Severe Acute Malnutrition

ALKAN HEALTH SCIENCE, BUISNESS AND TECHNOLOGY
COLLEGE
DEPARTMENT OF PHARMACY
Pharmacotherapy IV assignment
Group one
Name ID
Sifen getachew 274/12
Meklit babur 257/12
Yididya tadesse 284/12
Roza derebe 271/12
Hawi gezachew 245/12
Metages alemayehu 259/12
Hanna bekele 244/12
Melkam fekadu 258/12
MALNUTRATION
OUTLINE
• Introduction
• Etiology
• Classification
• Clinical feature
• Treatment
Introduction
• Malnutrition is a condition that results from lack of sufficient
nutrients in the body.
• It has different causes, sign and symptoms.
• Malnutrition can lead to complications such as respiratory

failure, heart failure, and unresponsiveness if left untreated.
• The under nutration could be acute or chronic.
SAM
• Severe acute malnutrition (SAM) results from insufficient energy
(kilocalories), fat, protein and/or other nutrients (vitamins and
minerals, etc.) to cover individual needs.
• Severe acute malnutrition is defined by a very low weight for
height by visible severe wasting or by the presence of
nutritional edema.
• Malnutrition in children typically develops during the period
from 6 to 18 months of age, when growth velocity and brain
development are especially high. Young children are particularly
susceptible to malnutrition if complementary foods are of low
nutrient density and have low bioavailability of micronutrients.
• Under nutrition is a critical determinant of mortality and
morbidity in young children worldwide: It is associated with
approximately one-half of all deaths in children under five years
of age.
• Malnutrition id defined as the cellular imbalance
between supply of nutrients and energy and the
bodies demand for them to ensure growth
maintenance and specific function.(WHO)
• Mid upper arm circumference ( MUAC) measurement

of less than 115 mm or weight for height ( wasting)
less than minus 3SD z-score below the median in 6 to
59 months of children.
SAM
Etiology
• Maternal /paternal factor

- Low social economic status and availablity of
food
- Cultural taboos regarding food and health,
access to water and sanitation
- Educational level of the family ( inablity of
mother to provide adequate careto the child)
- Large families and poor child spacing
- Health access
• Child factors
- Low birthweight( infants born small, remain small)
- Inadequate dietary intake
o These can be due to delayed complementary
feeding and adequate intake of food
o Insufficient quality, quantity and variety of food
o Eating with a large family together
- Infections eg, diarrhea and pneumonia and other
infections thatconsume energy hamper growth,
nutrition loss in stool,measles, tb,hiv,and other
chronic illness.
Classification of SAM
• Clinical classification
1) severe wasting or marasmus – charachterized
by no muscle mass, loose skin and visible
bone.
2) Nutritional edema or kwashakor –
charachterized by distended abdomen,
swallowen ankel and pitting edema.
Classification based on complication
uncomplicated SAM
• Child >6 months
• Child is alert
• Preserved appetite
• Clinically assessed to be well
• Child is living in conductive home environment
• Can be managed as out patient
Complicated SAM
• Child < 6 months
• Not alert
• Having loss of appetite
• Institutional or hospital care is considered
mandatory
Forms of SAM
• Kwashiorkor- inadequate protein intake
• Marasmus – inadequate intake of protien and
calories( total caloric deficiency)
• Although significant clinical difference
between kwashiorkor and marasmus exist,
some stuidies suggest that marasmus
represents an adaption to starvation whereas
kwashiorkor represents a dysadaptation to
starvation.
kwashiorkor
• Usually affects children aged 1-4 years
• The main symptoms are edema ,wasting ,liver
enlargement, hhypoalbuminemia, steatosis and
possibly depigmentation of skin and hair.
• General appearance : child may have a fat sugar
baby appearance
• Edema ranges from mild to gross may
represent 5-20% of the body weight
• Muscle wasting is always present, child is often
weak, hypotonic and unable to stand or walk
Marasmus( to waste away)
• Results from rapid deterioration in nutritional status
• Wasting of fat and muscle as tissues are consumed to make
energy
• The child appears very thin and has no fat. There is severe
wasting of the shoulders, arm buttocks and thighs.
• The loss of buccal pad fat creates the aged or wrinked
appearance that has been refered to once as monkey
facies.
• Affected child may appear to be alert inspite of their
condition
• There is no edema.
Marasmic-kwashiorkor
• Severely malnourished child with features of
both marasmus and kwashiorkor
• The features of kwashiorkor are severe
oedema of feet, leg , hand, lower arm,
abdomen and face. Also there is pale skin and
hair , also the child is unhappy.
• There is also a sign of marasmus , wasting of
the muscle of upper arm, shoulder and chest
so that you can see the ribs.
Clinical features of SAM
• Hair changes
-hair is dull, hypopigmented and loss character of curls.
Keratin synthesis impaired due to cysteien and methhionine
deficiency thus hair is brittle and easily breaks
Formation of pigmented melanin leads to hair color changes
to reddish or grey
• Eye sign
-Due to vitamin A deficiency
-Present as photophobic, dry cornea, bitot spots ,corneal
ulceration.
• Neurological-apathy
-they are unhappy, irritable with sad and intermittent cry.
-they show no sign of hunger and is difficult to feed them.
- hypokalemia- muscle weakness
• Cardiovascular and hematological
-cold, pale extremities due to circulatory insufficiency
and are associated with prolonged circulation
time ,bradycardia, hypotension,shock
-arrhythmias due to mg and p deficiency.
- Anemia due to iron deficiency,folic acid and Vb12
• Gastrointestinal
-mucous membrane lesion, anorexia, vomiting
- Stool may be watery, bulky with low ph and contain
unabsorbed sugars
- Diarrhea
• Skin changes
-Flaky paint dermatitis, crazy pavement dermatitis, due
to zinc and niacin deficiency
Assessment of child
• Evaluation is divided into:
- Assessment of past and present dietary intake
history
- Anthropometry examnination
- Laboratory assessments
Diagnostic features of severe acute malnutrition are:
• Infants less than six months:
-Weight –for- Length (W/L) less than 70% of NCHS median,
OR
-Presence of pitting Oedema of both feet, OR
-Visible Severe Wasting if it is difficult to determine W/L
• Children 6 months to 5 years:
-Weight for Height (W/H) or Weight –for- Length (W/L) less
than
-70 % of NCHS median, OR
-Presence of pitting Oedema of both feet, OR
-MUAC<11.5 cm for a child with a length greater than 65 cm
if
-W/L or W/H is difficult to measure
•Initial assessment of the severely malnourished child
•Take a history concerning:
 Recent intake of food and fluids
 Usual diet (before the current illness)
 Breastfeeding
 Duration and frequency of diarrhea and vomiting, if there is
recent sunkening of eyes
 Any of the following serious medical complications:
o Severe vomiting/ intractable vomiting
o Hypothermia: axillary’s temperature <35°C or rectal temperature < 35.5 o C
o Fever>39°C
•
 Number of breaths per minute:
• – 60 resps/ min for less than 2 months
• – 50 resps/ minute from 2 to 12 months
• – 40 resps/minute from 1 to 5 years OR
• – Any chest in-drawing
 Extensive skin lesions (+++ dermatosis)/ infection
 Very weak, lethargic, unconscious
 Fitting/convulsions
 Severe dehydration based on history & clinical signs
 Shock or any condition that requires an infusion or NG tube
feeding.
 Very pale (severe anemia): Hgb< 4 g/dl
 Hypoglycemia
 Jaundice
 Bleeding tendencies
 Other general signs the clinician thinks warrants transfer to the
in-patent facility for assessment
Management of SAM
• The general treatment involves 10 steps in 3 phases
1) Stablilization phase- focuses on restoring homeostasis and treating medical
complications and usually takes 1-2 days of inpatient treatment
-F-75 is used which promotes recovery of normal metabolic function and electrolite
imbalance
2)Transition phase – lasts 3-7 days
-it is intended to ensure the child is clinically stable and can tolerate an increased
energy and protien intake
-transition gradually from F -75 to F- 100
- A child moves to this phase from stablization when
loss of edema shown, return of appetite,no NG tube feeds and child is alert and
active
3) Rehablitation phase- takes 2 to 6 weeks
- Focuses on rebuilding wasted tissues, promote weight gain and stimulation of
emotion and physical development’
10 steps
• 1. hypoglycemia
• 2 hypothermia
• 3 dehydration
• 4 electrolyte
• 5 infections
• 6 micronutrients
• 7 Initiate feeding
• 8 catch-up feeding
• 9 sensory stimulation
• 10 Prepare for followup

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ALKAN HEALTH SCIENCE, BUISNESS AND TECHNOLOGY

• It has different causes, sign and symptoms.

• Malnutrition can lead to complications such as respiratory

• Mid upper arm circumference ( MUAC) measurement

• Maternal /paternal factor

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