Title: SEVRE ACUTE MALNUTRITION (SAM)!!!

ITS ABOUT MALNUTRITION

1. 12/16/2017 1 SEMINAR PRESENTATION BY:- SUAD ABDULAHI PRESENTATION TITLE :- SEVERE ACUTE MALNUTRITION(SAM)

2. PRESENTATION OUTLINE 12/16/2017 2 Introduction Epidemiology Etiology Risk factors Pathogenesis Classification Clinical manifestations Sign and symptoms Diagnosis Complications Non-pharmacological management Pharmacological therapy Prevention Prognosis Monitoring and evaluation Patient education References

3. Terms/Acronyms 12/16/2017 3 F75 -Therapeutic milk used only in Phase 1 of treatment for SAM F100 -Therapeutic milk used in Transition Phase and Phase 2 of treatment of SAM (for inpatients only) IU -International Units MUAC- Mid Upper Arm Circumference OTP -Out-patient Therapeutic Programme (treatment of SAM at home) ReSoMal -Oral Rehydration Solution For Severely Malnourished Patients RUTF- Ready-to-Use Therapeutic Food SAM -Severe Acute Malnutrition (wasting and/or nutritional oedema ) SFP- Supplementary Feeding Programme TFU- Therapeutic Feeding Unit (in hospital, health centre or other facility) TFP- Therapeutic Feeding Programme

4. INTRODUCTION 12/16/2017 4 Malnutrition : over nutrition (obesity) and under nutrition Severe acute malnutrition- It is a clinical syndrome due to deficiency of mainly macronutrients(Protein & Energy) and micronutrients(Vitamins & Minerals). Bilateral pitting edema WFH < 70 % or MUAC < 11 cm SAM can be edematous or non edematous.

5. EPIDEMOLOGY 12/16/2017 5 Under nutrition is prevalent in developing countries: one-third to one-half of all children are stunted and 20-40% are underweight in most countries of eastern, central, and southern Africa. One out of ten children suffer from acute malnutrition . 54 % of the deaths in children under-five in developing countries are directly or indirectly attributable to malnutrition

6. … In Ethiopia, 51%, 47%, and 11% of under-five children are stunted, underweight and wasted respectively. Malnutrition is the major cause of child mortality and is responsible for 58 % of under-five mortality . The peak age for malnutrition is 12 to 24 months. In Ethiopia, 27% of under 5 children suffer from sub clinical vitamin A deficiency and 17% of childhood deaths are attributable to vitamin A deficiency . Anemia and iodine deficiency are also very common cause of morbidity and mortality

7. ETIOLOGY 12/16/2017 7 low birth weight maternal under nutrition deficiencies of specific nutrients (iodine, vitamin A, iron, zinc) diarrhea HIV infection and other infectious diseases chronic illness inadequate infant and child feeding practices time constraints limited household income limited agricultural production food insecurity, environmental degradation urbanization

8. RISK FACTOR Inadequate food intake & Disease House Hold food insecurity Care & social env’t (drought , war) poor access to health & the health env't . Formal & Informal Infrastructure Education Political Ideology & Resources chronically ill patients in neonatal or pediatric intensive care units

9. CONT….. patients with burns , HIV, cystic fibrosis, failure to thrive , chronic diarrhea syndromes , malignancies , bone marrow transplantation, inborn errors of metabolism

10. Pathogenesis Different proposed mechanisms : Protein-energy deficiency Adaptation Free radical theory ( imbalance between oxidants and antioxidants)

11. CLASSIFICATION 12/16/2017 11

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13. CLINICAL MANIFESTATIONS 12/16/2017 13 NON EDEMATUS  characterized by the wasting of muscle mass and the depletion of body fat stores. It is the most common form of PEM and is caused by inadequate intake of all nutrients, but especially dietary energy sources (total calories Physical examination findings include:  • Diminished weight and height for age  • Emaciated and weak appearance  • Bradycardia, hypotension, and hypothermia  • Thin, dry skin  • Redundant skin folds caused by loss of subcutaneous fat  • Thin, sparse hair that is easily plucked

14. NON EDAMATES Severe wasting

15. EDAMATES characterized by marked muscle atrophy with normal or increased body fat caused by inadequate protein intake in the presence of fair to good energy intake. Anorexia is almost universal. Physical examination findings include:  • Normal or nearly normal weight and height for age  • Anasarca  • Pitting edema in the lower extremities and periorbitally  • Rounded prominence of the cheeks ("moon-face")  • Pursed appearance of the mouth  

16. It is an acute illness. Bilateral edema is a sine qua non for diagnosis.It is pitting & ussually starts in the lower legs and later involves the other parts of the body & face. Large ascites is uncommon, if there consider other causes. Hair-is red or brown, straight, sparse, lusterluss , easily & painlessly pluckable . Face appears moon-shaped & puffy(jowls). The Skin-is hyper pigmented at first and then become dry and peels off leaving hypopigmented and sometimes ulcerated area. Flaky paint dermatosis -the skin appears like old paint flaking off the surface of the wood.

17. The lesions frequently occur on pressure areas like the buttock, flexure areas, behind the ear & legs. Hepatomegaly occurs in 1/3 of pts(fatty liver). Mood(Behavior)- They are miserable , disinterested to their environment when undisturbed and irritable when disturbed. They have loss of appetite.

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20. Wasting 12/16/2017 20 The severity of wasting is determined as a percentage of the expected weight for height for the population. The expected weight for height is determined by plotting the child's height on the 50th percentile line of the standard growth curve (usually reflecting the size of a younger child) to determine the child's height age and then finding the 50th percentile weight for that age. Severity is assigned as follows : •Less than 90 percent: First-degree (mild) acute malnutrition  •Less than 80 percent: Second-degree (moderate) acute malnutrition  •Less than 70 percent: Third-degree (severe) acute malnutrition.

21. Stunting 12/16/2017 21 The severity of stunting is determined as a percentage of the expected height for age . The measured height is divided by the expected height for age and multiplied by 100. Severity is assigned as follows  • Less than 95 percent: First-degree (mild) chronic malnutrition • Less than 90 percent: Second-degree (moderate) chronic malnutrition • Less than 85 percent: Third-degree (severe) chronic malnutrition

22. DIAGNOSIS 12/16/2017 22 Key diagnostic features of severe acute malnutrition are: Infants less than six months: -Weight –for- Length (W/L) less than 70% of NCHS median, OR Presence of pitting Oedema of both feet, OR Visible Severe Wasting if it is difficult to determine W/L Children 6 months to 5 years: Weight for Height (W/H) or Weight –for- Length (W/L) less than 70 % of NC

23. Diagnosis Anthropometrics The most practical and commonly used measurements are body weight, height, triceps skinfold (TSF), and midarm muscle circumference (MAMC ) MUAC classification severe moderate normal 6-11mth <11cm 11-12cm >12cm 12-59mth <11cm 11-13cm >13cm 5-9yr <13.5cm 13.5-14.5cm >14.5cm 10-14yr <16cm 16-18cm >18cm Adult <18cm 18-21cm >21cm

24. COMPLICATIONS 12/16/2017 24 Dehydration Hypovolemic shock Septic shock Absent bowel sounds, gastric dilatation and intestinal splash with abdominal distension Heart Failure Hypothermia Severe anemia Hypoglycemia K. Dermatosis

25. Hypoglycemia Blood glucose<3mmol/L(<54mg/dl) Important cause of death in 1 st 2days Hepatic energy production from galactose & fructose is much slower Gluconeogenesis is limited Serious infection/not fed in the last 4-6hr, vomited or too weak to fed or waiting for admission S/S include: hypothermia, limpness/drowsiness, lethargy, loss of conscousness , lid retraction

26. Heart Failure HF when? -usually starts after mgt of SAM-iv infusion/ORS/high Na diet, blood or plasma transfusion, severe anemia -deterioration with wt gain -RD with wt gain -Enlarged tender liver -Increase in RR-Fast breathing/RD -grunting, creptations , prominent superficial & neck veins -Triple rhythm, increase/appearance of edema -the 3 rd type of shock-Cardiac shock -Pneumonia is less likely in a child with RD after wt gain

27. Where shall we admit them?

28. Criteria for Inpatient/SC admission All SAM who have: Failed appetite test Edema and non edema +++ edema Medical complications like: Intractable vomiting, severe dehydration, hypothermia, high grade fever, fast breathing, chest in drawing, extensive skin lesions/infections, very weak unconsciou very pale bleeding tendency, any condition needing I NGT

29. TREATMENT 12/16/2017 29 GOAL OF THERAPY Treat life-threatening complications Rehabilitate with nutrition Achieve catch-up growth

30. NON-PHARMACOLOGICAL MANAGEMENT Other innervation can helps optimize the treatment of SAM like: encourage to play Insure well- beings Stimulant the child Physical activity

31. PHARMACOLOGICAL THERAPY The treatment includes 3 phases of treatment: -Phase 1 -Transition phase & - Phase 2 1) PHASE - I - includes Feeding, Routine medication, Prevent & treat complications and monotoring A)Feeding - Feed F-75 which has 75 kcal/100 ml. - It has less protein, energy & sodium - Amount- Give 100 kcal (130 ml)/kg/day or use the look up table -Feed 8 times daily using a cup

32. NG tube is indicated in: -Pneumonia with fast breathing -Painful oral lesions -Disturbances of consciousness -taking < 75% of the daily milk B) Routine Medications- - Vit.A – Give on days 1, 2 and 14 100,000 IU for children of age < 1 yr & 200,000IU for those > 1 yr of age - Folic asid - give 5 mg po single dose - Antibiotics- During Phase-1 + 4 days (in transition phase) -First line - Amoxicilline if there is no apparent infn . -Second line- Chloramphenicol or Gentamycin -If there are signs of infection or complication, give Ampicilline & Gentamycin or Penicillin & Gentamycin

33. - Measles vaccination- for older than 6 months & not vaccinated - Treat malaria –According to national guideline C) Prevent & Treat Complications: 1) Hypoglycemia- - Prevent it by frequent feeding & keeping the temprature to normal. -If conscious – give 50 ml 10% sugar water( 5gm or 1 tsp of sugar in 100 ml of water) or F-75 by mouth. -If unconscious or convulsing, 5 ml/kg of 10% glucose IV or give sugar water by NG tube -Start second line antibiotics 2) Hypothermia (T< 35.5) -Environmental temprature must be monitored & kept b/n 28-32 degree celcius -Don’t wash a severely malnourished child

34. Cont… Treatment of hypothermia: -Warm with Gangaroo mathod for young infants -Put a hat on the child & wrap the mother and the child together -Feed frequently - Treat for hypoglycemia & start second line antibiotics -Monitor temprature every 30 minutes -Give hot drinks to the mother to warm her skin 3) Dehydration - - The treatment is different from normal children - Rehydrate as much as possible orally -IV infusions are almost never used unless clearly indicated ( i,e severe dehydration or septic shock) - ReSoMal , rather than standard ORS, is prefered b/c it has low sodium & osmolality and high potassium. -Rehydration should be slowly over 12 hours.

35. Cont… -Before treatment take Wt, PR, RR, Liver size. -Feed during rehydration -Monitor closely (every 1 hour)for both under & over hydration. -If the child has recent sunkening of the eyes or eager to drink and conscious, give ReSoMal 5 ml/kg every 30 minutes for the first 2 hours PO or through NG tube and then 5-10 ml/kg/hr for 10 hrs. -If the child is unconscious, start IV infusion to give RL or halve NS with 5% DW, add 20 mmol Kcl /L - Rate of infusion- 15 ml/kg over 1 hr and reassess. If improving give 15 ml/kg the next 1 hr -If the child regains his conscioussness or PR drops, continue the rest of the rehydration with 10 ml/kg/hr of ReSoMal . -Monitor Wt, PR, RR, Liver size & heart sound(gallop rhythm).

36. Cont… 4) CHF -Treatment-Stop all Po intakes and IV fluids -Give small amount of sugar water - Furosemide 1-2 mg/kg stat -Give a very small dose of digoxine (5 mic . Gm /kg ) -Do not transfuse even though anemic, treatment of heart failure takes precedence 5) Anemia -If Hgb < 4 gm% or Hct < 12% and with in 48 hrs of admission, transfuse with 10 ml/kg of packed cell vollume or whole blood over 3 hrs and give furosemide 1 mg/kg stat. -If Hgb is > or= 4 gm% or Hct > or= 12% or any level of Hct 2-14 days after admission, give iron during phase II

37. Phase I cont… D) Monitoring: - Temprature towice daily -Wt, Edema, diarrhea, vomiting, signs of dehydration, PR, RR & liver size daily

38. 2)TRANSITION PHASE Progress to transition phase: -If the edema starts to decrease -The appetite returns & -No NGT, infusion & severe medical problems - For Marasmic children, if the pt tolerates the diet for 2 days, the appetite returns & no NGT, infusion and severe medical problems Mgt in transition phase- - Is the same as Phase I (the Feeding, routine medications & Monitoring) except F-100 is given instead of F-75. - The same volume is given as F-75 so that the energy intake increased by 30% and the child starts to gain tissue without causing fluid- overload or CHF.

39. Cont… Indication to return to phase I: - Increasing edema -Rate of Wt gain > 10 gm/kg/day which is a sign of fluid retention -Any sign of fluid overload, heart failure, or resp. distress -Tense abdominal distention -Development of complications that require IV drugs or rehydration therapy or poor appetite - Refeeding diarrhea that result in Wt. loss

40. 3)PHASE II Also called phase of recovery Criteria to enter this phase(all should be fulfilled): -Good appetite -At least 2 days for wasted( marasmic ) pts -When the edema disappears (for edematous pts) -No other medical problems Protocol – Feed, Routine medication & Monitor A) Feed -It is the period of catch up growth so they need high protein & calorie diet -Feed F-100 five times a day based on the Wt, refer thart for the amount -Additionally, give porridge if the childs wt is > 8 kg

41. Phase II, cont… B) Routine Medications: -Start ferrous sulphate - Deworming -with mebendazole or albendazole -Give the 3 rd dose of vit . A at day 14. C) Monitor: -Weight 3 time/week - Temprature daily - Diarrhea, vomiting, dehydration, cough, PR, RR daily -Degree of edema every 2 weeks Good response – Wt. gain > 10 gm/kg/day Return to Phase I if there is any sign of morbidity

42. Discharge Criteria The child is discharged if he/she fulfills the following criteria: -Wt/Ht > or = 85% -No edema for the last 10 days -Complications are adequately treated -Health education completed -Immunization Up to date.

43. Feeding and NGT use 44 Indications for NGT use Taking <75% of prescribed milk in 24h in phase one Pneumonia with rapid RR/Respiratory distress Cleft palate or other oral deformities Painful mouth lesions Unconscious or lethargic child Use NGT only in Phase I and for max 3 days, try oral feeding at every feeding

44. Criteria to move from Phase I to transition phase or Stabilization Center(SC) /TFU Exit criteria 45 Return of appetite Edema reduced Clinically well No NGT or IV line If there is an OTP these children are transferred to OTP

45. Move the child back to Phase 1 46 If the patient gains weight more rapidly than 10g/kg/d increasing or new onset oedema rapid increase in the size of the liver significant re-feeding diarrhoea and weight loss. If patient develops medical complication If Naso-Gastric Tube is needed Patient taking less than 75% of the feeds in Transition Phase.

46. CRITERIA TO PROGRESS FROM TRANSITION PHASE TO PHASE 2 47 A good appetite, taking at least 90% of the RUTF or F100 prescribed for Transition Phase. Oedematous patients (kwashiorkor) should remain in Transition Phase until there is a definite and steady reduction in oedema (now at + level). Inpatients should remain in Transition Phase until they have lost their oedema entirely. Out -patients can go when their appetite is good (taking all the diet in Transition Phase - not just in the moderate range) and they have reduced their oedema to ++ or +.

47. MOVE BACK FROM PHASE 2 TO PHASE 1 48 Failure of the appetite test Increase/development of oedema Development of refeeding diarrhoea sufficient to lead to weight loss. Fulfilling any of the criteria of “failure to respond to treatment” Weight loss for 2 consecutive weighing Weight loss of more than 5% of body weight at any visit. Static weight for 3 consecutive weighing Major illness or death of the main caretaker so that the substitute caretaker requests inpatient care

48. PREVENTION 12/16/2017 49 food insecurity and under nutrition arise from a variety of social, economic, and ecologic situations that vary from time to time and from place to place.

49. PROGNOSIS 12/16/2017 50

50. MONITORING AND EVALUATION 12/16/2017 51

51. Monitoring -Wt each day -Degree of oedema (0 to +++)each day -Body T 2x/day -Stool, vomiting ,dehydration, cough, RR, liver size each day -MUAC every wk -Ht after 21 days

52. MONITORING AND EVALUATION 12/16/2017 53

53. PATIENT EDUCATION 12/16/2017 54   Parents should receive education regarding the causes of malnutrition and its prevention . Breast feeding is a particularly important and practical measure to prevent malnutrition, so all mothers should be educated to breast feed future infants whenever possible. Parents should also be given education about an appropriate diet and sanitary feeding techniques, strategies to stimulate the child's mental and emotional development, and other parenting skills.

54. PATIENT EDUCATION 12/16/2017 55 The mother should spend as much time as possible at the nutrition rehabilitation center with her child, and should provide care, including food preparation, for her child under supervision. She should be taught how to treat, or obtain treatment for, diarrhea and other infections, and to understand the importance of regular treatment for intestinal parasites.

55. REFERENCES 12/16/2017 56 Nelson textbook of pediatrics 19 th edition. Ethiopian Standard treatment guidelines for General hospital of 2014 Up to date 22.1 Ethiopia guideline for SAM Pediatric and child health lecture note for health sciences student in jimma Dipiro 9 th edition.

56. Thank You for Being Patient Till the End