1

Management of Protein Energy malnutrition

(Global Acute Malnutrition)

Melese.S(B.Pharm,Msc ,Ass.Professor )
Jimma University
Institute of Health
Faculty of Public Health, Nutrition & Dietetics Department
April 20,2021Melese.S 10/23/2023
 2
Objectives
 Be able to explain the underlying causes of acute malnutrition
 To understand basics about undernutrition: definition, causes and
consequences
 To know how to perform anthropometric measurements – identify
MAM and SAM children / PLW
 To know and understand the management of acute malnutrition
 Be able to explain the etiology of edematous malnutrition(SAM)

 Outline the treatment modalities

 Identify the complications

 Compare and contrast the center based treatment and CMAM

 Discuss the challenges of Center based management and CMAM

Melese.S 10/23/2023
 Nutrition
Nutritional status: balance
physiological state of an individual, which results from:
the relationship between nutrient intake and requirements, and
the body’s ability to digest, absorb and use these nutrients.

NUTRITIONAL FOOD INTAKE

REQUIREMENTS

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 Nutritional Status: not well balanced diet

NUTRITIONAL
REQUIREMENTS

FOOD INTAKE

Over-nutrition Obesity
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 Nutritional Status: not well balanced diet

FOOD INTAKE

NUTRITIONAL
REQUIREMENTS

Under-nutrition
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 Non-balanced nutrition can be caused by :

• Sufficient quantity but insufficient quality of food

(lack of diversified food)

• Sufficient quality but insufficient quantity of food

(lack of intake)

• Insufficient quantity and quality of food

(lack of intake and diversified food)
MALNUTRITION : Term for bad nutritional status
Definition: situation when the body does not receive the sufficient quantity
and/or quality of nutrients.
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 Food intake

• Food intake depends on different factors:

– Availability of the food

• For example: food available in the market

– Accessibility of the food

• For example: cost of the food in the market

• Possible influences??
– Harvest, price, soil, culture/beliefs, etc
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 The tree of malnutrition
Malnutrition
unbalanced nutritional status

Over nutrition Micronutrient deficiency

Under-nutrition

overweight

Chronic malnutrition Under-weight Acute malnutrition

OBESITY stunting wasting

Installed status
MALNUTRITION
 Incorrect definition: Malnutrition= acute
undernutrition
MAM SAM
 Correct definition: Mal + nutrition= “bad nutrition” Episodic status

ACF: Focus on Acute malnutrition ++

23/10/2023
 Consequences of malnutrition
• Short term consequences
– Mortality, morbidity, disability

• Long term consequences

– Intellectual capacity
– Economic productivity
– Reproductive performance
– Diseases
– Future psychological well being
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 Consequences and risks of malnutrition...

Lowered resistance to disease

Even not dangerous disease becomes dangerous

Increased risk of mortality

Learning difficulties

Reduced physical activity

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 Acute Malnutrition

• Acute Malnutrition = DISEASE

• Acute malnutrition
– Sudden deprivation / Short-term process
– Sudden weight loss
– More vulnerable population : Children 6-59
months and PLW
– Consequences if no treatment : DEATH

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 Under-nutrition : Causes
Malnutrition & mortality Manifestations

Immediate
Insufficient food Impairs growth
Diseases Causes
intake and development

Inadequate child
Poor acces, Underlying
Poor acces, availability and
availability and
care practices and
quality of health
Causes
psychological
quality of food services, unhealthy
environment
environment

Basic causes
Quantity, quality, and control of true resources within society
(human, economic, institutional)

Potential resources
23 octobre 2023 12
 Classification of Acute malnutrition

2 classifications according to gravity:

• Moderate Acute Malnutrition (MAM)

– Lost of weight is started
– Precede severe acute malnutrition if not treated

• Severe Acute Malnutrition (SAM)

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 Severe Acute malnutrition

3 forms
MARASMIC-
MARASMUS KWASHIORKOR KWASHIORKOR
Severely wasted Bilateral Oedema Both

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 Marasmus
• Skinny: underweight
• Old man’s face, Sunken eyes
• Irritability
• Subcutaneous fat and muscles loss
• Distended abdomen
• Impression of too much skin at the buttock
• Hungry

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 Kwashiorkor
• Nutritional bilateral oedema
• Skin lesions
• Lethargy
• Moon face
• Depigmentation: skin and hair
• Anaemia
• No appetite

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 Marasmic-kwashiorkor

Combination of
• Weight loss

AND

• Nutritional bilateral oedema

• Skinny arms and swollen feet

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 Different types of severe acute malnutrition

Marasmus Marasmus- Kwashiorkor

kwashiorkor
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 Acute Malnutrition
19

 Medical & social disorder

 End result of chronic nutritional &

emotional deprivation

 Management requires medical & social

interventions
Melese.S 10/23/2023
 Conceptual framework for causes of Malnutrition
20

Functional Consequences: Mortality, Consequences

Morbidity, Lost Productivity, etc.

Manifestations
Nutritional Status

Immediate
Diet Health Causes

Household Environ. Health, Underlying

Care of Mother
Food Security Hygiene & Sanitation Causes
and Child

Human, Economic, and

Institutional Resources

Political and Ideological Structure Root

Ecological Conditions Causes
Adapted from Melese.S 10/23/2023
Potential Resources
UNICEF
21 Acute malnutrition ?
 How can we measure it ??

Melese.S 10/23/2023
 Anthropometric measurement
Anthropometry is human body measurement:
nutritional status of a person is estimated by the
measure of some corporeal parameters.

In addition to the clinical picture, malnutrition

diagnosis will be confirmed by anthropometric
measurements. That’s why they need to be
taken properly and be accurate

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 Diagnosis of malnutrition
Types of Under-Nutrition Diagnostic tools

Acute Malnutrition (wasting) Weight, height, bilateral

(Marasmus oedema, MUAC, age, sex
Kwashiorkor)
Chronic malnutrition Height, age, sex
(Stunting)

Underweight Weight, age, sex

Micronutrient deficiencies… Hemoglobin level, paillor, night
vision reduction, gingival
bleeding, goiter, …

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 Anthropometric measurements
What is necessary to do a good
anthropometric
measurement?

• Good measurement
equipment
• Standardized measurement
procedure
• Well trained personnel
• …

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 MUAC Measurement

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 MUAC measurement
MUAC : Mid Upper Arm circumference

CHILDREN >6 months

 On the left folded arm, between

shoulder bone and tip of the elbow

 Put the tape to the length of the

folded arm,

 Mark midpoint

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 MUAC measurement
 Left arm is unfolded and
relaxed;

 Tape is wrapped aroune the

arm,at the midpoint, neither
too tighten or too loose/slack.
Do not lean fingers on the tape
or the arm

 Read the measure between

the arrows of 1mm for precise

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 How check oedema ?
Observe the depression on both
feet = pit

If it is the case => check the legs,

then hands, then face

Have a light pressure for 3

seconds on the top of the feet
at the same time

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 Oedema
• Graduation of oedema according severity:
– Grade 1+ : Bilateral pitting oedema of the feet

– Grade 2+(or ++) :Bilateral oedema of the feet and

lower limbs / hands

– Grade 3+(or +++) : Generalised oedema of feet,

lower limbs, hands and periorbital

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 Bilateral oedema
• Immune and inflammatory fonctions are severly
affected for kwashiorkor children, in such a way
that cutaneous lesions aren’t painful for them.

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 Height measurement
• For all children < 87cm

• Child straight along the

scale, chin raised and
feet down flat on the
cursor
• Read the measure on
the cursor level of
1mm for precise

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 Height measurement
Correct position

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 Height measurement
Ideal position

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 Standing height measurement

 For all children > 87cm

 Child straight along the

scale, joint feet
 Straight head, maintain the
chin
 Arms along the body
 Read the measure on the
cursor level of 1mm for
precise

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 Standing height measurement

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 Weight measurement
• SALTER scale
• Tare the scale before each
weighing, with the empty basin or
pants (the needle need to be in
front of the 0)
• Put the child in the pants
• Calm down the child if needed
• Place yourself in front of the scale,
your eyes at the same level as the
needles
• Read the weight indicated, of 100g
for precise

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Measures of Malnutrition
Development Contexts
Stunting Underweight
(Chronic) (Both) Wasting (Acute)

Index Height for Age Weight for Weight for Height

Age or MUAC

Moderate < -2 to -3 SD < -2 to -3 SD < -2 to -3 SD

Severe < - 3 SD < - 3SD < - 3SD

37
Measures of Undernutrition Moderate
Acute
Emergency Contexts Malnutrition
(MAM)

Stunting Underweigh
(Chronic) t Wasting (Acute)
(Both)
Index H/A W/A W/H
Moderate < -2 to -3 SD < -2 to -3 SD < -2 to -3 SD

Severe < - 3 SD < - 3SD < - 3SD

Severe Acute
Malnutrition
38
(SAM)
Nutrition Emergencies
Benchmarks and Emergency
Threshold
(moderate +
Thresholds severe)

Severity Prevalence of Acute

Malnutrition

Acceptable <5%

Poor 5–9%

Serious 10 – 14 %

Critical > = 15 %

WHO, Management of Malnutrition in Major Emergencies, 2000

39
 How identify malnourished children?
• Using combination of indexes : Index = difference
between the value of the measured parameter and
the reference value (mean or median) in the
international standards

• 2 indexes:
– MUAC index
– W/H index

– + oedema
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 Weight for Height
• Emaciated child has a lower weight than a « standard » child,
who has the same Height and Sex.
• Weight for Height (W/H) measure the child’s corpulence .
• Weight gain is sensitive to the actual situation.
• So W/H reflects a recent situation.
• It is a reliable and admitted.
• Doesnt require age estimation
• It is used for show recent food or health situation.

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 W/H reference table
• Exercice
Boys' weight (kg) Length Girls' weight (kg)
-4 Z -3 Z -2 Z -1 Z Median (cm) Median -1 Z -2 Z -3 Z -4 Z

1.7 1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9 1.7

1.8 2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0 1.9

2.0 2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2 2.0

2.1 2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3 2.1

2.2 2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4 2.2

2.4 2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6 2.4

2.5 2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8 2.5

2.7 2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9 2.7

2.9 3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1 2.8

3.1 3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3 3.0

3.3 3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5 3.2

3.5 3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7 3.4

Weight for Height Reference Card (WHO, 2006)

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 Identification of malnourished children 6-59 months

Classification of acute malnutrition in children 6-59

months based on anthropometry
Criteria
Age
Moderate Acute Malnutrition
Severe Acute Malnutrition (SAM)
(MAM)

 MUAC: less than 12.5 to  MUAC less than 11.5cm

11.5 cm OR
OR  W/H less than -3Z scores
 W/H less than -2Z to -3Z OR
scores  Bilateral oedema is present (+,
6 to 59 months AND ++ or +++)
 Oedema is absent

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Identification of malnourished children less than 6 months or < 4Kg

Criteria for referral of infants aged less than 6 months

to inpatient SAM treatment
Criteria
Age
Moderate Acute Malnutrition Severe Acute Malnutrition

 MUAC: Do not use

 MUAC: Do not use  WFH/L: Less than -3Z scores
 WFH/L: Less than -2Z to -3Z or
scores*  Bilateral pedal oedema
and  Visible severe wasting
 Oedema is absent
* Assess WFH/L if infant is more
than 45cm
* Assess WFH/L if infant is more than
Less than 6 months 45cm

 Infant is too weak to suckle effectively

 Infant is not gaining weight despite breastfeeding counselling
 Visible severe wasting

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Identification of malnourished PLW
Category Criteria

Pregnant women
 From the 2nd Trimester

Lactating Women MUAC < 23cm

 Breastfeeding infant aged less than 6
months

Eligibility criteria for identification of malnourished

PLW is only MUAC

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 IMAM Implementation

• IMAM = Integrated Management of Acute

Malnutrition
• Integrated to BPHS (and EPHS at provincial level)
• Target children 0-59 months and PLW
• 2 levels
– Community
Community Health Facility
– Health
- Active
Facility
screening and referral
- Sensitization
- Passive screening / orientation
- Treatment / Follow-up
- Follow-up (home visits) - Sensitization

CHWs CHS Health staffs

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 IMAM Implementation : COMMUNITY
Goals of community outreach
1. Maximize coverage and access
2. Maximize the timeliness of treatment
3. Maximize compliance with treatment

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 IMAM Implementation : COMMUNITY

• Focal point in community : CHWs

• Main activities:
– Active case finding => screening (house to house /
massive screening) : MUAC and Oedema
– Early Referral => referral slip
– Sensitization / health education => to raise knowledge
about malnutrition and its treatment (prevention ++)
– Follow-up => home visits (Beneficiaries, absentees,
defaulters..) : increase the impact and sustainability of
nutrition activities
23 octobre 2023 48
 ACTIVE CASE FINDINGS/SCREENING and EARLY
REFERRAL

COMMUNITY LEVEL
MUAC measurement and
verification of edema

IF MAM TREATMENT IF NO MAM TREATMENT

MUAC >= 12.5 cm
& MUAC < 12.5cm MUAC < 11.5cm
No oedema and / or and/ or
Bilateral oedemas Bilateral oedemas

Reference to the health centre for

confirmation of MUAC and oedema and
possibly having the weight and height taken
23 octobre 2023 49
 IT IS ALSO…
• The HOME VISITS for the high-risk cases
Non-response/ absents/ defaulters of the program…
• AWARENESS SESSIONS/SENSITIZATION/HEALTH
EDUCATION
Nutrition, health, hygiene promotion...

23 octobre 2023 © ACF, Christina Lionnet - Tchad 50

 IMAM : HEALTH FACILITY
1. Reception of referral from community : check again
anthropometric measurements to confirm diagnosis
2. Passive screening : each child from 0-59 months and PLW
(from 2nd trimester of pregnancy to 6 months of
breastfeeding)
3. Orientation : MAM/SAM identified => orientation to the
right service (OPD-MAM / OPD-SAM / IPD-SAM)
4. Treatment and follow-up : nutritional product and
systematic medical treatment, follow-up of nutritional
status (referral if needed)
Transversal => Sensitization-Counseling nutrition / health
23 octobre 2023
topics
51
 In HF where treatment is available
PASSIVE
SCREENING All the children who
fit the criteria for
All children 0-59m
acute malnutrition APPETITE
TEST

TREATMENT
ORIENTATION
&
TO THE Depending on:
FOLLOW-UP - Anthropo measures
RIGHT
- Appetite result
SERVICE - Clinical result
(OPD-MAM/SAM CLINICAL
or IPD-SAM) EXAM

23 octobre 2023 52
 Appetite test
For each child identified as acutely malnourished (MAM/SAM)
Aim:
• To see if the child is able to eat sufficient quantity of
nutritional product to recover
• The loss of appetite in a child with acute malnutrition may
indicate a serious pathophysiology

• Appetite test:
– Part of the initial diagnosis
– At every follow-up visit
23 octobre 2023 53
 Complications associated to acute
malnutrition (during clinical exam)
Clinical complication Criteria
High fever Greater than 39 C (102.2 F)
Hypothermia Less than 35.5 C (96 F)
Persistent vomiting Vomits all food and fluids
Severe dehydration Clinical signs + recent history of fluid loss
Severe anaemia Severe palmar pallor
Unconscious / convulsing Reduced level of consciousness / lethargy / fitting

2 to 12 months => Greater than 50 breaths / min

Difficult or fast breathing
12 to 59 months => Greater than 40 breaths / min

Skin lesions Extensive skin ulceration requiring IV / IM antibiotics

+ any other diseases that need to be treated at the hospital (inpatient)

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 Etiology of Severe edematous
malnutrition(Kwashiorkor)
57

1. Theory of Low Protein Intake

 Low protein intake, which leads to hypo-albuminemia, which in
turn leads to edema.
2. Theory of Dys-adaptation
Edema is determined not only by diet but also by intrinsic
differences among children with regard to their protein
requirement or hormonal response. Hence, kwashiorkor develops
in children that poorly adapted and Marasmus develops in
children that are well adapted to the states of lower nutrient
intake.
3. Theory of Aflatoxins
 Hendricks reported from a study in Sudan that children with
Aflatoxins developed edema compared to those with no aflatoxin
intake. Melese.S 10/23/2023
 AFLATOXIN POISONING
Noxae

D Low protein diet  growth stops  Stunting

I
Very low protein  Anorexia  Marasmus
E
T Insufficient diet  weight loss   wasting
Kwashiorkar (marasmic
kwashiorkar)
 FREE RADICAL THEORY
• Free oxygen radicals potentially toxic to cell membrane
and are produced during various infections
• These oxides are normally buffered by proteins and
neutralised by antioxidants such as Vit.A, C & E and
selenium
• In malnourished child deficiency of these nutrients in
the presence of infection or aflatoxin may result in the
accumulation of toxic – free oxygen radicals
• These may damage liver cells giving rise to Kwashiorkor
FREE RADICAL THEORY OF KWASHIORKOR
Noxae

Inadequate
protective Free Radicals
pathway

Fe Catalyzed

Malnutrition
Macro molecular damage

Inadequate Repair

Fatty Liver
 4. Free Radical theory of etiology of PEM
61

Melese.S 10/23/2023
 Measures of Undernutrition Case Fatality
of 50% to
60%
62 Severe Acute Malnutrition
Case Fatality
of 20% to 30%

Marasmus (gross Kwashiorker

wasting) (oedema)
Melese.S 10/23/2023
 3 Phases of Management
63

 INITIAL TREATMENT
 Life threatening problems identified & treated
 Specific deficiencies/metabolic abnormities corrected
 Feeding begun
 REHABILITATION
 Intensive feeding
 Emotional & physical stimulation
 Mother trained
 FOLLOW-UP
 Prevention of relapse
 Assure continued development Melese.S 10/23/2023
64
Treatment Facilities
 Initial treatment & beginning of rehabilitation
 SAM with complication (anorexia, infection, dehydration)
 Residential care in special nutrition unit(Hospital)
 SC

 SAM without complications, has appetite, gaining

weight, stable
 Nutritional rehabilitation center:
 CTC/OTP(Health center/HP)

Melese.S 10/23/2023
 Evaluation of malnourished child
65

 Nutritional status
 WFH, HFA, edema
 Moderate (-3<SD<-2) or severe (<3SD)
 History
 Physical Examination

 Lab tests

Melese.S 10/23/2023
66

Melese.S 10/23/2023
GENERAL PRINCIPLES FOR ROUTINE CARE

• These steps are accomplished in two phases:

• an initial stabilization phase where the acute
medical conditions are managed; and
• a longer rehabilitation phase.

• Note that treatment procedures are similar for

marasmus & kwashiorkor.
THE 10 STEPS
GENERAL PRINCIPLES FOR ROUTINE CARE
There are ten essential steps(the ‘10 Steps’)
1.Treat/prevent hypoglycemia
2.Treat/prevent hypothermia
3.Treat/prevent dehydration
4.Correct electrolyte imbalance
5.Treat/prevent infection
6.Correct micronutrient deficiencies
7.Start cautious feeding
8.Achieve catch-up growth
9.Provide sensory stimulation and emotional support
10. Prepare for follow-up after recovery

These steps are accomplished in two phases:

# an initial stabilisation phase where the acute medical conditions are managed
# longer rehabilitation phase
Note that treatment procedures are similar for marasmus and kwashiorkor
69 Melese.S 10/23/2023
 Time frame for management
70

Melese.S 10/23/2023
STEP 1. TREAT/PREVENT HYPOGLYCAEMIA

• Blood sugar level <54 mg/dl or 3 mmol/L

• Assume hypoglycemia when levels cannot be
determined.

• CONSCIOUS CHILD- 50 ml bolus of 10% glucose by

nasogastric (NG) tube.

• UNCONSCIOUS CHILD, lethargic or convulsing -IV

sterile 10% glucose (5ml/kg), followed by 50ml of 10%
glucose or sucrose by NG tube.
• Start two-hourly feeds, day and night
STEP 2. TREAT/PREVENT HYPOTHERMIA
• If axillary temperature <35oC, take rectal
temperature
• If the rectal temperature is <35.5oC (<95.9oF):
• rewarm the child: either clothe cover with
warmed blanket & place a heater or lamp nearby or
put the child on the mother’s bare chest (skin to
skin) and cover them – Kangaroo mother care
• feed straightaway
STEP 3.TREAT/PREVENT DEHYDRATION

• Difficult to estimate dehydration using

clinical signs alone
• Assume all children with watery diarrhea
may have dehydration
• Do not use the IV route for rehydration
except in cases of shock
• Continue feeding
 ASSESSMENT OF DEHYDRATION IN
SEVERELY MALNOURISHED CHILDREN
Basic format remains the same
Some signs unreliable
• Mental state
• Mouth, tongue and tears
• Skin turgor

Edema and hypovolemia can coexist

 DIAGNOSIS OF DEHYDRATION IN
SEVERELY MALNOURISHED CHILDREN
• History of diarrhea ( with large volume of stools)
• Increased thirst
• Recent sunken eyes
• Prolonged CFT, weak/absent radial pulse, decreased or
absent urine flow
Difficult using clinical signs alone
Best to assume that all with watery diarrhea have some
dehydration
Treat with ORS unless shock is present
 REHYDRATION SOLUTION FOR
MALNUTRITION (ReSoMal)

OLD WHO WHO Low ReSoMal

ORS osmolarity
ORS
Sodium 90 75 45
Potassium 20 20 40
Glucose 111 75 125
 WHICH ORS SHOULD BE USED IN SEVERE
MALNUTRITION?

OPTIONS
• Low osmolarity ORS with potassium supplements
• ReSoMal (not available in India)
IAP endorses the use of LOW OSMOLARITY WHO
ORS for all types of diarrhea and nutritional status for
logistics and programmatic advantages.
 STEP 4. CORRECT ELECTROLYTE
IMBALANCE
• Plasma sodium may be low though body sodium
is usually high. Sodium supplementation may
increase mortality.
• Potassium & Magnesium are usually deficient
and needs supplementation;may take at least
two weeks to correct.
• Edema if present is partly due to these
imbalances. Do NOT treat edema with a diuretic
 STEP 5. TREAT/PREVENT INFECTION
• Usual signs of infection, such as fever, are often
absent. Give broad spectrum antibiotics to all.
• Hypoglycemia/hypothermia usually coexistent with
infection. Hence if either is present assume infection
is present as well
• No complications - Co-trimoxazole
• Severely ill - Ampicillin + Gentamicin
• If the child fails to improve clinically within 48 hours,
add: cefotaxime/ceftrioxone
 STATUS ANTIBIOTICS
Infected child or  IV AMPICILLIN 50 mg/kg/dose q 6hrly and IV
complications* GENTAMICIN 2.5 mg/kg/dose q 8hrly
present  Add IV CLOXACILLIN 100 mg/kg/day q 6hrly if
staphylococcal infection is suspected.
 Revise therapy based on the culture sensitivity report
For septic shock or  Add third generation cephalosporins i.e. IV
No improvement or CEFOTAXIME 100 mg/kg/day q 8hrly
worsening in initial
48 hours
Meningitis  IV Cefotaxime 200mg/kg/day IV q 6hrly with IV amikacin 15
mg/kg/day q 8hrly
Dysentery  CIPROFLOXACIN 30mg/kg/day in 2 divided doses.
 IV ceftriaxone 50mg/kg/day in od or q 12 hourly if child is sick
or has already received nalidixic acid
 STEP 6. CORRECT MICRONUTRIENT
DEFICIENCIES
• All severely malnourished children have
vitamin and mineral deficiencies
• Vitamin A orally on Day 1
• Give daily :
Multivitamin supplement
Folic acid 1 mg/d (give 5 mg on Day 1)
Zinc 2 mg/kg/d
Iron 3 mg/kg/d after first week
 COMPOSITION OF ELECTROLYTE ­MINERAL
SOLUTION FOR SEVERELY MALNOURISHED
CHILDREN
Ingredient Mass (g) mmol per 20
ml
Potassium chloride (KCl) 224 24
Tripotassium citrate 81 2
Magnesium chloride (MgCl2.6H20) 76 3
Zinc acetate (Zn accetate.2H20) 8.2 0.3
Copper sulphate (CuSO4.5H20) 1.4 0.045

• To be added to diet or oral rehydration salts solution.

• Add 20 ml of the solution to a litre of diet or oral rehydration salts.
However, appropriate Vitamin mineral mix is not available in India.
In this scenario, one may use combinations of various
commercial preparations available
 STEP 7. START CAUTIOUS FEEDING
• Small, frequent feeds
• Oral or nasogastric (NG) feeds (never parenteral
preparations)
• Milk-based formulas such as starter F-75 containing 75
kcal/100 ml and 0.9 g protein/100 ml will be
satisfactory for most children
• 130 ml/kg/d of fluid (100 ml/kg/d if the child has
severe edema)
• If the child is breastfed, encourage to continue
breastfeeding
 STEP 7. START CAUTIOUS FEEDING
• A gradual transition is recommended to avoid
the risk of HEART FAILURE.
• Monitor during the transition for signs of heart
failure
– If respirations increase by 5 or more breaths/min &
– pulse by 25 or more beats/min for two successive 4-
hourly readings, reduce the volume per feed
STEP 8. ACHIEVE CATCH-UP GROWTH
• Readiness to enter the rehabilitation phase is
signaled by a RETURN OF APPETITE, usually
about one week after admission
• Recommended milk-based F-100 contains 100
kcal & 2.9 g protein/100 ml
• In rehabilitation phase vigorous approach to
feeding is required to achieve very high intakes
& rapid weight gain of >10 g gain/kg/d
TO CHANGE FROM STARTER TO CATCH
- UP FORMULA
• Replace starter F-75 with the same amount of
catch-up formula F-100 for 48 hours then,
• Increase each successive feed by 10 ml until
some feed remains uneaten.
• The point when some remains unconsumed is
likely to occur when intakes reach about 30
ml/kg/feed (200 ml/kg/d)
RECIPES FOR STARTER AND CATCH-UP
FORMULAS
 STEP 9. PROVIDE SENSORY STIMULATION
AND EMOTIONAL SUPPORT
• Delayed mental and behavioral development is
present
• Provide:
 Tender loving care
 Cheerful, stimulating environment
 Structured play therapy 15-30 min/d
 Physical activity as soon as the child is well enough
 Maternal involvement when possible (e.g.
Comforting, feeding, bathing, play)
STEP 10. PREPARE FOR FOLLOW-UP AFTER
RECOVERY
• A child who is 90% weight-for-length (equivalent to -
1SD) can be considered to have recovered
• Show parent or caregiver how to:
 Feed frequently with energy - and nutrient-dense foods
 Give structured play therapy
• Advise parent or caregiver to:
 Bring child back for regular follow-up checks
 Ensure booster immunizations are given
 Ensure vitamin A is given every six months
90
Initial Treatment
 Hypoglycemia  Dehydration
 Cause death first days  Reliable signs
 Sign of infection, treat  Diarrhea, thirst, eyes, weak pulse
 Sign of infrequent feedings  Unreliable signs
 50ml D10%, F75 PO/NGT  MS, mouth/tongue/ tears/skin
 Never use bottles elasticity
 Hypothermia  ReSoMal: 70-100ml/kg/12h
 Kangaroo
 Breastfeed, F-75
 Warm  Septic shock
 Treat for hypoglycemia  ATB broad spectrum
 Sign of infection, treat  Treat hypoGly, hypothermia
 CHF,Melese.S
anemia 10/23/2023
 Initial Treatment
91
 Infections  Vitamin deficiencies
 ↓ fever, inflammation  Folic acid
 Measles vaccine  Vit mix: riboflavin, ascorbic acid,
 1st line, all children pyridoxine, thiamine, fat soluble vit D, E,
 Cotrimoxazole K
 Complications: ampicili+ gentamycin  Vit A PO or IM
 2nd line, > 48 hr antibiotic  Eye pads NS solution
 + chloramphenicol  Tetracycline + atropine eye drops
 Malaria, candidiasis  Severe Anemia
 Helminthiasis  Transfusion
 TB  No Iron at this stage
 Dermatosis Kwashiorkor  CHF
 1% K permanganate soaks  Overhydration (>48hr)
Melese.S 10/23/2023
 Nystatin  Stop feeds, Give furosemide
92
ReSoMal
 Severely malnourished children
 Potasssium deficient, high Na levels
 Mg, Zn, copper deficiency
 ReSoMal is Commercially available
 Dilute 1 packet of standard WHO ORS in 2 liters water
+ 50 g of sucrose (25g/l) + 40 ml (20ml/l) mineral mix
solution
 5ml/kg PO/NGT q30min
 Continue till thirst & urine
Melese.S 10/23/2023
 Formula diets for severely
93
malnourished children
 Impaired liver & intestinal function + infection
 Food must be given in small amounts, frequently (PO/NG)
 Unable to tolerate usual amounts of dietary protein, fat, Na
 Diet low in above, high in carbohydrates

 F-75
 75kcal or 315kj/100ml
 Initial phase treatment, 130ml/kg/d
 Feed q 2-3hr (8 meals/d)
 F-100
 100kcal or 420kj/100ml
 Feed q 4-5 h (5-6 meals/d) Melese.S 10/23/2023
 Composition F-75 and F-100
94

F-75 F-100
 Dried skimmed milk 25g 80g
 Sugar 70g 50g
 Cereal flour 35g -
 Vegetable oil 27g 60g
 Mineral mix 20ml 20 ml
 Vitamin mix 140ml 140 ml
 Water 1liter 1 liter
 Protein 0.9g 2.9g
 Lactose 1.3g 4.2g
 K 3.6mmol 5.9mmol
 Na 0.6mmol 1.9mmol
 Mg 0.43mmol 0.73mmol
 Zn 2.0mmol 2.3mmol
 Copper 0.25mg 0.25mg
 Osmolarity 333mOsmol/l 419mOsmol/l
 Energy from protein 5% 12% Melese.S 10/23/2023

 Continue Breastfeeding
95

Melese.S 10/23/2023
96 Melese.S 10/23/2023
97
Rehabilitation
 Principles & criteria
 Good appetite(eating well)
 Smiles, responds to stimuli
 No signs of infection
 No edema
 Gaining Wt: > 5g/kg of body wt/d x 3 days
 Most important determinant of recovery:
 Amount of energy consumed: calories, protein,
micronutrients (K, Mg, I, Zn)
Melese.S 10/23/2023
Emotional & physical stimulation
100

 primary/seconadry prevention DD, MR

 Start during rehabilitation
 Avoid sensory deprivation
 Maternal presence
 Environment
 Play activities, peer interactions
 Physical activities

Melese.S 10/23/2023
Rehabilitation
101

 Parental teaching
 Correct feeding/food preparation practices,
 Stimulation, play, hygiene
 Treatment diarrhea, infections
 When to seek medical care
 Preparation for dischanrge
 Reintegration into family & community
 Prevent malnutrition recurrence
Melese.S 10/23/2023
 Criteria for Discharge
102

 Child
 WFH reached -1SD
 Eating appropriate amount of diet that mother can prepare at home
 Gaining wt at normal or ↑rate
 Vit/mineral deficiencies treated/corrected
 Infections treated
 Full immunizations
 Mother
 Able & willing to care for child
 Knows proper food preparation
 Knows appropriate toys & play for child
 Knows home treatment fever, diarrhea, ARI
 Health worker Melese.S 10/23/2023

103
Follow up
 Prevention of recurrence severe malnutrition
 Strategy for tracing children

 Growth monitoring till age 3yrs

 WFH no less than -1SD

 Assess overall health, feeding, play

 Immunizations, treatments, vitamin/minerals

 Record progress

Melese.S 10/23/2023
 Failure to respond Criteria
104

 Primary failure to respond

 Failure to regain appetite by day 4
 Failure to start to lose edema by day 4
 Edema still present by day 10
 Failure to gain at least 5g/kg/d by day 10

 Secondary failure to respond

 Failure to gain at least 5g/kg/d during
rehabilitation Melese.S 10/23/2023
 Failure to respond
105

 Problems with treatment

facilities
 Poor environments
 Insufficient or inadequately
trained staff
 Inaccurate weighing machines
 Food prepared or given
incorrectly
Melese.S 10/23/2023
 Failure to respond
106

 Problems w/ individual children

 Insufficient food given
 Vitamin or mineral deficiency
 Malabsorption of nutrients
 Rumination
 Infections
 Diarrhea,
dysentery, OM, LRI, TB, UTI, malaria, intestinal
helminthiasis, HIV/AIDS
 Serious underlying disease
 Congenital
abnormalities, inborn errors metabolism,
malignancies, immunological diseases
Melese.S 10/23/2023
107

Traditional Treatment
VS
CMAM
Melese.S 10/23/2023
 Nutrition Emergencies
Traditional Response
108

No Malnutrition Screen the population

Children with Moderate Children with Severe

Malnutrition Malnutrition

Supplementary Therapeutic Feeding

Feeding Program Center (TFC)
Recovered

Melese.S 10/23/2023
 Traditional Response Case Fatality
of less than

Therapeutic Care…Cont’d 10%

Phase I – Phase II –
Stabilization* Rehabilitation
Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**

Care Attend to complications (e.g. shock,

hypoglycemia)**
Feed F-75 Therapeutic Milk F-100 Therapeutic Milk

Quantity 135ml/kg/day** 200ml/kg/day**

Length of Time 1-7 Days, 3 to 4 Weeks

109
 Traditional Response
• Inpatient care in a
– Pediatric ward
– Nutrition rehabilitation unit (NRU),
or
– Therapeutic feeding center (TFC)
• Global standards call for:
– No more than 50 beds per TFC
– 1 Nurse
– 2 trained health workers
– 1 nursing aid for every 10 children

110
 Challenges of the traditional
111
center based management
 Labor Intensive(work burden)
 Cross-infection

 Does not consider the social aspects of SAM

treatment(Opportunistic cost)
 Low coverage

 No food for the mother/caregiver

 Involvement of care givers in risky sexual

practices to access foodMelese.S 10/23/2023

Evolution of a New Approach
CMAM: 1998-99
 Development of
PlumpyNut–a Ready to Use
Therapeutic Food (RUTF)
equivalent to
F-100

 South Sudan

112
 Principles and Components of CMAM

Principles: Components:
 Maximum access and

coverage
 Timeliness

 Appropriate medical and

nutrition care
 Care for as long as

needed

Melese.S 10/23/2023
113
 Evolution of a New Approach
Additional Screening
114

Uncomplicated Complicated

Melese.S 10/23/2023
 Review
115 Traditional Response
No Malnutrition Screen the population

Children with Moderate Children with Severe

Malnutrition Malnutrition

Supplementary Therapeutic Feeding

Feeding Program Center (TFC)
Recovered

Melese.S 10/23/2023
 Review:
116
New Approach–CMAM
No Malnutrition Screening

Children with Severe

Children with Moderate
Malnutrition
Malnutrition

No Complications Complications
Supplementary
Feeding Program
Outpatient Inpatient Therapeutic
Therapeutic Care Care

Melese.S 10/23/2023
CMAM Impact 85% can be
treated as
117 outpatients

No Malnutrition Screening

Children with Severe

Children with Moderate
Malnutrition
Malnutrition

No Complications Complications
Supplementary
Feeding Program
Outpatient Inpatient Therapeutic
Therapeutic Care Care

Melese.S 10/23/2023
CMAM Impact…Cont’d Time in
hospital
118 reduced
considerably

No Malnutrition Screening

Children with Severe

Children with Moderate
Malnutrition
Malnutrition

No Complications Complications
Supplementary
Feeding Program
Outpatient Inpatient Therapeutic
Therapeutic Care Care

Melese.S 10/23/2023
CMAM Impact…Cont’d Outpatient
Care

Phase I – Stabilization Phase II – Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.**

Care Attend to complications (e.g. shock, hypoglycemia)**

Feed F-75 Therapeutic Milk RUTF

Quantity 100kcal/kg/day** 200kcal/kg/day**

Length of Time 1-7 Days, 3 to 8 Weeks

See WHO, Management of Severe Malnutrition, 1999, and CTC Field

**

Manual for further detail.

119
 CMAM Better than
traditional
Does it Work?
120
approach

100% Outcomes from CTC 2000 - 2003, (n = 7,408), & TFCs 1992-1998
(n= 11,287) against SPHERE minimum standards

75%

50%

25%

0%
recovered died default LTF
CMAM 77% 5% 11% 7%
SPHERE 75% 10% 15% 0%
TFC 65% 12% 18% 5%

Melese.S 10/23/2023
 CMAM
Does it Work?...Cont’d
121
Coverage
Increases
Dramatically

CMAM (70%) Traditional (30%)

Melese.S 10/23/2023
CMAM Scaling Up Modality
122
5. Strengthen and improve

WASH facilities in OTPs/ SCs

atient
3 . In - p t Hygiene promotion
en
treatm
amme
progr
RH) 2. Out-patient treatment
(SCs/N
programme (OTPs)

4. Programmes to address MAM

(capacity building and Counselling of
family and communities on IYCF and
care, health, ECD, and WASH) 1. Community
outreach/social
mobilization/
Screening

Melese.S 10/23/2023
Commodities for TFP and TSF
123

SEVERE ACUTE MALNUTRITION(SAM)

 inpatients

 F100
 F75
 Outpatient
 Plumpy nut
 BP100
MODERATE ACUTE MALNUTRITION(MAM)
 CSB
 Plumpy Sup Melese.S 10/23/2023
 Discussion Points
124

 What are the Causes of Poor adherence to

MAM?
 How cost Effective is the CTC compared with

Centre based treatment?

 How can the supply of the plumpy nut be

sustained?
 Any treatment modality for MAM cases

 Cut-off point for SAM and MAM?

 Are anthropometrically cured medically cured?

Melese.S 10/23/2023
EMERGENCY TREATMENT OF
SHOCK AND SEVERE ANEMIA
 Fluid therapy in severe dehydration
Use intravenous or intraosseus route
Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose at 15 ml/kg/hour for the
first hour
* do not use 5% dextrose alone

Continue monitoring every 5-10 min.

Assess after 1 hour

If no improvement or worsening If improvement(pulse slows/faster

consider capillary refill /increase in blood pressure)
septic shock consider severe dehydration with shock
Repeat Ringers Lactate 15 ml/kg over 1 h

Assess

If accepts orally start ORS Clinically better but not

accepting orally give
10ml/kg/h till accepts orally
 SEVERE ANAEMIA
• Blood transfusion is required if:
– Hb < 4 g/dl or if there is respiratory distress & Hb 4-6 g/dl
• Give:
– Whole blood 10 ml/kg slowly over 3 hours
– Furosemide 1 mg/kg IV at start of transfusion
• If CARDIAC FAILURE present, transfuse packed cells (5-
7 ml/kg) rather than whole blood
• Monitor RR & HR every 15 minutes. If either of them
rises, transfuse more slowly.
• Give oral iron for two months to replenish iron stores
128

Thank You

Melese.S 10/23/2023