Severe Acute Malnutrition (SAM)

Three step approach to severe acute malnutrition

WHO 10 steps of management of SAM

STEP 1: HYPOGLYCEMIA

STEP 2: HYPOTHERMIA

STEP 3: DEHYDRATION AND SHOCK

STEP 4: ELECTROLYTE IMBALANCES

STEP 5: INFECTIONS

STEP 6: MICRONUTRIENTS

STEP 7: STABILISATION FEEDING

STEP 8: TRANSITION FEEDING AND CATCH UP GROWTH

STEP 9: SENSORY STIMULATION

STEP 10: PREPARE FOR DISCHARGE AND FOLLOW-UP

Severe acute malnutrition case definition (WHO, 2009): Severe acute malnutrition (SAM) in 6-59 months old children, defined as severe deficits in anthropometric indicators of wasting (WFH Z-score < -3 SD), or a mid-upper arm circumference (MUAC) of less than 11.5cm, or the presence of nutritional oedema of both feet. Severe acute malnutrition (previously termed Protein Energy Malnutrition) is a multi-deficiency state of severe under nutrition of protein, energy and various other minerals, micronutrients and vitamins that includes the clinical entities of Kwashiorkor (severe underweight with oedema), Marasmus (severe wasting) and Marasmic-Kwashiorkor (severe wasting with oedema). 

THREE STEP APPROACH TO SEVERE ACUTE MALNUTRITION

STEP 1: Define SAM based on WHO classification (Z-Scores) in children aged 6–60 months

STEP 2: Differentiation between COMPLICATED and UNCOMPLICATED SAM

STEP 3: Risk assessment of complicated SAM

WHO 10 STEPS OF MANAGEMENT OF SAM

MANAGEMENT OF SEVERE ACUTE MALNUTRITION (ACCORDING TO WHO 10 STEPS)

STEP 1: HYPOGLYCEMIA: GLUCOSE < 3 mmol/l

PREVENTION

• Feed immediately “stabilizing feed” F75 every 3 hours (8 feeds), day and night. Start straightaway i.e. on arrival at hospital and within 30 minutes after admission. (Use feeding chart to find amount to give).
• Encourage mothers to stay with very ill children to watch for any deterioration, help feed and keep child warm.Defer feeding immediately in following cases:
• While shock is being corrected• Surgical abdominal emergency

WARNING SIGNS

• Low temperature (hypothermia) noted on routine check.
• Child feels cold.
• Child becomes drowsy or lethargic.
• Signs of Shock
• If blood sugar is low, monitor blood sugar every 30 minutes to 60 minutes and intervene accordingly.

IMMEDIATE ACTION

1. If conscious and blood sugar is below 3 mmol/L:
   • Feed 2hourly (12 feeds in 24 hours). Use feeding chart to find amount to give. Start straightaway. Afterwards, feed 3-4hours.
2. Give 50 ml of 10% glucose (to prepare mix 10ml 50% dextrose with 40ml sterile water) or sugar solution (1 rounded teaspoon sugar in 3 tablespoons of plain water) orally or if child refuses, via nasogastric tube (NG tube). Test again 30 minutes after treatment. If blood sugar is still low, repeat oral 50ml 10% glucose or sugar solution. Consider putting up a short IV line.
3. If unconscious, give dextrose IV 2ml/kg of 10% glucose (1ml/kg 50% DW with 4ml/kg sterile water), followed by oral 50ml of 10% glucose or oral sugar solution or via NG tube. Monitor response to treatment.
4. Monitor blood sugar 3-hourly until stable especially in first 48hours.
5. If blood sugar is persistently low, review feed and look for infections.

STEP 2: HYPOTHERMIA (AXILLARY TEMPERATURE <35 degrees Celsius)

PREVENTION

• Keep covered, especially head, all the time
• Avoid drafts
• Keep dry, change wet napkins regularly
• Avoid exposure during examination and bathing
• Keep child in warm area (Temp 25-30°C)
• Ensure regular correct feeding
• Check axillary temperature 3 hourly
• Temp <36°C indicates urgent need to warm child

WARNING SIGNS

• Cold extremities
• Lethargic
• Poor appetite

NOTE: Rule out shock, dehydration and sepsis

IMMEDIATE ACTION

• If Tempt <36.5°C, rewarm the child ASAP
• Skin-to-skin contact (Mother-Child)
• Wrap child with warm blanket
• Place heater nearby
• External warmer: Bear-Huggers, radiant heaters, Hot-water bottle (beware of burning child!)
• During rewarming, monitor body temp every 30 mins. Stop rewarming when body tempt stabilized >36.5°C

STEP 3: DEHYDRATION AND SHOCK

Recognizing shock:

• Shock is not easy to identify in SAM, especially if very oedematous or septic
• Assume child in shock if history of profuse diarrhea
• Shock is recognized by one or more of following:

Compensated shock:

• Delayed capillary filling time >3secs
• Increased pulse rate (>140-160 bpm)
• Cool peripheriesLate (preterminal) shock:
• Decreased level of consciousness (lethargic)
• Decreased blood pressure
• Decreased pulse volume

NOTE: Assess, Classify and Triage all children appropriately. Shock is regarded as an emergency sign requiring immediate treatment. Do not transfer/move child until shock is treated.

IMMEDIATE ACTION

• Give oxygen
• Resuscitate with fluid bolus: RL or 0.9% NS 10ml/kg
• Time: over 10 mins
• Monitor for response (Watch for fluid overload)• If no response (pulse volume still decreased, prolonged capillary filling time): Repeat Fluid bolus
• If no circulatory overload AND not out of shock then repeat fluid bolus up to 4 times (40ml/kg over 1 hour)
• If still requiring further fluid support, then admit to high care/ICU: insert CVP line and commence inotropes.
• If the child is Hypoglycemic give 10% glucose 2 ml/kg IV (Dilute 1ml 50% dex with 4ml sterile water)
• Keep the child warm
• IV Antibiotics ASAP

Once shock is treated rehydrate over 24 hours as per rehydration protocol.

Rehydrate with ORS and avoid IV fluids.

STEP 4: ELECTROLYTE IMBALANCES (hypokalaemia / hypomagnesaemia and hypernatraemia)

WARNING SIGNS

• Oedema develops or worsens
• Poor appetite
• Apathy
• Vomiting

PREVENTION

• Use ORS 60mmol sodium/L and F75 formula as these are low in sodium.
• Do not add salt to food.
• Do not treat oedema with diuretics.
• Give extra potassium and magnesium (either as CMV in feeds or as a supplement).

POTASSIUM

• Serum potassium does not indicate total body potassium status. Potassium supplementation is required unless frank hyperkalaemia.
• Add: KCl 25–50 mg/kg/dose, oral, 8 hrly until oedema subsides: If < 10 kg: 250 mg. If > 10 kg: 500 mg.

MAGNESIUM

• Feeds made with combined mineral and vitamin complex or trace element mix contains magnesium. If formula is made without either of these additives, add magnesium:
• 50% Magnesium sulphate 0.2ml /kg daily PO; additional IV/IM doses for proven hypomagnesaemia.

PHOSPHATE

• F75 used is supplemented with Phosphate
• Oral replacement therapy: 0.1ml/kg/dose 6 hourly Phosphate containing Paediatric fleet enema. (This will give you 90mg/kg/day of phosphate).
• If requiring IV fluids and with hypokalaemia: Potassium Phosphate 15-45mg/kg IVI over 24hrs, by adding 2ml K2PO4/200ml ½ DD (instead of 2ml KCl).

STEP 5: INFECTIONS

The usual signs of infection, such as fever, are often absent so assume all SAM children have infections and treat with antibiotics. Hypothermia and hypoglycaemia are signs of severe infection.

PREVENTION

1. Good nursing care
2. Reduce overcrowding if possible (separate room or ward for malnourished children)
3. Wash hands before preparing feeds and before and after dealing with any child.
4. Follow Guidelines for “safe preparation, storage and handling of feeds”
5. Give measles vaccine to unimmunized children over 6 months of age.

TREATMENT

Starting on the first day, give antibiotics to all children.

• Severely ill (apathetic, lethargic) or has complications (hypoglycaemia, hypothermia, raw skin/fissures, meningitis, respiratory tract or urinary tract infection) give IV/IM Ceftriaxone 100mg/kg/day for 7days
• Medical complications but not seriously ill, give IV/IM Ampicillin: 50mg/kg IM/IV 6-hourly for 7 days AND Gentamicin: 7.5mg/kg IM/IV once daily for 7 days. If a child fails to improve after 48 hours, search for new infection, then change to Ceftriaxone 100mg/kg daily IM/IV for 5-7 days (or guided by local microbiological flora). If child does not improve after 5 days: Refer to higher level of care
• No medical complications, give antibiotics orally Amoxicillin 15mg/kg 8-hourly for 5 days

Assess and Classify TB Status in all cases

• Suspect TB in all cases of SAM
• Investigate: TST/Mantoux, GW or sputums, CXR
• Start TB treatment immediately if possible infection
• Repeat TST once immunity improved

Treat for intestinal infestation (parasitic worms)

• 1-2 yrs / < 10kg Mebendazole 100mg po bd for 3 days
• > 2 yrs / > 10kg Mebendazole 500mg po single doseAssess and Classify HIV Status in all cases
• Start ART once stabilized and in rehabilitation phase

STEP 6: MICRONUTRIENTS

STEP 7: STABILISATION FEEDING (See feeding chart below)

STABILISATION PHASE (Day 1-7):

Feeding to start as soon as possible (within 4 hours after admission).Give from a cup. Very weak children may be fed by spoon, dropper or syringe. If feeds refused/not finished (i.e. less than 80% of daily amount taken) give all feeds via nasogastric tube.Start with F75 formula only and NO solids.Give “F75/stabilising feed” at 130 mL/kg/day 3 hourly feeds in no oedema, but if there is oedema up to or beyond the knees give 100 mL/kg initially and increase progressively. Only if there are signs of improvement (eg. Less edema and able to eat) move on: Day 3: Start with 1 small portion of rice porridge. Day 4: Rice porridge twice a day. Day 5: Rice porridge twice a day and puree diet for lunch

Monitor and record intake carefully. Weigh daily and plot weight gain. 

STEP 8: TRANSITION FEEDING AND CATCH UP GROWTH (See feeding chart below)

TRANSITION PHASE (Day 8-9)

For the first two days replace the initial feeds with equal amounts of “catch-up/F100 formula”.

REHABILITATION PHASE: (Day 10 onwards)

Gradually increase the volume by 10 mL/feed until some formula remains unfinished, max 200mL/kg/day.

When appetite returns introduce a modified diet. Balance the intake by giving 3 modified meals and 5 feeds of F100. Prepare food without adding salt.

Monitor progress after the transition by assessing the rate of weight gain.

Weigh child each morning before feeding and plot the weight. 

STEP 9: SENSORY STIMULATION

Provide stimulation and tender loving care.Help and encourage mothers to comfort, feed and play with their children.Involve occupational therapist, if available, for structured play otherwise arrange this as best possible in the ward.

Provide a stimulation program in the ward.

STEP 10: PREPARE FOR DISCHARGE AND FOLLOW-UP

Essential elements at referral and discharge:

1. Involve mother in the discharge process and follow-up plans.
2. Refer all children to Social Services (SASSA) and hospital social workers. Before discharge, ensure parent/caregiver is able to access food for the child, ensure all financial supports and grants have been accessed.
3. Provide nutritional education and education about when to return urgently to clinic, Hygiene, Infant feeding, Complementary feeding advice, Stimulation, Family planning, Role of male partner.
4. Clear FEEDING PLAN must be in place: Work with Dietician to counsel mothers/caregivers on how to modify family foods, how often to feed and how much to give. Ready to Use Therapeutic Foods (RUTF) may be supplied to facilitate earlier discharge where this is indicated and available.
5. Register child on the Severe Acute Malnutrition In-Patient care or NTP register.
6. Make follow-up arrangements. Link patient to Community Based Services (CBS) for close follow-up and monitoring of feeding and compliance with therapeutic feeding program.
7. Ensure that HIV / TB were excluded / treatment started.
8. Ensure all immunisations are up to date.
9. Prepare a Discharge Summary and write a brief clinical summary in RTHB and send a NTP referral letter to the local PHC clinic. Book hospital outpatient in one week.

Discharge from inpatient care to outpatient care when:

• Good appetite
• Oedema resolved
• Child clinically well and alert
• Medical complications resolved
• Infections treated fully
• Persistent and good weight gain over five days
• Playful and alert
• All preparation in place for discharge

Investigations must include 

• U&E, CMP, Alb, Tot Protein 
• Basic liver functions: AST, ALT (consider INR/PTT) 
• B/C, CRP, FBC & Diff 
• Clean urine specimen for dipstix and MC&S 
• Full TB Workup: Mantoux, Chest X-ray, sputum / gastric washings 
• HIV testing all children 
• Dietician and social worker referral 
• If oedematous, do urine dipstix (Urine Pr:Cr ratio if protein) to exclude nephrotic syndrome. Rule out other causes of oedema, eg cardiac failure.