Presented By-

BIBHU PRASAD SAHU

RUPSY
DIYA SAHA
HITESH KHATUA
ARPIT PATEL
PRITH
VI SENA JAS
1. Definition
2. Etiology
3. Pathogenesis/ Pathophysiology
4. Complications
5. Principles of management
6. Summary
 Hunger– Physiological state when food is not able to
meet energy needs.
 Malnutrition– Malnutrition refers to deficiencies or
excesses or imbalances intake of energy and/or
nutrients in a person .
It could be under-nutrition or over-nutrition(obesity) .
 Undernutrition – most common form of malnutrition
in developing countries.
 Overnutrition(obesity)- common on developed
countries
Fig: Undernourished and Obese
WHO and UNICEF defines Severe Acute
Malnutrition (SAM) for children aged 6 months to 60
months as :
◆Weight for height below -3 SD score of the median
WHO growth standards.
◆ By visible severe wasting.
◆ Bipedal oedema ; and
◆ Mid upper arm circumference below 115mm.
• Primary - when the otherwise healthy
individual's needs for protein, energy, or both
are not met by an adequate diet. (most
common cause worldwide)

• Secondary - result of disease states that may

lead to sub-optimal intake, inadequate
nutrient absorption or use, and/or increased
requirements because of nutrient losses or
increased energy expenditure.
 Lack of food (famine, poverty)

 Inadequate breast feeding

 Wrong concepts about nutrition

 Diarrhoea & malabsorption

 Infections (worms, measles, T.B)

 The “Vicious Cycle”of Undernutrition & Infection
Weight loss
Growth faltering
Lowered immunity
Inadequate Mucosal damage Disease:
. incidence
dietary intake .severity
.duration

Appetite loss
Nutrient loss
Malabsorption
Altered
metabolism
F i g u r e 2 . T h e Sy n e rg i s t i c c y c l e of
Across all organ systems !!

13
Infection : lung , blood, UT, GIT, skin

Metabolic
hypoglycemia
 hypocalcemia
 hypomagnesemia

Hypothermia
• Severe vomiting/ intractable vomiting

4/10/2016 44
 Hypothermia :
axillary’s temperature < 35°C
or rectal <
35.5°C Fever
> 39°C

4/10/2016 45
 The WHO has developed guidelines have been
adapted by the Indian Academy of Pediatrics.
*The general treatment involves ten steps in two
phases:
i. The initial Stabilization phase focuses on restoring
homeostasis and treating medical complications
and usually takes 2-7 days of inpatient treatment.
ii. The Rehabilitation phase focuses on rebuilding
wasted tissues and may take several weeks.
Step 1: Treat/Prevent Hypoglycemia
*Blood glucose level <54 mg/dl or 3 mmol/l.
*If blood glucose cannot be measured, assume hypoglycemia.
*Hypoglycemia, hypothermia and infection generally occur
as a triad.
Treatment
*Give 50 ml of 10% glucose or sucrose solution orally or by
nasogastric tube followed by first feed.
*Feed with starter F-75 every 2 hourly day and night
Prevention
*Feed 2 hourly starting immediately.
*Prevent hypothermia.
Step 2: Treat/Prevent Hypothermia
*Rectal temperature less than <35.5°C or 95.5°F or
axillary temperature less than 35°C or 95°F.

Treatment
*Clothe the child with warm clothes.
*Provide heat using overhead warmer, skin contact or heat
convector.
*Avoid rapid rewarming as this may lead to disequilibrium.
*Feed the child immediately.
Prevention
*Place the child's bed in a draught free area.
*Always keep the child well covered
*Feed the child 2 hourly starting immediately after
Step 3: Treat/Prevent
Dehydration with Shock
*All severely malnourished children with watery
diarrhea have some dehydration.
Treatment
*Use ORS with potassium supplements.
*Initiate feeding within two to three hours of starting
rehydration.
Prevention
*Give ORS at 5-10 ml/kg after each watery stool, to
replace stool losses.
*If breastfed, continue breastfeeding.
*Initiate refeeding with starter F-75 formula.
Step 4: Treat/Prevent Infection
*Multiple infections are common.
*Majority of bloodstream infections are due to gram-
negative bacteria.
Treatment
*Treat with parenteral ampicillin 50 mg/kg/ dose 6
hourly
for at least 2 days
*followed by oral amoxicillin 15 mg/kg 8 hourly for 5 days
and
*gentamicin 7.5 mg/kg once daily for 7 days.
*If other specific infections are identified, give
appropriate antibiotics.
Prevention
*Follow standard precautions like hand
hygiene.
Step 5: Correct Electrolyte Balance
*Give supplemental potassium at 3-4
mEq/kg/ day for at least 2 weeks.
*On day 1, give 50% magnesium
sulphate IM once. Thereafter, give
extra magnesium (0.8-1.2 mEq/kg
daily)

Step 6: Correct Micronutrient

Deficiencies
*Use up to twice the recommended daily
allowance of various vitamins and minerals
*On day 1, give....
 Micronutrient Supplementation
MICRONUTRIENT DOSING

Vitamin A

Vitamin A,C, D, E and B12 TWICE RDA

Zinc 2 mg/kg/day

Iron Start after two days on catch up diet, elemental

iron @ 3 mg/kg/day

Copper *Micronutrient
0.3 mg/kg/day (if separate preparation not
available use commercial preparation containing
copper)
supplementati
Folate
on
5 mg on day 1, then 1 mg/day
36
GOI OPERATIONAL GUIDELINES
MALNUTRITION
ON 2011
Step 7: Initiate Re-feeding
*Start feeding as soon as possible as frequent small feeds.
*If unable to take orally, initiate nasogastric feeds.
*Total fluid recommended is 130 ml/kg/day.
*If breast feeding, then continue breast feeding.
*Start with F-75 starter feeds every 2 hourly.
*If persistent diarrhea, give a cereal based low lactose F-75
diet as starter diet.

Step 8: Achieve Catchup Growth

*Once appetite returns in 2-3 days, encourage higher
intakes
*Increase volume offered at each feed and decrease the
frequency of feeds to 6 feeds per day.
*Make a gradual transition from F-75 to F-100 diet.
Step 9: Provide Sensory Stimulation & Emotional
Support
*A cheerful, stimulating environment.
*Age appropriate structured play therapy for at least 15-
*30min/ day.
Tender loving care.

Step 10: Prepare for Follow-up

*Primary failure to respond is indicated by:
*Failure to regain appetite by day 4.
*Presence of edema on day 10.
*Failure to gain at least 5 g/kg/day-by-day 10.
*Secondary failure to respond is indicated by:
*Failure to gain at least 5 g/kg/day for consecutive days
during the rehabilitation phase.
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 Clinical complex, which includes
electrolyte changes associated
wit h metabolicabnormalities
that can occur as a result
of nutritional
support ( enteral or parenteral),
in severely malnourished
patients.

 Also called “the hidden syndrome”

 History
 Nausea, vomiting, and lethargy

 Respiratory insufficiency, cardiac

failure, hypotension,
arrhythmias, delirium, coma, and
death
 Refeeding a malnourished patient can result
in Heart failure due to:

 Atrophic myocardium in malnutrition

 Muscle depletion of Mg, K, P

 Sodium and water overload

 Feeding and correction of
biochemical abnormalities can
occur in tandem
without deleterious effects to
the patient.(NICE)

 Early identification of at risk

individuals,

 Monitoring during refeeding ,

and
Sam is major burden in deveoping countries.
SAM is a medical emergency
Pathophysiology still elusive and incomplete
Ten steps are the key to successful management
Community based treatment has revolutionised
management of SAM
Special needs for young infants and follow up
issues need to be recognised
*