Severe acute malnutrition presentation ppt

Presentation on SAM

1. SEVERE ACUTE MALNUTRITION DR. GOOLLA AKHILA PG RESIDENT

2. BALANCED DIET: Defined as nutritionally adequate & appropriate intake of food items that provide all the nutrients in required amounts & proper proportions to ensure normal growth, development, disease free optimum health among children and adolescents. CARBOHYDRATES-55-60% ( 4kcal/g) FATS-30-35% ( 9kcal/g) PROTEINS-10-15% ( 4kcal/g)

3. MALNUTRITION Refers to deficiencies, excesses or imbalances in a person’s intake of energy and or nutrients ( WHO). The term malnutrition is used to denote UNDERNUTRITION OVERNUTRITION SELECTIVE NUTRITIONAL DEFICIENCIES Undernutrition occurs due to -inadequate intake -poor absorption -excessive loss of nutrients Overnutrition includes overweight and obesity.

4. PEM It is defined as range of pathological conditions arising from coincidental lack of proteins and calories in varying proportions in infants and young children. -commonly associated with infections. - one of the major causes of death in children below 5years of age. CAUSES OF PEM : Primary causes : due to lack of adequate intake of food Poverty Traditional habits Social and cultural factors Congenital defects like cleft lip and cleft palate IUGR and Maternal malnutrition predisposes the child to undernutrition

5. Secondary causes : despite adequate amount of food intake - Chronic illness and infections increasing metabolic demand and decrease in appetite.It includes : Inborn errors of metabolism GIT infections: cleft lip,cleft palate,malabsorption Pancreas: pancreatic insufficiency Renal : UTI, RTA Respiratory causes: asthma, recurrent respiratory tract infections Endocrine : GH deficiency, hypothyroidism, DM Neurological : MR, Cerebral palsy Malignancies

6. SPECTRUM OF PEM Kwashiorkor Marasmus Marasmic kwashiorkor Pre kwashiorkor Nutritional dwarfing Under weight Early lactational failure syndrome Severe acute malnutrition

7. INDICATORS OF PEM Weight for age(W/A) Weight for Height(W/H) Height for age(H/A) INDICATORS ACUTE MALNUTRITION CHRONIC MALNUTRITION Weight for age Low Low Height for age Normal Low Weight for height Low Normal

8. CLASSIFICATION CRITERIA AS PER WHO GRWOTH STANDARD Underweight Low weight for age Weight for age < -2SD Stunting Low height or length for age Height for age <-2SD Wasting Low weight for height Weight for height <-2SD CLASSIFICATION OF UNDERNUTRITION

9. CLINICAL SYNDROMES OF UNDERNUTRITION Moderate and severe malnutrition is associated with one of the classical syndromes namely Marasmus and Kwashiorkor. MARASMUS : Most common in preschool children. Diet deficient in both calories and proteins Decreased levels of Insulin & Increased levels of cortisol Decrease in GH Levels

10. SALIENT FEATURES OF MARASMUS : -Weight < 60% of expected ( acc. To WELLCOME TRUST CLASSIFICATION) with no edema . - child appears very thin and no fat with severe wasting at shoulders, arms, buttocks and thighs. -loss of buccal pad of fat creates aged or wrinkled appearance that is referred to as monkey facies. -Baggy pants appearance refers to loose skin of the buttocks hanging down.Axillary pad of fat may also be diminished. -Affected children may appear to alert inspite of their condition.

11. KWASHIORKOR : It usually affects children between 1-4 years of age . GENERAL APPEARANCE: Child may have fat sugar baby appearance. EDEMA: It may be mild to gross approximating 5-20% of body weight, MUSCLE WASTING: It is always present. The child is weak, hypotonic and unable to stand or walk. SKIN CHANGES: Increased pigmentation, desquamation, dyspigmentation Flaky paint or individual enamel spots usually on buttocks, thighs. petechiae over the abdomen peeling of outer layers of skin and ulcerations

12. MUCOUS MEMBRANE LESIONS: Smooth tongue , cheilosis, angular stomatitis HAIR: Dyspigmentation Loss of characteristic curls and sparseness over temples and occipital regions Loss of lusture and easily pluckable alternate bands of hypopigmented and normally pigmented hair resembling Flag sign MENTAL CHANGES: include unhappiness, apathy, irritability,intermittent cry , no signs of hunger

13. GIT: Anorexia,Abdominal distension stools may be watery or bulky or semisolid with low Ph and unabsorbed sugars, NUTRITIONAL ANEMIA CVS: Bradycardia, prolonged capillary refilling time, decreased cardiac output and hypotension RENAL : There is aminoaciduria and inefficient excretion of acid load

14. FLAG SIGN BAGGY PANTS

15. IDENTIFICATION OF SEVERE ACUTE MALNUTRITION Criteria for identifying SAM in children < 6 months of age: Weight for height less than -3SD Edema of both feet Criteria for identifying SAM in children > 6months of age: Weight for height less than -3SD on WHO Growth Standard Oedema of both feet Mid upper arm circumference < 11.5cms

16. PATHOLOGICAL CHANGES SEEN IN SAM Liver -Reduced glucose production causing HYPOGLYCEMIA -Reduced ability to synthesize albumin,transferrin,transport proteins Kidneys - Reduced excretion of sodium and excess fluids causing FLUID OVERLOAD Cardiovascular system-Reduced myocardial mass,atrophy,patchy necrosis of myocardium Respiratory system- Atrophy of intercostal muscles Reduced thermogenesis

17. GIT-Mucosal atrophy,reduced gastrointestinal enzyme secretions Delayed mucosal repair Atrophy of intestinal villi(malabsorption) Endocrine system- Decrease in- Thyriod hormone Increase in Cortisol levels Insulin Growth hormone Immunological system-Cell mediated immunity is reduced Impaired T and B lymphocytes function Decreased Lymphocyte count Micronutrient deficiency- Reduced free radical deactivation leading to cell damage

18. CRITERIA FOR IDENTIFYING CHILDREN WITH SAM FOR TREATMENT Early detection of children with SAM will ensure that these children will be identified before they develop medical complications. MUAC is the simple measure for detection of SAM. MUAC in children from 6months to 59 months and look for bilateral pitting edema. MUAC is less than 11.5 cms or any degree of bilateral pedal edema immediately child is referred for full assessment and further medical management.

19. SCREENING OF SAM Active screening of children by AWW,ASHA through house to house visit and measuring of MUAC using tape and look for bilateral pitting pedal edema. Passive screening during growth monitoring,village health nutrition days using MUAC and b/l pitting pedal edema If features of SAM present look for complications -severe edema +++ -poor appetite (failed appetite test) -medical complications-severe anemia pneumomia diarrhoea dehydration cerebral palsy, TB, HIV, Heart disease -one or more IMCI danger signs

20. SUPERVISED HOME MANAGEMENT OR OUTPATIENT MANAGEMENT OF UNCOMPLICATED SAM Counselling about breast feeding,supplementary feeding,immunization and hygiene. Community health care workers or peer counselors are involved to support the family. Theraputic food adhering to WHO and UNICEF specifications to be provided like RUFTs( ready to use therapeutic food). 2-3 hourly feeds with plenty of water. Periodic monitoring of growth and medical condition Child should be monitored by health care workers for signs of under nutrition( weight,height,MUAC,edema etc., every week.

21. MANAGEMENT OF COMPLICATED SAM IN HOSPITAL All children with complicated SAM should be admitted to a Nutritional Rehabilitation Centre(NRCs) or health facility. Children with severe malnutrition has a complex backdrop with dietary, infective, social, economic factors. History of events leading to child’s admission should be obtained. Socio economic history and family circumstances should be explored to understand the underlying and basic causes.

22. Initial assessment of severely malnourished child History & Examination Recent intake of foods and fluids including breast feeding Usual diet before the illness Duration and frequency of diarrhea and vomiting Loss of appetite Bowel and bladder habits Known or suspected HIV & TB contact Immunization history History of measles infection in the past Developmental history

23. On examination Anthropometry Edema Anemia Signs of dehydration and shock Eye signs of vitamin A deficiency Localizing signs of infections Skin changes of kwashiorkar Fever,Hypothermia (<35.5*c) Signs of dehydration and shock Severe anemia Extensive skin lesions,mouth ulcers and eye lesions Localizing signs of infections

24. PRINCIPLES OF HOSPITAL MANAGEMENT OF SAM The general treatment includes 10 steps in two phases STABILIZATION PHASE- It focuses on restoring homeostasis and treating medical complications.It usually takes 2-7 days. REHABILITATION PHASE- It focuses on rebuilding wasted tissues and may take 2-6 weeks

25. MANAGEMENT OF SAM HYPOGLYCEMIA – Blood glucose levels < 54mg/dl or 3mmol/l Hypoglycemia, Hypothermia, Infections occur together in malnourished children. TREATMENT- Asymptomatic hypoglycemia- 50ml of 10% glucose or sucrose solution followed by first feed with F 75 every 2hourly day and night. Symptomatic hypoglycemia- 10% D IV 5ml/kg follow with 50ml of 10%D or sucrose solution by nasogastric tube Feed with F 75 every 2hourly day and night Start with appropriate antibiotics PREVENTION - feed 2 hourly and prevent hypothermia

26. HYPOTHERMIA - Rectal temperature < 35.5 degree C or 95.5 degree F Axillary temperature <35 degree C or 95 degree F TREATMENT- Cloth the child with warm clothes; head covered with cap Provide heat using headwarmer,skin contact or heat convector Avoid rapid rewarming as this may lead to disequilibrium Feed the child immediately Start appropriate antibiotis

27. DEHYDRATION - Difficult to assess the dehydration status in severely malnourished child. Assume that all the children with watery diarrhea have some dehydration TREATMENT- Use reduced osmolrity ORS solution with potassium supplements for rehydration and maintainence . Initiate feeding within 2-3 hours of starting rehydration:use F75 formula on alternate hours. Be alert with signs of dehydration PREVENTION- Give reduced osmolarity ORS at 5-10ml/kg after each watery stool If breastfed continue breastfeeding

28. ELECTROLYTES - Supplemental potassium at 3-4mEq/kg/day for 1-2 weeks 50% of MgSO4 0.1-0.2ml/kg/dose in 2 divided doses for 1-3 days Sodium is restricted to 2-3meq/kg/day INFECTIONS- majority caused by gram negative bacteria. TREATMENT- Give broad spectrum antibiotics, penicillins or ampicillin with aminoglycosides If no improvement occurs with in 48 hours change to IV Cefotaxime or Ceftriaxone. PREVENTION- Follow hand hygiene

29. MICRONUTRIENTS - On day1 give oral Vitamin A. Folic acid 1mg/day Zinc 2mg/kg/day Iron 3mg/kg/day once child starts gaining weight after first week INITIATE FEEDING- small and frequent feeds Oral or nasogastric feeds Continue breast feeding Start with F75 feeds every 2hourly In persistent diarrhea give cereal based low lactose F75 diet as starter diet If diarrhea continues on low lactose diet give F75 lactose free diet

30. CATCH UP GROWTH- Return of appetite within one week signals Rehabilitation phase Increase volume offered at each feed and decrease the frequency of feeds Continue breast feeding Make gradual transition from F75- F100 diet Increase calories from 150-200kcal/day and proteins to 4-6g/kg/day Add complementary feeds as soon as possible SENSORY STIMULATION- A cheerful stimulating environment structural play therapy for 15-30min physical activity as soon as the child is healthy Tender loving care

31. COMPLICATIONS OF TREATMENT: Protein overload syndrome Encephalitis like syndrome Nutritional Recovery syndrome Pseudotumor cerebri Refeeding syndrome

32. REFEEDING SYNDROME

33. FAILURE TO RESPOND TO TREATMENT : Primary failure when the child donot improve after treatment. failure to regain appetite -4 th day failure to start losing edema -4 th day presence of edema -10 th day failure to gain atleast 5g/kg/day - 10 th day Secondary failure - failure to gain at least 5g/kg/day for 3 consecutive days in rehabilitation phase

34. CRITERIA FOR DISCHARGE No edema for atleast 2 weeks plus W/H -2SD or higher on WHO Growth Standard Absence of infection Completed immunization appropriate foe age Caretakers sensitized to home care Return of social smile Eating atleast 120-130kcal/kg/day Consistent weight gain (5g/kg/day) for 3 consecutive days on exclusive oral feeding

35. PREVENTION OF UNDER NUTRITION In around 1/3 rd of children with PEM it is sequel of low birth weight.Hence antenatal care should be emphasized and strengthened. The stratagies for prevention can be summarized as NIMFES N-NUTRITION & GROWTH MONITORING I- IMMUNIZATION M-MEDICAL CHECKUP AND MEDICAL CARE F-FAMILY WELFARE( timing,spacing,limiting of births) E-EDUCATION S- STIMULATION ( tender love caring)

36. ICDS ( Integrated child development services) A package of 6 services provided under ICDS Scheme: Supplementary nutrition for mother and child Immunization of pregnant women and child as per NIS Non formal preschool education Health checkups Referral services Nutrition and health education

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