Severe Acute Malnutrition PDF

# Severe Acute Malnutrition ## Criteria for SAM - One or more of the following: - weight for length/height z-score < (-3) [severe wasting] - < 11.5 cm: SAM - 11.5-12.4 cm: MAM - 12.5-13.5 cm: mild - > 13.5 cm: - MUAC < 11.5 cm - presence of bilateral pi...

# Severe Acute Malnutrition ## Criteria for SAM - One or more of the following: - weight for length/height z-score < (-3) [severe wasting] - < 11.5 cm: SAM - 11.5-12.4 cm: MAM - 12.5-13.5 cm: mild - > 13.5 cm: - MUAC < 11.5 cm - presence of bilateral pitting edema ## MAM - weight for length/height z-score between -2 and -3 [wasting] - MUAC = 11.5 - 12.4 cm - if a child has MAM but also edema, they are classified as SAM ## Pathophysiology and Adaptation - Malnutrition affects every organ system. - It results in metabolic and physiological changes. - Functional capacity of heart, liver, kidney, and GIT are all ↓ in physical and metabolic activity. ## Cellular Function and Circulation - ↑ in total body water as a % of body weight - ↓ disappearance of fat stores + washing of muscle and tissue - Edema - ↓ serum albumin - electrolyte imbalance - To conserve K, the number of Na-K pumps in the cell membrane are ↓. - The remaining pumps work more slowly. - Na accumulates inside the cell while K leaks out to the extracellular space → unnecessary. - ↑ total body Na⁺ and total body K⁺ & plasma K⁺. - During treatment, Na-K pumps are stimulated - so a large amount of Na leaves cells and K enters → so circulating blood volume ↑ and Hb & ↓ distribution. - If edema is corrected too fast - danger of pumps exporting Na faster from the intracellular compartment than the kidney can excrete. ## Acute exacerbated by interstitial deficit. - When corrected with IV fluid, blood transfusion → fluid shifts from interstitial to intravascular space. - Risk of acute heart failure and sudden death. - ↑ cortisol and activation ADH contribute to edema. - Edema aggravated by hypoalbuminemia (↓ oncotic P of plasma), ↓ CO and ↓ LGFR ## Cardiovascular System - Cardiac myofibrils ↓ contractility → CO and Stroke volume are ↓ in proportion to weight loss. - It also contributes to ↓ Hb & K (hypokalemia) - Severely affected → Bradycardia and hypotension. - Edematous → fragile fluid balance. ## Liver - Hepatic glucose stores are depleted + gluconeogenesis is impaired. - Lipoprotein synthesis is impaired → limited ability to mobilize fat - fatty infiltration. (triglyceride accumulation) - It disappears at 3 weeks. - Synthesis of albumin is low (other synthetic functions preserved) - Metabolism and excretion of toxins → severely compromised. ## Genito-urinary System - GFR ↓ (excess) - Capacity of kidneys to excrete Na⁺, excess fluid or a water load ↓. - UTI - common ## Gastrointestinal Tract - Atrophy of bowel mucosa - villous atrophy ↓ disaccharide enzymes (esp. lactase) - Production of membrane nutrient transporters is ↓. - Intestinal permeability is ↑. - Pancreatic enzyme secretion ↓ + ↓ pancreatic amophy - Results in malabsorption. - Secrenon of gastric acid ↓. - Intestinal munlity + intestinal bacterial overgrowth. - Diarrhoea – common, serious, fatal - Enteric infx's with pathogens - Bacterial overgrowth in upper small bowel - Abn. of digestion and absorption 2° to atrophic bowel mucosa. ## Endocrine System - Glucose levels ↑. - Hormonal response - ↑ in insulin and insuline-life-GF and an ↓ in glucagon. - Glycogen converted to glucose → gluconeogenesis is stimulated. - May develop glucose intolerance → at risk for hypoglycemia during infx and refeeding. - Cortisol + GH ↑ → induces consumption of limited glycogen stores and fatty acids. - ↓ hypoalbuminemia → ↓ binding of cortisol → higher unbound content in plasma → contributes to abn. glucose tolerance... and moon face - Evidence of thyroid hormone def (but↑) ## Metabolism - BMR ↓ 30% - Heat generation + Heat loss impairment - Hot → hyperthermic, cold → hypothermic. ## Immune System - Atrophy of lymph glands, tonsils, and thymus → cellular immunity affected. - Loss of delayed hypersensitivity, impaired phagocytosis (2° ↓ complement and IgA). - Prevalence && severity of infx – greater - compromising nutrition = anorexia, ↓ nutrient absorption, ↑ metabolic demands. - False-ve Tuberculin test (≠ assess for TB) - ↓ reduced acute phase immune response - typical signs of infx - leucocytosis + fever → absent. ## Haematological - Low red cell count → anemia - Normocytic normochromic - Hypochromic micro/macrocytic - Anemia of undernutrition – may be due to iron def, ↓ red cell prod, / erythropoietin def, / vitamin def, & other trace element. - Blood clotting is preserved. ## Neurological System - Behavioral changes → irritability, apathy, decreased social responsiveness, and attention deficits. - Severe malnutrition → ↓ in number of neurons, synapses, & myelination → result of ↓ brain size. - Degree of delay depends on severity of nutritional compromise and the age it occurs. - At younger age → worse outcomes. ## Skin, Muscles, and Glands - Skeletal muscle is lost. - An, pyruvate, and lactate are used for gluconeogenesis. - Later, fat is mobilized → lipolysis and ketogenesis. - Skin & subcutaneous fat → atrophied (loose skin folds) - Signs of dehydration are unreliable - Assessment of skin turgor - Sunken eyes (loss of subcutaneous fat at orbit) - Dryness of mouth (atrophy of salivary glands) - Resp muscles → easily fatigued. ## Management - Children w/ SAM and associated poor prognostic signs (IMCI danger signs) → treat in hospital*. ### Poor Prognostic Signs 1. Lethargy 2. Refusal to feed/anorexia 3. Convulsions 4. Vomiting all feeds 5. Jaundice 6. Respiratory Distress 7. Shock 8. Hypothermia 9. Hypoglycemia 10. Dehydration. 11. Weeping skin lesions 12. Bleeding ### General Guidelines - Priority to SAM pts- fed every 2-3 hours a day and night - Avoid IV infusions - Atrophic muscle – risk of heart failure, ↓ Hb - High intracellular Na - Electrolyte imbalance - * Only indication is SAM w/ shock - # Excrete excess Na⁺ - Dermatosis - Leave skin open to dry during the day. - Wash with antibacterial solution and cover with sterile dressing. - Barrier creams - raw areas. - Rx for malnutrition = 2 phases - Stabilization and rehabilitation separated by transition phase. - Follow-up after discharge. ## Principles of Treatment ### Phase I (Stabilize) - Goal: stabilize child, allow them to return to homeostasis. - Given enough et protein to meet basic needs. - Sufficient to halt catabolic processes, but avoids stress to vital organs (eg intestine, kidney, and liver – still in a state of reductive adaptation) - Adaptation to undernutrition to maintain vital functions, slowing down cell growth and differentiation, to mobilize rate. - 3-5 days - Life-threatening complications are treated. - Hypoglycemia - Hypothermia - Infections - Severe dehydration - Severe anemia - Correction of electrolyte imbalance and micronutrient deficiencies are initiated, BUT iron supplementation is delayed. ### Transition phase - Amount of food ↑ over 4-5 days as correction of metabolic disturbances leads to a return of appetite. ### Phase II (Rehab / Catch up growth) - Few days: metabolic systems more functional. - Safe to give high energy, high protein diet to allow catch-up growth. - 120-140% of estimated KJ requirement. - 2-6 weeks - Child in stimulated emotionally and physically – mum trained to continue care. - At home: follow-up phase – monitor growth and development of child. ## WHO 10 Steps 1. **Treat / Prevent Hypoglycemia (Blood glucose < 3 mmol/L)** - Risk for hypoglycemia due to impaired liver gluconeogenesis and ↓ glycogen reserves. - Feed immediately - small frequent feeds day and night. - Mild asymptomatic hypoglycemia: Rx with 10% dextrose (1 mL/kg) orally - Symptomatic hypoglycemia: Rx with IV 10% dextrose bolus (5mL/kg) 2. **Treat / Prevent Hypothermia (Rectal/Oral T°< 35.5°C & axillary < 35°C)** - Heat production and distribution & metabolic rate ↓. - Heat loss ↑ due to less insulation. - Loss of body fat. - Infections and skin lesions are at risk. 3. **Treat / Prevent Dehydration** - May be falsely assessed. - All children with frequent, watery diarrhoea are assumed to have dehydration - provide ORS. - History: recent sunken eyes; no urine passed for 12 hours; history of dehydration/thirst → when circulatory collapse is severe enough, to cause lethargy, unconsciousness → cold hands & feet; weak or absent radial pulses. - If shock: Ringer's Lactate with 5% dextrose @ 15 mL/kg within an hour. 4. **Correct Electrolyte Imbalances** - Excess body Na⁺; def. of K⁺ a Mg. - Edema → Never treat with diuretics (high Na loads – kill child) 5. **Treat Infection** - Broad spectrum antibiotics on admission. - Oral antibiotics (amoxicillin): uncomplicated cases. - IV ampicillin and gentamycin: ill/lethargic or complications (hypoglycemia; hypothermia; weeping skin lesions; respiratory/UTIs) - Acyclovir: evidence of oral herpes - Hypothermia: sign of septic shock - Established septic shock: superficial veins - dilated (scalp, text, jug). 6. **Correct Micronutrient Deficiencies** - Everyday nutritional rehab → vitamin A, multivitamin supplement; folic acid, zinc and copper (combined mineral vitamin solution) - Single dose on admission: Vitamin A: - < 6m: 50, 000 IU - 6-12m: 100, 000 IU - > 12m: 200, 000 IU - Single dose folic acid (2.5mg) - Give iron only rehab phase – less transferrin to bind iron and free iron promotes growth of pathogens & oxidative damage to cell membranes. - Hb < 4 g/dL/ 4-6 g/dL with respiratory distress: blood transfusion. - Packed red cells 5 mL/kg over 3 hours (slowly) + Furosemide 1 mg/kg. - Blood transfusions after first 48 hours → heart failure. 7. **Start Cautious Feeding** - F-75: Starter - lower fat and protein (avoid refeeding syndrome) - 75 kcal (315 kJ), 0.9 g protein / 100 mL. - Children with edema, recover physiologically. - Spoon, syringe, nasogastric. 8. ** Achieve Catch-up Growth** - F-100: milk based (Rehab phase) - 100 kcal (420 kJ), 2.9 g protein / 100 mL. - Signalled by return of appetite (usually 1 week after admission). 9. **Provide Sensory Stimulation and Emotional Support** - Delayed mental and behavioral development. - Supply adequate diet - improve physical growth. - Not mental. - Provide tender, loving, child-oriented care. → Play and exercise. - 10. **Prepare for Discharge and Follow-up After Recovery** - Discharge only when: - No edema - Good appetite - Good weight gain - No infection. - Playful and alert child. - Follow-up to prevent relapse. - Good feeding practices at home - Ensure immunizations + Vit A are done - Catch up to at least z-score -2 (WFA).