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Questions and Answers
Which z-score indicates severe acute malnutrition (SAM) due to weight for length/height?
Which z-score indicates severe acute malnutrition (SAM) due to weight for length/height?
What is the maximum MUAC measurement indicative of moderate acute malnutrition (MAM)?
What is the maximum MUAC measurement indicative of moderate acute malnutrition (MAM)?
Which of the following is a potential consequence of correcting edema too rapidly?
Which of the following is a potential consequence of correcting edema too rapidly?
What physiological change occurs in the cardiovascular system due to severe malnutrition?
What physiological change occurs in the cardiovascular system due to severe malnutrition?
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Which condition characterizes severe acute malnutrition (SAM) aside from low z-scores?
Which condition characterizes severe acute malnutrition (SAM) aside from low z-scores?
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What is a common metabolic effect of malnutrition on the liver?
What is a common metabolic effect of malnutrition on the liver?
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What happens to total body water percentage in individuals suffering from malnutrition?
What happens to total body water percentage in individuals suffering from malnutrition?
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Which imbalance is observed in patients experiencing severe edema due to malnutrition?
Which imbalance is observed in patients experiencing severe edema due to malnutrition?
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What is one of the common signs of dehydration in malnourished children?
What is one of the common signs of dehydration in malnourished children?
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Which condition is NOT considered a poor prognostic sign in children with severe acute malnutrition (SAM)?
Which condition is NOT considered a poor prognostic sign in children with severe acute malnutrition (SAM)?
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What is the first phase in the management of severe acute malnutrition?
What is the first phase in the management of severe acute malnutrition?
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During the stabilization phase of treatment for a child with SAM, which condition is addressed first?
During the stabilization phase of treatment for a child with SAM, which condition is addressed first?
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What dietary strategy is recommended during the rehabilitation phase for children recovering from SAM?
What dietary strategy is recommended during the rehabilitation phase for children recovering from SAM?
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What is the maximum duration for the transition phase in SAM management?
What is the maximum duration for the transition phase in SAM management?
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Which of the following is a critical element of the follow-up care after discharge for a child recovering from SAM?
Which of the following is a critical element of the follow-up care after discharge for a child recovering from SAM?
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What management practice should be avoided in cases of SAM?
What management practice should be avoided in cases of SAM?
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Which of the following conditions is likely to occur due to atrophy of the bowel mucosa?
Which of the following conditions is likely to occur due to atrophy of the bowel mucosa?
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What characterizes the immune response in severe malnutrition?
What characterizes the immune response in severe malnutrition?
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Which hormonal change can lead to glucose intolerance during infection and refeeding?
Which hormonal change can lead to glucose intolerance during infection and refeeding?
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What type of anemia may result from undernutrition?
What type of anemia may result from undernutrition?
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Which of the following is a consequence of elevated glucose levels in malnutrition?
Which of the following is a consequence of elevated glucose levels in malnutrition?
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What neurological changes may result from severe malnutrition?
What neurological changes may result from severe malnutrition?
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What effect does malnutrition have on body temperature regulation?
What effect does malnutrition have on body temperature regulation?
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What happens to the capacity of kidneys in the case of excess fluid in malnutrition?
What happens to the capacity of kidneys in the case of excess fluid in malnutrition?
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What is the recommended treatment for mild asymptomatic hypoglycemia?
What is the recommended treatment for mild asymptomatic hypoglycemia?
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Which condition indicates the need for administration of Ringer's Lactate with 5% dextrose?
Which condition indicates the need for administration of Ringer's Lactate with 5% dextrose?
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What is a significant risk factor for hypothermia in children?
What is a significant risk factor for hypothermia in children?
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Which of the following micronutrient deficiencies is specifically treated with a single dose during admission?
Which of the following micronutrient deficiencies is specifically treated with a single dose during admission?
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What is NOT recommended for treating excess body sodium in children?
What is NOT recommended for treating excess body sodium in children?
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What form of antibiotic treatment is recommended for ill or lethargic patients with complications?
What form of antibiotic treatment is recommended for ill or lethargic patients with complications?
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At what age is a child recommended to receive a single dose of Vitamin A of 200,000 IU?
At what age is a child recommended to receive a single dose of Vitamin A of 200,000 IU?
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What is the caloric and protein content of F-75, the starter formula for cautious feeding?
What is the caloric and protein content of F-75, the starter formula for cautious feeding?
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Study Notes
Criteria for SAM
- Severe acute malnutrition (SAM) is defined by one or more of the following:
- Weight for length/height z-score < -3 (severe wasting).
- If the mid-upper arm circumference (MUAC) is < 11.5 cm, the child is categorized as SAM.
- If the MUAC is 11.5-12.4 cm, the child is categorized as moderate acute malnutrition (MAM).
- MUAC < 11.5 cm.
- Presence of bilateral pitting edema.
- Weight for length/height z-score < -3 (severe wasting).
MAM
- MAM is characterized by a weight for length/height z-score between -2 and -3 (wasting).
- The MUAC is between 11.5 and 12.4 cm.
- Children with MAM who also have edema are classified as SAM.
Pathophysiology and Adaptation
- Malnutrition affects all organ systems, leading to metabolic and physiological changes.
- The functional capacity of the heart, liver, kidneys, and gastrointestinal tract is decreased.
Cellular Function and Circulation
- Malnutrition increases total body water as a percentage of body weight.
- Fat stores are depleted, and muscle and tissue are wasted.
- Edema occurs due to a decrease in serum albumin and electrolyte imbalances.
- To conserve potassium, the number of sodium-potassium pumps in the cell membrane decreases, reducing pump function.
- Sodium accumulates inside cells while potassium leaks out, leading to a higher total body sodium and potassium and plasma potassium.
- During treatment, sodium-potassium pumps are stimulated, causing sodium to leave cells and potassium to enter. This increases circulating blood volume and hemoglobin, but also decreases potassium levels.
Cardiovascular System
- Reduced contractility of cardiac myofibrils decreases cardiac output and stroke volume in proportion to weight loss.
- This contributes to decreased blood hemoglobin and potassium levels (hypokalemia).
- Severe malnutrition can lead to bradycardia and hypotension.
- Edema contributes to a fragile fluid balance.
Liver
- Hepatic glucose stores are depleted, and gluconeogenesis is impaired.
- Lipoprotein synthesis is impaired, limiting the ability to mobilize fat and leading to fatty infiltration (triglyceride accumulation).
- Albumin synthesis is low but other hepatic synthetic functions are preserved.
- Liver metabolism and excretion of toxins are severely compromised.
Genito-Urinary System
- Glomerular filtration rate (GFR) is decreased.
- The kidneys’ capacity to excrete sodium, excess fluid, and water load is reduced.
- Urinary tract infections are common in malnourished children.
Gastrointestinal Tract
- The bowel mucosa experiences atrophy, leading to villous atrophy and a decrease in disaccharidase enzymes.
- Production of membrane nutrient transporters is reduced, and intestinal permeability is increased.
- Pancreatic enzyme secretion and pancreatic amylase levels are decreased.
- Malabsorption results.
- Gastric acid secretion is decreased, along with gut motility and increased bacterial overgrowth.
- Diarrhoea is common, and can be serious or fatal.
Endocrine System
- Glucose levels are elevated in malnourished children.
- Hormonal responses include an increase in insulin and insulin-like growth factor and a decrease in glucagon.
- Conversion of glycogen to glucose and stimulation of gluconeogenesis occurs.
- Children may develop glucose intolerance and be at risk for hypoglycemia during infection and refeeding.
- Cortisol and growth hormone levels are elevated, contributing to the consumption of limited glycogen stores and fatty acids.
- Hypoalbuminemia leads to decreased cortisol binding, resulting in higher unbound cortisol in plasma and contributing to abnormal glucose tolerance.
- There is evidence of thyroid hormone deficiency, but output is increased.
Metabolism
- Basal metabolic rate is decreased by 30%.
- Heat generation and heat loss are impaired.
Immune System
- Atrophy of lymph glands, tonsils, and the thymus affects cellular immunity.
- Delayed hypersensitivity is decreased, and phagocytosis is impaired due to reduced complement and immunoglobulin A levels.
- The prevalence and severity of infections are increased.
- Malnourished children experience anorexia, decreased nutrient absorption, and increased metabolic demands.
- The tuberculin test is often false-negative (not reliable for assessing Tuberculosis).
- The acute phase immune response is reduced, so typical signs of infection, such as leukocytosis and fever, may be absent.
Haematological
- Anemia is common, and may be normocytic normochromic, hypochromic microcytic, or hypochromic macrocytic.
- Anemia associated with undernutrition can result from iron deficiency, reduced red cell production, erythropoietin deficiency, vitamin deficiencies, and other trace element deficiencies.
- Blood clotting is preserved.
Neurological System
- Behavioral changes include irritability, apathy, decreased social responsiveness, and attention deficits.
- Severe malnutrition can lead to a decrease in the number of neurons, synapses, and myelination, resulting in a smaller brain size.
- The degree of developmental delay depends on the severity of nutritional compromise and the age at which it occurs.
- Children who experience malnutrition at a younger age have worse outcomes.
Skin, Muscles, and Glands
- Skeletal muscle is lost.
- Alanine, pyruvate, and lactate are used for gluconeogenesis.
- Fat is mobilized later, leading to lipolysis and ketogenesis.
- The skin and subcutaneous fat are atrophied (loose skin folds).
- Signs of dehydration are unreliable.
- Respiratory muscles are easily fatigued.
Management
- Children with SAM and associated poor prognostic signs (IMCI danger signs) should be treated in a hospital.
Poor Prognostic Signs
- Lethargy
- Refusal to feed/anorexia
- Convulsions
- Vomiting all feeds
- Jaundice
- Respiratory distress
- Shock
- Hypothermia
- Hypoglycemia
- Dehydration
- Weeping skin lesions
- Bleeding
General Guidelines
- Priority should be given to SAM patients.
- Infants and children with SAM should be fed every 2-3 hours throughout the day and night.
- IV infusions should be avoided.
- The only indication for IV fluids is SAM with shock.
- Dermatosis should be managed by leaving skin open to dry during the day, washing with antibacterial solution, covering with sterile dressing, applying barrier creams to raw areas.
- Treatment for malnutrition is divided into two phases: stabilization and rehabilitation.
- A transition phase occurs between the two phases.
- Follow-up is required after discharge.
Principles of Treatment
Phase I (Stabilize)
- The goal of this phase is to stabilize the child and allow them to return to homeostasis.
- Children are given enough energy and protein to meet basic needs.
- This is sufficient to halt catabolic processes, but avoids stress to vital organs.
- This phase lasts for 3-5 days.
- Life-threatening complications are treated immediately.
- Electrolyte imbalances and micronutrient deficiencies are corrected, but iron supplementation is delayed.
Transition Phase
- The amount of food is increased over 4-5 days as the correction of metabolic disturbances leads to a return of appetite.
Phase II (Rehab / Catch-up Growth)
- This phase begins after a few days, when metabolic systems are more functional.
- Children are given a high-energy, high-protein diet to allow catch-up growth.
- The diet provides 120-140% of the estimated kilocalorie requirement.
- This phase lasts for 2-6 weeks.
- Children are emotionally and physically stimulated.
- Mothers are trained to continue care at home.
- Follow-up monitoring of growth and development is required after discharge.
WHO 10 Steps
-
Treat/Prevent Hypoglycemia (Blood Glucose < 3 mmol/L)
- Risk for hypoglycemia is due to impaired liver gluconeogenesis and decreased glycogen reserves.
- Immediate, small, frequent feeds are given day and night.
- Mild asymptomatic hypoglycemia is treated with oral 10% dextrose (1 mL/kg).
- Symptomatic hypoglycemia is treated with an IV 10% dextrose bolus (5 mL/kg).
-
Treat/Prevent Hypothermia (Rectal/Oral Temperature < 35.5˚C & Axillary < 35˚C)
- Heat production, distribution, and metabolic rate decrease.
- Heat loss increases due to less insulation and loss of body fat.
- Children with infections and weeping skin lesions are at higher risk.
-
Treat/Prevent Dehydration
- Dehydration may be falsely assessed.
- Oral rehydration solution (ORS) is provided for all children with frequent, watery diarrhea.
- Children with a recent history of sunken eyes, no urine passed for 12 hours, or a history of dehydration/thirst are assumed to have dehydration.
- If shock is present, Ringer’s Lactate with 5% dextrose (15 mL/kg) is administered within an hour.
-
Correct Electrolyte Imbalances
- Excess body sodium and deficiencies of potassium and magnesium are common.
- Edema is NOT treated with diuretics, as they can lead to higher sodium loads and kill the child.
-
Treat Infection
- Broad-spectrum antibiotics are administered on admission.
- Oral antibiotics (amoxicillin) are used for uncomplicated cases.
- IV ampicillin and gentamycin are used for ill/lethargic children or those with complications (hypoglycemia, hypothermia, weeping skin lesions, respiratory/UTIs).
- Acyclovir is used for oral herpes infection.
- Hypothermia is a sign of septic shock.
- Established septic shock can result in superficial veins becoming dilated (scalp, chest, jugular).
-
Correct Micronutrient Deficiencies
- Vitamin A, a multivitamin supplement, folic acid, zinc, and copper (combined mineral vitamin solution) are provided daily during nutritional rehabilitation.
- A single dose of vitamin A on admission is administered.
- Iron supplementation is only given during the rehabilitation phase, as less transferrin is available to bind iron, and free iron can promote the growth of pathogens and oxidative damage to cell membranes.
- Blood transfusions (packed red cells 5 mL/kg over 3 hours) are administered to children with hemoglobin levels <4 g/dL or 4-6 g/dL who have respiratory distress and are given furosemide 1 mg/kg.
- Blood transfusions are avoided after the first 48 hours of hospitalization to prevent heart failure.
-
Start Cautious Feeding
- F-75 is used as a starter, as it is lower in fat and protein to avoid refeeding syndrome.
- This formula includes 75 kcal (315 kJ) and 0.9 g protein per 100 mL.
- Children with edema recover physiologically.
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