Severe Acute Malnutrition

Pediatric

1. Presented By- BIBHU PRASAD SAHU RUPSY DIYA SAHA HITESH KHATUA ARPIT PATEL PRITHVI SENA JAS SEVERE ACUTE MALNUTRITION (SAM)

2. Outline Definition Etiology Pathogenesis/ Pathophysiology Complications Principles of management Summary

3. Introduction Hunger – Physiological state when food is not able to meet energy needs. Malnutrition – Malnutrition refers to deficiencies or excesses or imbalances intake of energy and/or nutrients in a person . It could be under-nutrition or over-nutrition(obesity ) . Undernutrition – most common form of malnutrition in developing countries. Overnutrition (obesity)- common on developed countries

4. Fig: Undernourished and Obese

5. Definition-Severe Acute Malnutrition (SAM) WHO and UNICEF defines Severe Acute Malnutrition (SAM) for children aged 6 months to 60 months as : ◆ Weight for height below -3 SD score of the median WHO growth standards. ◆ By visible severe wasting. ◆ Bipedal oedema ; and ◆ Mid upper arm circumference below 115mm.

6. ETIOLOGY

7. ETIOLOGY Primary - when the otherwise healthy individual's needs for protein, energy, or both are not met by an adequate diet . (most common cause worldwide ) Secondary - result of disease states that may lead to sub-optimal intake , inadequate nutrient absorption or use, and/or increased requirements because of nutrient losses or increased energy expenditure.

8. PRECIPITATING FACTORS Lack of food (famine, poverty) Inadequate breast feeding Wrong concepts about nutrition Diarrhoea & malabsorption Infections (worms, measles, T.B)

9. PATHOPHYSIOLOGY

10. PATHOPHYSIOLOGY The “Vicious Cycle”of Undernutrition & Infection Disease: . incidence . severity . duration Appetite loss Nutrient loss Malabsorption Altered metabolism Inadequate dietary intake Weight loss Growth faltering Lowered immunity Mucosal damage Figure 2 . The Synergistic cycle of infection and malnutrition

11. Pathological Effects of SAM : Across all organ systems !! 13

12. COMPLICATION

13. Infection : lung , blood, UT, GIT, skin  Metabolic hypoglycemia hypocalcemia hypomagnesemia  Hypothermia

14.   Marasmus-Kwashiorkor

15. Bilateral pitting edema Grade 3 (+++)

16. Severe vomiting/ intractable vomiting 4/10/2016 44

17. Extensive skin lesions/ infection

18. Very weak, lethargic, unconscious

19. Fitting/convulsions

20. Severe dehydration

21.  Hypothermia : axillary’s temperature < 35°C or rectal < 35.5°C F ever > 39°C 4/10/2016 45

22. Very pale (severe anemia )

23. Jaundice

24. Bleeding tendencies

25. Management of sam (Severe Acute Malnutrition)

26. The WHO has developed guidelines have been adapted by the Indian Academy of Pediatrics . The general treatment involves ten steps in two phases: The initial S tabilization phase focuses on restoring homeostasis and treating medical complications and usually takes 2-7 days of inpatient treatment. The R ehabilitation phase focuses on rebuilding wasted tissues and may take several weeks. Management of sam (Severe Acute Malnutrition)

27. Step 1: Treat/Prevent Hypoglycemia Blood glucose level <54 mg/dl or 3 mmol /l. If blood glucose cannot be measured, assume hypoglycemia. Hypoglycemia, hypothermia and infection generally occur as a triad. Treatment Give 50 ml of 10% glucose or sucrose solution orally or by nasogastric tube followed by first feed. Feed with starter F-75 every 2 hourly day and night Prevention Feed 2 hourly starting immediately. Prevent hypothermia.

28. Step 2: Treat/Prevent Hypothermia Rectal temperature less than <35.5°C or 95.5°F or axillary temperature less than 35°C or 95°F. Treatment Clothe the child with warm clothes . Provide heat using overhead warmer, skin contact or heat convector. Avoid rapid rewarming as this may lead to disequilibrium. Feed the child immediately. Prevention Place the child's bed in a draught free area. Always keep the child well covered Feed the child 2 hourly starting immediately after admission.

29. Step 3: Treat/Prevent Dehydration with Shock A ll severely malnourished children with watery diarrhea have some dehydration. Treatment Use ORS with potassium supplements. Initiate feeding within two to three hours of starting rehydration . Prevention Give ORS at 5-10 ml/kg after each watery stool, to replace stool losses. If breastfed, continue breastfeeding. Initiate refeeding with starter F-75 formula.

30. Step 4: Treat/Prevent Infection Multiple infections are common. Majority of bloodstream infections are due to gram-negative bacteria. Treatment Treat with parenteral ampicillin 50 mg/kg/ dose 6 hourly for at least 2 days followed by oral amoxicillin 15 mg/kg 8 hourly for 5 days and gentamicin 7.5 mg/kg once daily for 7 days. If other specific infections are identified, give appropriate antibiotics. Prevention Follow standard precautions like hand hygiene. Give proper vaccination if not immunized and is of suitable age

31. Step 5: Correct Electrolyte Balance Give supplemental potassium at 3-4 mEq /kg/ day for at least 2 weeks. On day 1 , give 50% magnesium sulphate IM once. Thereafter, give extra magnesium (0.8-1.2 mEq /kg daily ) Step 6: Correct Micronutrient Deficiencies Use up to twice the recommended daily allowance of various vitamins and minerals On day 1, give....

32. Micronutrient supplementation GOI OPERATIONAL GUIDELINES ON MALNUTRITION 2011 36 MICRONUTRIENT DOSING Vitamin A Vitamin A,C, D, E and B12 TWICE RDA Zinc 2 mg/kg/day Iron Start after two days on catch up diet, elemental iron @ 3 mg/kg/day Copper 0.3 mg/kg/day (if separate preparation not available use commercial preparation containing copper) Folate 5 mg on day 1, then 1 mg/day Micronutrient Supplementation

33. Step 7: Initiate Re-feeding Start feeding as soon as possible as frequent small feeds. If unable to take orally, initiate nasogastric feeds. Total fluid recommended is 130 ml/kg/day. If breast feeding, then continue breast feeding. Start with F-75 starter feeds every 2 hourly. If persistent diarrhea, give a cereal based low lactose F-75 diet as starter diet. Step 8: Achieve Catchup Growth Once appetite returns in 2-3 days, encourage higher intakes Increase volume offered at each feed and decrease the frequency of feeds to 6 feeds per day. Make a gradual transition from F-75 to F-100 diet. Increase calories to 150-200 kcal/kg/ day, and proteins to 4gm/kg/day.

34. Step 9: Provide Sensory Stimulation & Emotional Support A cheerful, stimulating environment. Age appropriate structured play therapy for at least 15-30min / day. Tender loving care. Step 10: Prepare for Follow-up Primary failure to respond is indicated by: Failure to regain appetite 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 consecutive days during the rehabilitation phase.

35. Structure Play & Loving C are 39

36. Refeeding Syndrome

37. WHAT IS REFEEDING SYNDROME?  Clinical complex, which includes electrolyte changes associated with metabolic abnormalities that can occur as a result of nutritional support ( enteral or parenteral), in severely malnourished patients. Also called “the hidden syndrome” History

38. PATHOPHYSIOLOGY

39. CLINICAL MANIFESTATIONS Nausea, vomiting, and lethargy Respiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma, and death

40. REFEEDING SYNDROME  Refeeding a malnourished patient can result in Heart failure due to: Atrophic myocardium in malnutrition Muscle depletion of Mg, K, P Sodium and water overload

41. MA N AGEME N T Feeding and correction of biochemical abnormalities can occur in tandem without deleterious effects to the patient.(NICE) Early identification of at risk individuals, Monitoring during refeeding , and An appropriate feeding regimen are important.

42. TAKE HOME MESSAGE Sam is major burden in deveoping countries. SAM is a medical emergency Pathophysiology still elusive and incomplete Ten steps are the key to successful management Community based treatment has revolutionised management of SAM Special needs for young infants and follow up issues need to be recognised

43. THANK YOU