (CMV if available) or electrolytes/mineral solution if CMV not available commercially

Step 7: Start cautious feeding including breastfeeding

Start feeding with F-75 containing 75 kcal and 0.9 g protein/100 mL feed from cup/spoon/syringe. The following Table  is the usually recommended schedule: For children with severe edema, the volume/feed and volume/day (100 mL/kg/day) are reduced until edema disappears. If intake is less than 80 kcal/kg/day, give remaining by NG tube. In rare cases with feeding difficulty and food intolerance continuous slow feeding may be required with feeding pump as shown down

Breastfeeding

 • Breastfeeding is encouraged in between feeds 

 • Required amounts of therapeutic diet are ensured even if the child is breastfed, that is required amount of F-75/ F-100 diet are not curtailed if the child breast- feeds.

Treatment of Associated Conditions Emergency Management of Shock

Severe dehydration/dehydration shock and septic shock are difficult to differentiate on clinical signs alone. Signs of septic shock may include: 

 • Signs of shock but without  history of watery diarrhea. Do not drink eagerly like severe dehydration 

 • Hypothermia or hypoglycemia Diagnosis of shock is based on following criteria: 

 • Lethargy and unconscious 

 • Cold clammy hands and feet plus either of the following: – Slow capillary refill time (>3 sec), or – Weak fast pulse (>160/min in 2–12 months of age, >140/ min in 1–5 years of age).

Treatment of shock Six important components: 

 1. Give oxygen. 

 2. Give sterile 10% glucose (5 mL/kg) IV route. 

 3. Keep the child warm. 

 4. Give an antibiotic. 

 5. Give IV fl uid at 15mL/kg over 1 hour. Use Ringer’s lactate with 5% dextrose or half strength normal saline with 5% dextrose.

 6. Measure and record pulse and respiration rate every 30 minutes. 

If the shock is due to severe diarrhea: Use half strength cholera saline (15 mL/kg for first 2 hours to prevent symptomatic hyponatremia). If there are signs of improvement after 1 hour (pulse and respiratory rate decreasing): 

 • Repeat IV fl uid 15 mL/kg for 1 hour (total 2 hour). 

 • Switch to oral or NG rehydration with ReSoMal 10 mL/kg/ hr in alternate hours with F-75 diet. 

 • Continue feeding with F-75 diet. If the child fails to improve (pulse and respiratory rate remains high) after 1 hour, assume septic shock. In this case: 

 • Give maintenance IV fluid (3 mL/kg/hour) while waiting for blood. 

 • Transfuse whole blood at 10 mL/kg slowly over 3 hours 

 • Stop infusion if signs of overhydration appears (pulse suddenly increases by >25/min or respiration rate increases by >5/min from existing condition).

Anemia in Malnourished Children 

Anemia, particularly iron deficiency (ID) is commonly associated with severe PEM. 

In the majority of cases, normocytic normochromic anemia is common. However associated vitamin and mineral deficiencies, including ID and ongoing sepsis may modify the picture. 

The normocytic normochromic anemia in severe PEM is associated with the decrease in circulatory erythrocytic mass. Th e metabolic changes in red blood cell, decrease in erythrocytes, and fall in erythropoietin production cause erythroid hypoplasia with the increase in the myeloid/erythroid ratio. However, associated ID may cause iron deficiency anemia (IDA). 

The incidence of IDA is variable and depends on a number of factors such as dietary habits, parasitic infestation, chronic blood loss, etc.

Although the majority of hypochromic microcytic anemia are due to ID but other conditions like the ongoing infection is frequently associated with PEM. Infection decreases Hb synthesis and iron is less utilized for Hb synthesis and it is eliminated rapidly from blood to reticuloendothelial system in the form of ferritin. Characteristically in IDA serum iron (SI) is decreased with an increase of total iron binding capacity (TIBC) and the decrease in serum ferritin. However, in anemia with severe PEM, SI though less, TIBC is also less and serum ferritin may be increased

Not only iron is unutilized in PEM, the unaltered ferrous ion catalyzes the reaction of superoxide and hydrogen peroxides (H2O2) to produce highly reactive hydroxyl (OH) ion through Fenton reaction, which is capable of producing chemical injury to the cell membrane. Lipid peroxidation has been proposed as the primary mechanism for cellular dysfunction and tissue injury. In malnourished children, oxidative process overwhelms the antioxidant protection. These facts are the basis of withholding of iron supplementation in the early phase of management of severely malnourished children. In mild to moderate anemia, iron should be given for 3 months to replace the iron store, but this should not be started until after the initial stabilization phase has been completed

Emergency Treatment of Severe Anemia in Malnourished Children

A blood transfusion is required 

 • If Hb is less than 5 g/dL 

 • If Hb is between 5 g/dL and 7 g/dL with respiratory distress. Transfuse: 

 • Whole blood 10 mL/kg slowly over 3 hours 

 • Furosemide 1 mg/kg at the start of transfusion. 

If signs of cardiac failure appear, transfuse. Packed cell 5–7 mL/ kg body weight rather than whole blood.

Vitamin A Deficiency:

Vitamin A on day 1, 2 and 14. If there is corneal clouding or ulceration 

• Chloramphenicol or tetracycline eye drop 

• Atropine eye drop 

• Cover with eye pads soaked in saline solution and bandage. 

Dermatosis:

 • Apply gauze soaked in 1% potassium permanganate solution over affected area and keep it for 10 minutes twice daily 

 • Omit nappies so that perineum can remain dry 

 • Zinc oxide paste/ointment 

 • Antifungal (Clotrimazole) twice daily for candidiasis, oral nystatin (100,000 IU), four times daily for oral candidiasis, which also acts as a reservoir for gut and skin candidiasis. the picture shows before and after treatment of both edema and dermatoses.

Helminthiasis:

Helminthiasis is frequently associated with malnourished children. Anthelmintic given during rehabilitation phase.

 • Single dose of 200 mg of albendazole, if age is more than 3–23 months, 400 mg of age is more than 24 months 

 • 100 mg of mebendazole twice daily for 3 days for children more than 24 months. For Giardiasis: 

 • Metronidazole (7.5 mg/kg, 8 hourly for 7 days.)

Tuberculosis:

If tuberculosis is suspected due to contact with adult TB patient, chronic cough (>2 weeks), chest infection not responding to conventional antibiotics, perform a Mantoux test. 

In malnourished children, the interpretation of Mantoux test is made with caution. 

It may be false negative or mildly positive (if induration <5 mm) in spite of the presence of active tuberculosis due to impaired cell-mediated immunity.

Continuing Diarrhea and Dysentery

Loose or poorly formed stool are frequently associated with malnourished children, particularly in rehabilitation phase requiring no treatment provided the child is not sick and weight gain is satisfactory. Similarly food intolerance like lactose intolerance, milk protein allergies, etc. is frequently over-diagnosed in malnourished children. Rarely diarrhea is due to lactose intolerance. Treat only if continuing diarrhea is preventing general improvement. In that case, substitute normal milk with non-milk formula (Rice, suji, comminuted chicken soup)

Osmotic diarrhea:

Some malnourished children cannot tolerate high osmolar diet during rehabilitation phase (F-100). 

In that case, low osmolar cereal based F-75 diet should be continued for a long time and F-100 should be gradually introduced

Persistent diarrhea:

Diarrhea associated with severe malnutrition is a special entity and require special approach. 

Persistent diarrhea commonly associated with severely malnourished children not only responsible for treatment failure with poor weight gain, but also associated with high mortality. 

It should be treated with easily digestible protein and energy rich diet (Rice, suji, comminuted chicken soup, elemental and pre-elemental diet, etc.), together with appropriate micronutrients (Zinc, vitamin A, copper, potassium) and appropriate antibiotics when required

HIV/AIDS:

It may hinder recovery and may be associated with food intolerance (like lactose intolerance) and persistent diarrhea. Lactose-free diet may be tried. 

Pneumonia:

Pneumonia is one of the most frequent medical complications contributing to increased case fatality. Characteristic clinical features of pneumonia (tachypnea, lower chest in drawing, cough) may not be evident due to poor host response associated with poor intercostal, subcostal and diaphragmatic muscle mass. For a given sensitivity and specifi city they produce fi ve breaths fewer respiratory rate than well-nourished children. A number of children do not have fever and X-ray chest fi nding may not be conclusive. Therefore, high index of clinical suspicion of pneumonia should be adopted with mild cough and suboptimal tachypnea and even when characteristic WHO defi ned features of pneumonia are absent. Failure to recognize the above facts may cause failure to diagnose pneumonia early in malnourished children and also can delay timely treatment for pneumonia which may be potentially catastrophic. 

Rehabilitation Phase 

Step 8:Achieve catch-up growth

 Signs of entrance to the rehabilitation phase are return of appetite and loss of edema in oedematous malnutrition 

• It should be gradual and takes usually 1 week. Recommended food: F-100 (every 10 mL containing 100 kcal energy and 2.9 gram of protein) To change from starter (F-75) to catch-up formula: 

• Replace F-75 with same amount of F-100 every 4 hours for 48 hours 

• Increase each successive feed by 10 mL until some feed remains uneaten 

• The point when some remains unconsumed after most feeds is likely to occur when intake reach about 30 mL/kg/ feed (200 mL/kg/day)

• In place of F-100 diet, non-milk formula like khichdi, haluva, modified porridge or modified family food can be used, provided they have comparable energy, protein and micronutrient concentration. 

Step 9: Sensory stimulation and emotional support 

• Tender loving care 

• A cheerful, stimulatory environment 

• Toys made of locally available discarded materials 

• Physical activity as soon as the child is well enough 

• Parental involvement when possible, comforting, bathing, play and to be continued at home.

 Step 10: Prepare for discharge and follow-up 

Regularly Criteria for discharge from inpatient care in areas where there is no community-based outpatient care:

Child factor 

• Weight for height median (WHM) more than 80% or more than WHZ more than –2 SD 

• Edema has resolved 

• Good appetite and gaining weight 

• Child has been provided with appropriate micronutrients. List out of the fundamental rights and duties of the citizens of India.

Mother factor 

• Mother can prepare appropriate food and feed for child 

• Has financial resources to feed the child 

• Can recognize danger sign and early access to hospital for urgent re-admission 

• Can be visited weekly. 

Failure to respond to treatment Indicators: 

• High mortality 

• Poor weight gain

Death occurring within 24 hours of admission Consider untreated or delayed treatment of sepsis, pneumonia, severe anemia, hypothermia, incorrect rehydration fluid, overuse of IV fluids. Table down summarizes the causes of death of severely malnourished children at different stages after admission in facility-based care.

Within 72 hours Low volumes to high volume feed or feeding with

wrong formula

Weight gain is considered poor, moderate and good on the basis of weight gain in gram/kg/day as mentioned down

If weight gain is poor, then major changes of management and overhauling of department of nutrition will be necessary.  Undiagnosed infections [(TB, asymptomatic urinary tract infection (UTI)] may also be considered. Other factors involved in poor weight gain are: 

• Inadequate feeding, particularly night feed, wrong feeding technique and wrong preparation of food 

• Specific nutrient deficiency, particularly not providing zinc and potassium to diet. Zinc and potassium particularly required during catch-up growth, as growing muscles require zinc and potassium 

• Psychological problems and psychosocial problem are frequently associated with malnourished children. They are quite often emotionally deprived due to dysfunctional family unit and functionally single parent family. The psychological problems are characterized by stereotyped movements, rocking, rumination, etc. Treat by providing extra care, love and attention