SEVERE ACUTE MALNUTRITION SEMINAR new.pptx

Severe acute malnutrition

1. MANAGEMENT OF S EVER E A C U T E MA L N U T R I T I O N Dr P. Priyanka 1 st year PG

2. DEF IN I T I ON Malnutrition - undernutrition resulting from i n ad e qua t e c o n s u m p t i o n , p oo r ab s o r p t i o n o r excessive loss of nutrients or overnutrition, resulting from excessive intake of specific nutrients. Und e r n u t ri t i o n is u s ua l l y a n o u t c o m e o f 3 f a c t o r s : household food supply, child-caring practices, and access to health and sanitation. More than 33% of deaths in 0-5 years are a ss o c i a te d w i t h m a l nu t r i t i o n .

3. T ERMINOLOGY Underweight C h r o n i c o r a c u te o r b o t h , WFA Z score<-2SD Stunting Linear Growth Retardation/ recurrent infections HFA Z score<-2 SD Wasting Re c e n t f a il u r e to r e c e i v e a d e qu a te nu t r i t i o n WFH Z score< -2 SD Severe Acute Malnutrition WFH Z score <-3 SD MUAC <115 cms Oedema V i s i b l e s e v e r e w a s t i n g M o d e r a te A c u te Malnutrition WFH Z score -3Sd to 2 SD MUAC 115-125 No oedema

4. A S S E S S M E NT O F P E M Weight for age - acute Height for age - chronic Weight for height – acute on chronic

5. MAC INTERPRETATION >13.5 NORMAL 12.5-13.5 MODERATE M A L N U T R I T ION <12.5 SEVERE M A L N U T R I T ION <11.5 S E V E RE W A S T I N G

6. FACTORS RESPONSIBLE FOR SAM Lack of exclusive breast feeding Late introduction of complementary feeds, Feeding diluted feeds containing less amount of nutrients, Repeated enteric and respiratory tract infections, Ignorance,and Poverty are some of the factors responsible for Severe Acute Malnutrition (SAM).

7. HOW TO IDENTIFY??? CRITERIA FOR IDENTIFYING SAM IN INFANTS >6 MONTHS OF AGE weight -for-height less than -3 SD and/or Visible severe wasting and/or Visible M UAC < 11.5 cm and/or bilateral pitting ede ma of both feet (Other causes like nephrotic syndrome to be ruled out) CRITERIA FOR IDENTIFYING SAM IN INFANTS <6 MONTHS OF AGE Infant too weak or feeble to suck effectively (independent of his/her wt for length ) OR w eight-for-height less than -3 SD (in infants >45 cm ) OR Visible severe wasting in infants <45 cm OR Presence of oedema of both feet .

8. APPETITE TEST FAIL PASS PHASE 1 TREATMENT PHASE 2 TREATMENT

9. APPETITE TEST FEED Roasted ground nut 1000gm Milk powder 1200 gms Sugar 1120 gms Coconut oil 600 gms PREPARATION Take roasted groundnuts and grind them in water Grind sugar separately or with roasted groundnut Mix groundnut , sugar,milk powder and coconut oil Store them in air tight container and in refrigerator Prepare only for one week to ensure quality of feed

10. How to do appetite test Do in a separate quiet area Explain mother how the test will be done The mother should wash her hands The mother sits comfortably with child on her lap and offers therapeutic food The child shouldnot have taken any food for last 2 hrs The test is usually take upto 1 hr The child must not be forced to take the food offered

11. Appetite test is fail if baby is not eating that much amount of EPD according to weight BW (Kg) EPD 3-3.9 4-6.9 7-7.9 8-9.9 10-11.9 12-14.9 BW(Kg) EPD 3-3.9 <15 gms 4-6.9 <20 gms 7-7.9 <25 gms 8-9.9 <30 gms 10-11.9 <35 gms 12-14.9 <40 gms

12. SAM COMPLICATED UNCOMPLICATED SEVERE EDEMA LOW APPETITE MEDICAL COMPLICATIONS ONE OR MORE DANDER SIGN AS PER IMNCI ALERT GOOD APPETITE NO MEDICAL COMPLICATIONS NO DANGER SIGNS

13. MEDICAL COMPLICATIONS Anorexia Fever (39 degree or more ) or temperature lessthan 35 degree Persistent vomiting Severe dehydration Not alert ,very weak ,apathetic , unconscious,convulsions Hypoglycemia Severe anemia Severe pneumonia Extensive superficial infections requiring im injections Any other clinical sign that a clinician thinks require admission for further assessment and care

14. REDUCTIVE ADAPTATION The systems of the body begin to “shut down’ with severe malnutrition to allow survival on limited calories. This slowing down is known as reductive adaptation. Reductive adaptation affects treatment by f o l l ow i n g w a y s : As the child’s intake is insufficient, fat stores and proteins are mobilized to provide energy. E n e r g y is c o n s e r v e d b y r e du c i n g p h y s ic a l a c t i v i t y , growth, BMR The usual signs of infection may not be apparent

15. Due to reductive adaptation, children make less haemoglobin. Children have ‘extra’ iron in the body even though they may appear anaemic. As the Na+/k+ pumps’ maintaining this balance become slower, potassium is lost from t h e b o d y w h i l e f l u id m a y a cc u m u l a t e o u t s i d e t h e cells.

16. SAM CHILD AT RISK FOR … Children with Severe Acute Malnutrition are at risk of death from: ™ H y p o g l y c a e m i a , a s t h e r e is l e s s s upp ly o f g l u c o s e and high demand for glucose ™ Hypothermia, as Basal Metabolic Rate is reduced. Fluid overload and cardiac failure due to changes in t h e f u n c t i o n i n g o f t h e k i d n ey s an d h e a r t ; an d I n f e ct i o n s , a s the b o d y ’ s i n f l a mm a t o r y a nd immune responses slow down.

17. CASE FATALITY RATE IN SAM CFR in SAM has been attributed to various factors related to the management and includes: Inability to distinguish between acute and rehabilitation phases Excessive use of intravenous (IV) fluids Fluid overload due to lack of monitoring during rehydration Use of diuretics (for oedema) and albumin Not keeping the child warm and euglycaemic (normal blood glucose levels) Low index of suspicion for infection Early use of diets high in protein, sodium, energy Failure to monitor food intake Early treatment of anaemia with oral iron

18. CLINICAL FEATURES HAIR -Lack of lustre -thinness and sparseness of hair -straightness -dyspigmentation -flag sign -easy pluckability

19. FLAG SIGN

20. FACE : -Diffuse depigmentation -Naso labial dyssebacia -Moon face E Y E S : -Pale conjunctiva -bitot’s spots -conjunctival xerosis -corneal xerosis -keratomalacia -angular palpebritis

21. LIPS : -Angular stomatitis -angular scars -Cheilosis TONGUE : -Oedema -Scarlet and raw Tongue -atrophic papillae

22. TEETH - mottled enamel GUMS – spongy bleeding gums GLANDS – thyroid and parotid enlargement SKIN – Xerosis f o l l ic u l a r k e r a t o s is petechiae pellagrous dermatosis flaky point dermatosis scrotal and vulval dermatoses NAILS - Koilonychia

23. SUBCUTANEOUS TISSUE : -Oedema -amount of subcutaneous tissue reduced MUSCULAR AND SKELETAL SYSTEMS : -muscle wasting -craniotabes -frontal and parietal bossing -epiphyseal enlargement -beading of ribs -wide open AF -knock knees or bow legs -diffuse or local skeletal deformities -deformities of thorax -musculo skeletal hemorrhages

24. GIT – hepatomegaly NERVOUS SYSTEM -psychomotor change -mental confusion -sensory loss -motor weakness -loss of position sense -loss of ankle and knee jerks

25. SPECTRUM OF PEM 1.KWARSHIORKAR : Prof cicely williams Grading : Grade 1 : pedal oedema Grade 2 : gr 1 + facial oedema G r ad e 3 : g r 2 + pa r a s p i n a l an d c h e s t e d e m a Grade 4 : gr 3 + ascites Triad of growth retardation , oedema and mental changes Other names – sugar baby, red boy, deposed child

26. C/F KWARSHIORKAR

27. 2 . M A R A S M U S : M e an s ‘w a s t i n g ’ in g r ee k E x t r e m e wa s t i n g an d h a v e a n o ld m a n app e a r an c e w i t h j u s t s k in an d b o n e s Grading -Grade 1: wasting often starts in axilla and groin - G r ad e 2 : wa s t i n g i nv o l v e s t h i g h an d bu t t o c k -Grade 3:f/b chest and abdomen - G r ad e 4 : B u cc a l pa d o f f a t l o s t

28. 3 . M A R A S M I C K W A R SH I O R K AR : Marasmic children with edema – marasmic kwarshiorkar Features of both often co exist

29. 4.PREKWARSHIORKAR : Affected children have features of kwarshiorkar like hair changes, moon faces and hepatomegaly but NO edema 5 . N U T R I T I O N AL D W A R F I N G : Evidence of stunting but no wasting Prolonged PEM over a long period without developing kwarshiorkar and marasmus BONSAI CHILDREN or POCKET EDITIONS M i c r o nu t r i e n t d e fici e n c i e s - c au s e

30. 6 . U N D E R WE IGHT : The child is malnourished and doesnot have any features of kwarshiorkar and marasmus Weight for height is 60-80% of the expected 7. INVISIBLE PEM : Breastfed toddlers are suspected Average moderately malnourised child in 6-24 m o n t h s l o o k s n o r m a l ( s o , p r eve n t i o n an d c u r e is also difficult) but too small for age, lowered resistance for infection. Use of growth charts is the best way to identify children with invisible PEM

31. 7. EARLY LACTATION FAILURE SYNDROME : E a rly l a c t a t i o n f a i l u r e , ab r u p t s t o ppa g e o f breast feeding and early introduction of dilute starch based liquid diet without any good quality protein result mostly in kwarshiorkar. It will result in different type of kwarshiorkar even with keratomalacia in very young infant

32. FEATURE MARASMUS KWARSHIORKAR APPEARANCE O L D M A N A PP E A RA N C E , S K IN A N D BONES, GENERALISED WASTING M OO N F A C E , D E P E N D E N T EDEMA,UPPER LIMBS WASTED AGE GROUP INFANTS 1-5YEARS PREVALENCE COMMON RARE WEIGHT <60% 60-80% GROWTH RETARDATION ++ + OEDEMA NIL ++ APATHY NIL/MILD ++ MOOD USUALLY ALERT IRRITABLE APPETITE GOOD POOR HAIR CHANGES NIL/MILD + SKIN CHANGES NIL/MILD + F A TT Y L I V E R ABSENT/MILD ++ INFECTIONS + ++ LIFE T HR E A TE N I N G M E D I C A L EMERGENCIES + ++

33. FEATURES MARASMUS KWARSHIORKAR S. PROTEIN & ALBUMIN LOW NORMAL V E RY L O W CARRIER PROTEINS LOW NORMAL V E RY L O W ANABOLISM + V E RY L O W CATABOLISM ++ + R E S P O N S E T O T R E A T M E N T GOOD POOR

34. PRINCIPLES OF TREATMENT EMERGENCY STABILIZATION REHABILITATION

35. 3 PHASES STABILISATION phase : first 2 days Aim is to repair cellular function Correct fluid and electrolyte imbalances Restore homeostasis Prevent death from interlinked triad hypoglycemia,hypothermia ,infection Diet given is starter diet Monitor overfeeding,over hydration TRANSISTION phase: 3 to 7 days To tolerate increase in energy ,protein intake Diet catchup diet same quantity as starter diet REHABILITATIVE phase :next 2weeks Aim is to restore wasted tissue Rapid weight gain Diet catchup diet

36. Emergency Signs Not breathing at all or gasping O b st r u c ted b r e a th i ng C e n t r a l c y a n o s i s Severe respiratory distress Shock : Cold hands and ‹‹ Capillary refill >3 seconds Weak and fast pulse Coma Convulsions Diarrhoea with severe dehydration: Any two signs: Lethargy ‹‹ Sunken eyes ‹‹ Very slow skin pinch

37. EMERGENCY MANAGEMENT Mana g e m e n t o f s h o c k : In SAM children shock from dehydration and sepsis often coexist Since severely malnourished children can qu ic k ly s u cc u m b t o fl u id o ve rl o ad , t h e y m u s t b e monitored closely.

38. H y p o gl y c e mia Defined as GRBS <54mg% lethargy, limpness, and loss of consciousness. Sweating and pallor may not occur in malnourished children with hypoglycaemia. C lini c al co ndi t i on treatment c h il d c a n d r i n k 50 ml 10% glucose orally child is alert but not drinking, give the 50 ml by NG tube. l et h a r g i c , un c o n s c i o u s , o r c o n v u l s i n g , g i v e 5 m l / k g b o d y w e i g h t o f s te r il e 10 % glucose by IV, followed by 50 ml of 10% glucose or sucrose by NG tube.* If the IV d o s e c a nn o t b e g i v en i mm e dia te l y , g i v e t h e NG dose first. Start feeding Starter diet half an hour after giving glucose and give it every half-hour during the first 2 hours. For a hypoglycaemic child, the amount to give every half-hour is ¼ of the 2- hourly amount.

39. Very severe anemia Hb less than 4 g/dL If very severe anemia (or Hb 4-6 g/dL AND respiratory distress): Stop all oral intake and IV fluids during the transfusion Look for signs of congestive heart failure Give 10 ml/kg of packed cells (in CCF) or whole fresh blood. Give Furosemide (1 mg/kg, given by IV) after starting BT.

40. Emergency eye care Corneal ulceration If corneal ulceration: Give vitamin A immediately I,e., days 1, 2 and 14 age <6 mo -50,000 IU 6-12 mo -100,000 IU >12 mo -200,000 IU Instill 1 drop atropine (1%) into affected eye to relax the eye and prevent the lens from pushing out. Give antibiotic eye ointment. Bandaging may be needed Chloramphenicol or tetracycline eye drops are given for eye infection or possible eye infection Oral – oil based IM – water based

41. TRANSITION

42. STEP 1: HYPOGLYCEMIA- PREVENTION : If child’s RBS is normal , feeding can be started with starter diet directly. The child should be fed every 2 hrs throughout day and night

43. STEP 2: HYPOTHERMIA Axillary <35C Rectal <35.5 C If the temperature is below 35 degree centigrade , ™ Ka n g a r o o t ec hniqu e Provide heat with an overhead warmer, an incandescent lamp or radiant heater. ™Monitor temperature every 30 minutes during rewarming if a radiant warmer is used I f t h e r e c t a l t e m pe r a t u r e < 32 º C, c h il d ha s s e v e r e h y po t he rm i a a n d s h o u l d be treated as follows: ™ Give warm humidified oxygen. ™ G iv e 5 m L / k g o f 10 % d e x t r o s e I V immediately or 50 mL of 10% dextrose by nasogastric route ™Start intravenous antibiotics. ™Rewarm: Avoid rapid rewarming as this may lead to dysequilibrium. ™ Give warm feeds immediately, Start maintenance IV fluids (prewarmed), if there is feed intolerance ™ R e hyd r ate u s in g w a r m fluid s immediately, when there is a history of diarrhoea or there is evidence of dehydration.

44. STEP 3: DEHYDRATION In children with SAM all the classical signs of dehydration are unreliable Therefore, the main diagnosis comes from the HISTORY rather than from the examination frequency quantity Every 30 minutes for the first 2 hours 5 ml/kg body weight A l te r n a te h o u r s f o r u p to 1 h o u r s 5 - 10 ml/kg* Signs to check ™ Respiratory rate- Count for a full minute. ™ Pulse rate- Count for 30 seconds and multiply by Urine frequency ™ St oo l o r v o m i t f r e q u e n c y ™ S i g n s o f h y d r a t i o n IV FLUIDS SHOULD BE AVOIDED EXCEPT IN SHOCK

45. Signs of improving hydration status L e ss t h i r sty Skin pinch not as slow Less lethargic Note: many severely malnourished children will not show these changes even when fully rehydrated . Signs of over hydration Increased respiratory rate(by 5) and pulse(by 15). Jugular veins engorged. Puffiness of eye. Stop ORS as soon as possible as the child has 3 or more of the following signs of improved hydration status : Child no longer thirsty L e s s l e t h a rg i c S l o w i n g o f r e s p i r a t o r y a n d pu l s e r a t e s f r o m p r e v i o u s h i g h r a t e Skin pinch less slow Tears

46. COMPOSITION OF RESOMAL FOR SAM CHILD : INGREDIENT AMOUNT WATER (BOILED AND COOLED) 2 l itres WHO-ORS O N E 1 L SACHET SU CROSE 50 g E L E C T RO L YT E / M I N E R A L S O L U T ION 40 ML

47. COMPOSITION OF ELECTROLYTE MINERAL SOLUTION : QUANTITY IN GMS MOLAR CONTENT OF 20 ML P O T A SSI U M CHLORIDE 224 24 MMOL T R I P O T A SSI U M CITRATE 81 2 MMOL M A G N E SI U M CHLORIDE 76 3 MMOL ZINC ACETATE 8.2 300 MICROMOL COPPER SULPHATE 1.4 30 M I C RO M O L W A TE R M A K E UP TO 2500 ML

48. C O N T I N U I N G DIARRHOEA FOR > 1 WEEK INFECTION OSMOTIC LACTOSE I N T O L E R A N C E GIARDIASIS AMOEBIASIS T R E A T W I T H M ET R O N I D A Z O LE LOW O S M O LARI T Y CEREAL BASED L O W LACTOSE AND FREE LACTOSE DIET S U S P E C T A N D T R E A T O T H E R A SSO C I A TE D C O N D I T IO N S L I K E U T I, P N E U M O N IA, HI V , FUNGAL INFECTIONS

49. STEP 4: CORRECT ELECTROLYTE IMBALANCE Potassium: 3-4 meq/kg/ day for at least 2 weeks. Magnesium: D a y 1 - 50 % m a g n e s i u m s u l p ha t e I M o n c e ( 0. 3 mL/kg) up to a maximum of 2 ml Thereafter, give extra magnesium (0.4 - 0.6 mm o l / k g /da i l y ) o r a l l y f o r 2 w ee k s . ™ Food without added salt

50. STEP: 5 PREVENT INFECTIONS All admitted cases with any complications o t h er t h a n s h o c k, m e n i n g i t i s o r d y s e n te r y I n j . A m p i c illi n 5 m g / k g / d o s e 6 h r l y a n d I n j . G e n t a m i c i n 7 . 5 m g / kg o n c e a d a y f o r 7 d a y s A d d I n j . C l o x a c il l i n 10 m g / k g d a y 6 hrly if staphylococcal infection is suspected For septic shock or worsening/no i m p r o v e m e n t i n i n i t ia l h o u r s I n j . C e f o t a x i m e 15 m g / k g / d a y i n 3 d i v i d e d doses or Ceftriaxone 100 mg/kg/day in 2 divided doses along with Inj Gentamicin 7.5 mg/kg in single dose. Meningitis IV Cefotaxime 50mg/kg/dose 6hrly or Inj Ceftriaxone 50 mg/kg 12 hrly plus Inj. A m i k a c i n 1 5 m g / k g / d a y d i v i d ed i n 8 h r l y doses. Dysentery Give Ciprofloxacin 15mg/kg in two divided d o s es p er d a y f o r 3 d a y s . If c h il d i s s i c k o r h a s al r e a d y r ece i v ed c i p r o f l o x a c i n , g i v e I n j . Ceftriaxone 100 mg/kg once a day or d i v i d ed i n 2 d o s es f o r 5 d a y s

51. STEP 6: MICRONUTRIENT DEFICIENCIES Given daily for at least 2 weeks: Multivitamin supplement (should contain vitamin A, C, D, E and B12 and not just vitamin B-complex): 2x RDA Folic acid: 5 mg on day 1, then 1 mg/day. Elemental Zinc: 2 mg/kg/day. Copper: 0.3 mg/kg/day Iron: Start daily iron supplementation after two days of the child being on Catch up diet at the dose of 3 mg/kg/day in two divided doses Do not give iron in stabilization phase

52. STEP 7: INITIAL FEEDING Starter Diet: 100 mL 75 Kcal 0.9 gm proteins Frequency of feed (Night feeds are important) Day 1: 2 nd hrly (if vomiting-feed twice as often) T he r e af t e r 3 r d a n d 4 t h h r ly Amount 130 mL/kg/day If edema: 100 mL/kg/day Feeding in diarrhea and vomiting <2yrs 50 mL of ORS >2yrs 100 mL of ORS

53. C o n t e n t s ( p e r 100 ml)) Starter diet Starter diet (Cereal based L a c t o s e f r e e di et F r e s h C o w ’ s m il k o r e qu i v a l e n t m il k 300 300 sugar 100 70 Cereal flour Powdered puffed rice 35 70 V e g et a b l e o i l ( m l ) 20 20 40 Water :to make upto (ml) 1000 1000 1000 Energy (kcal/100ml) 75 75 75 P r o te i n ( g / 10m l ) 0.9 1.1 1 Lactose (g/100ml) 1.2 1.2 -- Egg white (g) 50 Glucosr (g) 35

54. Nasogastric feeding : The minimum acceptable amount for the child to t a k e is 80 % o f t h e a m o un t o f f e r e d Use an NG tube if the child does not take 80% of the feed for 2 or 3 consecutive feeds Remove the NG tube when the child takes: 80% of the day’s amount orally; T w o c o n s e c u t i v e f ee d s f u l l y b y m o u t h .

55. R E H A B I LI T A T I O N P H A S E Feed with catchup diet (after 2-7 days) 10 m L c o n t ai n s 10 K c a l 2.9 gms of proteins Frequency-4 th hrly (6 feeds daily- 3 catchup +3 mixed) Amount Max 22 m l / k g / d ay M i n 15 m l / k g / d ay I f i n ta k e i s < 13 K c a l , c h il d f a i l s to re s p o n d Can introduce solid food for >24 months Kichdi, banana, curd rice, locally available diets Daily care Involving mothers in care

56. CATCH – UP DIET C O N T E N T S ( P E R 100 ML) CATCH UP DIET LOW LACTOSE CATCH UP DIET (EGG BASED) COW’S MILK OR TONED DAIRY MILK (ML) 750 250 SUGAR (G) 25 --- EGG WHITE (G) ---- 120 V E G E T A BL E O IL ( G ) 20 40 PUFFED RICE (G) 70 120 WATER TO MAKE (ML) 1000 --- E N E R G Y ( K C A L / 100 M L ) 100 100 PROTEIN (G/100ML) 2.9 2.9 LACTOSE (G/100ML) 3 1

57. STEP 8: CATCH UP PHASE Signs of readiness: usually after 2-7 days Return of appetite (easily finishes 4-hourly feeds of Starter diet). Reduced oedema or minimal oedema. The child may also smile at this stage Transition takes 3 days First 48hrs : give same quantity as f75 every 4 hours On 3 rd day : increase each feed by 10 ml as long as the child is finishing feeds. Maximum 30 ml/kg per feed If the transition is too rapid, heart failure can occur

58. T r an s i t i o n u s ua l l y t a k e s 3 d a y s . Af t e r t r an s i t i o n , t h e c h i l d is in t h e “ r e hab i l i t a t i o n ” pha s e Criteria for transfer to a rehabilitation care Eating well Responds to stimuli, interest in surroundings M i n i m a l o r N o o e d em a , N o na s o g a s t ric t ub e , I V i n f u s i o n s s t o pp e d Gaining Weight >5 gm/kg per day for 3 successive days.

59. DAILY CARE Sensory stimulation S t r u c tu r ed p l a y a c t i vi t i es Care of the skin Soap P o t a ss i u m p e r m a n g a n a t e ( d e r m a t o s i s ) N y s t a t i n ( d ia p er r a s h ) Care of the eyes- Vitamin A Recognize danger signs Anorexia Ch a n g e i n m e n t a l s t a t e Jaundice/cyanosis/difficulty in breathing Edema/petechiae/abdominal distension Large weight changes

60. STEP 9: PROVIDE LOVE AND CARING A c h ee rf u l s t i m u l a t i n g e n v i r o n m e n t A g e app r o p ri a t e s t r u c t u r e d p l a y t h e r ap y f o r atleast 15-30 minutes A g e app r o p ri a t e p h y s ic a l a c t i v i t y Tender loving and care

61. D I S C H A R G E C R I TE R I A C r i t e r i a f o r di s c h a r g e CHILD W t g a i n > 5 g m / k g / d a y x 3 d a y s Edema has resolved C h il d e a t i n g a d e qu a te a m o un t (120-130 kcal/kg/day ) Infections treated Micronutrient supplementation given I m m un i z a t i o n upd a ted A l b e nd a z o l e g i v en Return of social smile MOTHER Knows how to prepare appropriate diet, toys H o m e t r e a t m e n t f o r d i a rr h e a , f e v er a n d A RI F o ll o w u p p l a n i s c o m p l eted

62. CHILD DISCHARGED EARLY :WHAT TO DO ? Child can be discharged early if : Child >1yr,good appetite, weight gain, no edema ,antibiotic treatment completed, vit k ,minerals given for 2 weeks Mother available at home , motivated and trained to look after ,have resources,reside near hospital local health worker can provide support, trained, motivated MONITORING FEEDING AT HOME ESSENTIAL FEED FREQUENCY ATLEAST 5 TIMES A DAY MODIFY HOME FOOD TO SUIT F-100 HIGH ENERGY SNACKS BETWEEN MEALS GIVE ELECTROLYTES /MINERAL SOLUTION BREAST FEEDING SHOULD CONTINUE

63. STEP 10: FOLLOW UP 1 week after discharge 2 weeks for the next month Then monthly till child reaches -1 SD WHZ

64. MONITORING AND PROBLEM SOLVING PRIMARY FAILURE: Failure to gain apetite by D4 Failure to start losing edema by D4 Presence of edema on D10 F a il u r e t o g a in a t l e a s t 5 g / k g /d a y b y D 1 SECONDARY FAILURE F a i l u r e t o g a in 5 g / k g /d a y du ri n g r e hab i l i t a t i o n phase

65. INFANTS LESS THAN 6 MONTHS Any infant more than 49 cm* in length who has following features is treated as severe acute malnutrition: Weight-for-height less than - 3 SD; and /or Visible severe wasting; and/or Oedema of both feet. If <49 cms, severe wasting can be used as criteria Feeding: Feed the infant with appropriate milk feeds for initial recovery and metabolic stabilization. Wherever possible breastfeeding or expressed milk is preferred in place of Starter diet. If the production of breast milk is insufficient initially, combine expressed breast milk and non cereal starter therapeutic diet initially. For non breastfed babies, give Starter diet feed prepared without cereals.

66. P r o v i d e s upp o rt t o r e - e s t ab l ish b r e a s t f ee d i n g Give supplementary milk feeds if breast milk is not enough or if breastfeeding is not possible or in HIV positive mothers Gi v e g oo d d i e t an d m ic r o nu t ri e n t s s upp l e m e n t s t o the mother Ar t if i c i a l l y f e d i n f an t s s h o u ld b e g i v e n d i l u t e d Catch-up diet. [Catch-up diet diluted by one third extra water to make volume 135 ml in place of 100 ml] Discharge the infant from the facility when gaining weight for 5 days on breastfeeding alone and has no medical complications.

67. PREVENTION

68. CL IN IC A L F E A T U R E S : < 2 WEEKS : -increased weight gain, tachypnoea,features of cardiac failure, dilutional hyponatremia-s/o fluid overload -neuromuscular weakness like weakness pa r e s t h e s ia r e s p i r a t o ry m u s c le w e akn e s s du e t o electrolyte imbalance -abdominal distension, increasing liver size,ascites s/o fatty liver

69. >2 WEEKS : Prominent thoraco abdominal venous network H y p e r t ri c h o s is a f t e r 6 d a y s Parotid swelling Gynaecomastia E o s i n o ph ilia a f t e r 6 d a y s Splenomegaly CAUSE : Not clear. Probably due to excessive intake of high quality protein which increases various hormones produced by recovering pituitary gland

70. M I S T A K E S I N T R E A T M E N T Refeeding syndrome treat edema with a diuretic give a high-protein diet in the early phase of treatment. Treating SAM child like a normal child

71. THANK YOU