Severe Malnutrition (SAM) in Children

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CLINICAL DESCRIPTION

Severe acute malnutrition in children is the presence of bilateral pitting oedema or WFH of <-3 Z score or 

  • In children 6- 59 months MUAC <11.5 cm
  • Children 5 - 9 years MUAC <13.0 cm
  • Children 10 – 15 years <16.0 cm

SEVERE CHILDHOOD ACUTE MALNUTRITION WITHOUT COMPLICATIONS 

CLINICAL FEATURES 

Any Children with SAM who meet the following criteria: 

  • The child is > 6 months of age and weight 3kg
  • Pitting oedema of ≤ +2
  • The child is alert (not lethargic)
  • The child has a good appetite and is feeding well
  • The child does not have any danger signs and is clinically well

TREATMENT 

General measures:

  • Children with severe acute malnutrition without complications should be admitted in the Outpatient Therapeutic Program (OTP) and followed up every 2 weeks.
  • Conduct appetite test in a quite separate area. The child passes the test if he/she eats at least one-third (1/3) of a packet of RUTF (92g).
  • Conduct medical assessment

PHARMACOLOGICAL

  • Antibiotics
    • All children with SAM without complications should receive oral antibiotics.
    • Amoxicillin is the antibiotic of choice in OTP and it given as shown in the table below:

Weight of the Child (Kg)

Syrup 125mg/5ml

Syrup 250mg/5ml

Tablets 250mg

< 2.0

62.5mg (2.5ml) every 8 hours

62.5mg (1.25ml) every

8 hours

62.5mg (1/4 tablet) every 8 hours

2.0-9.9

125mg (5ml) every 8 hours

125mg (2.5ml) every 8 hours

125 (1/2 tablet) every 8 hours

10.0-30.0

250mg (10ml) every 8 hours

250mg (5ml) every 8 hours

250mg (1tablet) every 8 hours

>30.0

Give tablets

Give tablets

500mg (2 tablets) every

8 hours
  • If Amoxicillin is not available, use Cotrimoxazole according to IMCI protocol
  • Do not give Vitamin A Supplementation to children with SAM in OTP
  • Do not give Iron and Folic acid to children with SAM in OTP
  • Children with diarrhea with mild and moderate dehydration should receive only RUTF and water
  • ORS contains high sodium and is inappropriate (and potentially fatal) for children with SAM
  • All children with severe dehydration they should be referred for inpatient care
  • Zinc should not be given in children on RUFT

Antimalarial

  • Lumefantrine/Artemether (LA) should only be prescribed if there is a positive diagnostic test

Deworming

  • All children in OTP should be dewormed using Albendazole or mebendazole as shown in the table below.
  • If the child is transferred between OTP and NRU ensure that this dose is not repeated.

Age

Albendazole

Mebendazole

<12 months

None

None

12 to 23 months

200mg single dose

100mg EVERY 12HRS for 3 days

24 to 59 months

400mg single dose

100mg EVERY 12HRS for 3 days

Nutritional management

  • The nutritional treatment is managed in the home, with the children attending OTP sessions on a weekly basis to monitor the health and nutritional status and replenish RUTF stocks
  • Ready to Use Therapeutic Food (RUTF) is used to treat patients with SAM in OTP
  • Amounts of RUFT to give are given in the table below:

Weight of the Child (Kg)

Packets Per Day

Packets Per Week

3.5-3.9

1.5

10

4.0 -4.4

1.5

11

4.5-4.9

1.75

12

5.0-5.9

2

14

6.0-6.9

2.5

17

7.0-7.9

3

20

8.0-8.9

3.25

23

9.0-9.9

3.75

26

10-11.9

4

28

≥12

5

35

 

SEVERE CHILDHOOD ACUTE MALNUTRITION WITH COMPLICATIONS

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Any child with SAM has ONE of the following features:
    • <6 months of age or weighs <3 kg
    • Pitting Oedema of 3+
    • Refusing feeds or is not eating well (poor appetite)
    • Eye signs of Vitamin A deficiency
    • Localizing signs of infection (pneumonia, skin, ear / nose / throat)
    • Mouth ulcers
    • Skin changes of Kwashiorkor:
      • Hypo- or hyper-pigmentation
      • Desquamation
      • Ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)
      • Exudative lesions (resembling severe burns) often with secondary infection (including candida)
  • Signs of developmental delay
  • Signs of any underlying chronic disease / condition
    • HIV/AIDS
    • TB
    • Cerebral palsy
    • Congenital anomalies (e.g. congenital heart disease and cleft palate)

TREATMENT General measures:

  • Must be admitted to hospital -NRU
  • Do a full assessment especially looking for underlying disease such TB, HIV infection, cardiac or neurological disorder.
  • Assess and treat common complications and other medical condition such as:
    • Signs of shock
    • Hypoglycemia
    • Hypothermia
    • Diarrhoea
    • Dehydration
    • Severe anaemia
    • Skin lesions (dermatosis)
    • Eye problems
    • Oral Candidiasis

Nutrition Management

Phase 1

  • F75 is used to stabilize malnourished children in Phase 1 of treatment
  • On the first day, feed the child small amounts of F-75 2 hourly (12 feeds in 24 hours, including through the night)
  • After 24 hours give 8 feeds of F75 (130mls/kg/day) (3 hourly). This will assist to prevent and treat hypoglycaemia and Hypothermia
  • Give F75 to all children except infants <6 months where breastfeeding is being established. For these infants use dilutes F100 except if oedema is present
  • Continue breastfeeding on demand

Transition phase 

  • A patient in phase 1 is moved to the transition phase as soon as the patient’s appetite returns and or oedema starts to subside.
  • Children with severe oedema [+++] should undergo transition when oedema has reduced to moderate [++].  
  • Transition using RUTF
    • Introduced RUTF gradually alongside F-75 
    • When the child finishes 50% of RUTF, reduce the volume of F-75 by 50%
    • Stop F75 when the child can finish 75 – 100% of the daily RUTF ration 
  • Transition using F-100
    • The volume of feeds remains the same as in the stabilization phase
    • Give 130 ml of F100 per kg bodyweight per day every 3 hours

Routine Medical Treatment and Prophylaxis

  • Give Vitamin A only if there are eye signs of vitamin A deficiency (dry conjunctiva or cornea, corneal clouding or ulceration, Bitots spots, keratomalacia) on day 1, Day 2 and Day 14 as follows:

Age

Vitamin A orally on day 1, day 2 and day 14

<6 months

50, 000 IU {2 drops or one third redcap)

6 to 12 months

100, 000 IU

>12 months

200,000 IU

 

Antibiotic regimen in NRU

All patients with SAM should receive antibiotics as follows:

On Admission if

Give

IV antibiotics may not be given 

Amoxicillin orally, 15mg/kg 8 hourly for 7 days

With Complications

Give Benzyl penicillin 50,000iu/kg 6 hourly IV/IM for 48 hours then oral amoxicillin 15mg/kg 8 hourly for 5 days AND If the child fails to improve within 48 hours add Gentamycin 7.5mg/kg 24 hourly IV/IM for 7 days.

If no improvement after 48 hours give Ceftriaxone 100 mg/kg IV or IM 24 hourly for 5 days (Infants <3 kg: 50 mg/kg)

If the child fails to improve within 48 hours and if suspected staphylococcal infection, give: Cloxacillin 25-50 mg/kg/dose IV (or IM) 6 hourly for 5 days (Infants <3 kg: 25-50 mg/kg/dose every 8 hours).

If child is HIV infected or exposed give cotrimoxazole preventive therapy (CPT)

Cotrimoxazole:

<6 months-120mg/day

>6 months-5 years 240mg every day

>5 years-480mg every day

 

MANAGEMENT OF DEHYDRATION IN CHILDREN WITH SEVERE ACUTE MALNUTRITION

  • It is difficult to estimate dehydration status in a child with SAM using clinical signs alone.
  • A diagnosis of dehydration therefore needs to be associated with a definite recent history of significant fluid loss; watery diarrhoea (not just soft or mucoid) and frequent (more than 3 stools per day) with a recent onset.
  • Assume that all children with watery diarrhoea may have dehydration and give ReSoMal as follows:
    • Give ReSoMal 5mls/kg every 30 minutes for the first 2hrs.
    • Then, if the child is still dehydrated, give ReSoMal 5–10 mL/kg/h in alternate hours with F-75, up to a maximum of 10 h; Encourage mother to give the fluid slowly, and to persist even if the child is slow to take the fluids. Give the mother only the amount of fluid required for the next hour.
    • If the child is refusing or vomiting insert a naso-gastric tube and commence NG fluids.
    • Do not treat dehydration with intravenous fluids as these children can become overloaded with fluid very quickly and this is very dangerous and can lead to heart failure and death.
    • Continue breastfeeding.

During treatment, rapid respiration and pulse rates should slow down and the child should begin to pass urine. 

SHOCK MANAGEMENT IN SEVERE ACUTE MALNUTRITION

A child with SAM is considered to have shock if he/she:

  • is lethargic or unconscious,
  • and has cold hands 

plus, either:

  • slow capillary refill (longer than 3 seconds),
  • or weak or fast pulse
  • If the child is in shock:
    • Give Oxygen 1-2 litre per minute.
    • Give Sterile 10% glucose 5 ml/kg IV over about 10 minutes.
    • Keep the child warm.
  • Infuse IV fluid at 15 ml/kg over 1 hour. Use one of the following solutions, listed in order of preference:
    • Half-strength Darrow’s solution with 5% dextrose
    • Ringer’s lactate solution* with 5% dextrose
    • If the above fluids are not available, give half-normal (0.45%) saline solution with 5% dextrose.
    • If either of these is used, add sterile Potassium chloride (20 mmol/L) if possible.
  • If the child fails to improve after the first hour of IV fluids, then assume that the child has septic shock. A blood transfusion is indicated. 
  • Give maintenance IV fluids (4 ml/kg/hour) while waiting for blood.
  • When blood is available, stop all oral intake and IV fluids, give a diuretic to make room for the blood & then transfuse whole fresh blood at 10 ml/kg slowly over 3 hours.
  • If there are signs of heart failure, give packed cells instead of whole blood as these have a smaller volume
  • Observe the child and check respiratory and pulse rates every 10 minutes.
  • If the respiratory rate increases by 5 breaths/minute and the pulse rate increases by 25 beats/minute, stop the IV.
  • If respiratory rate and pulse rate are slower after 1 hour, the child is improving. Repeat the same amount of IV fluids for another hour. Continue to check respiratory and pulse rates every 10 minutes.
  • Once signs of shock resolves, switch to oral or NG rehydration with ReSoMal.
  • Give 5 -10 ml/kg ReSoMal in alternate hours with F-75 for up to 10 hours. Leave the IV line in place in case it is needed again

All children with SAM and shock should receive antibiotics; ideally parenteral antibiotics as indicated under the section of routine medical treatments and prophylaxis.

TREATMENT OF OTHER COMPLICATIONS OF SAM

  • Hypothermia:
    • Re-warm
    • Consider the possibility of sepsis or hypoglycaemia
  • Hypoglycaemia:
    • Give the child a 50 ml (infant less than 6 months 25 ml) bolus of 10% glucose or sucrose (i.e., sugar water) orally or by nasogastric (NG) tube
    • If the child can drink, give the 50 ml bolus orally. If the child is alert but not drinking, give the 50 ml by NG tube
    • Then give F75 orally or via NGT as soon as possible and recheck the blood sugar after 1 hour
    • Note: Hypothermia and hypoglycaemia are frequently signs of sepsis. Consider sepsis treatment if present
  • Cardiac failure:
    • Give Frusemide 1-2 mg/kg IV or IM
    • Digoxin is contraindicated in kwashiorkor
  • Severe anemia:
    • Transfuse 10 mL/kg packed cells
  • Mouth ulceration:
    • If not severe use GV Paint
    • If severe like cancrum oris use
      • Give Benzylpenicillin 25,000 units/kg per dose IM 6 hourly and
      • Give Metronidazole 7.5 mg/kg 8 hourly for 7 days
  • Skin ulcers:
    • Soak lesion with Potassium Permanganate 1% solution for 10-15 minutes then
    • Apply a paraffin Gauze Dressing

Note: provide psycho-social stimulation for all children treated for acute malnutrition