SAM

Sisay Shewasinad
 Malnutrition

• “Malnutrition” means badly malnourished or shortage of

many nutrients.
 Malnutrition includes:
• Macronutrient deficiency
• Micronutrient deficiency
• Over nutrition-obesity
They are two types of under Nutrition
-Acute malnutrition
-Chronic malnutrition
• Sever acute malnutrition (SAM) ;-is syndrome a multi-
deficiency state involving PEM & other micronutrients
deficiency (anemia , vit,- A & D deficiency ).
 Cause Malnutrition
Cause
• Lack of knowledge
• Poverty (low-income) or starvation
• Infection e.g diarrhea, I/P
• Emotions deprivation
• Cultural factors e.g -age bias
-Sex bias
• Taboos
• Season
• Improper weaning practice
• Lack of breast milk
 Diagnosis Malnutrition
1. Anthropometric measurement / assessment/.
2. Biochemical
3. Clinical examination based on sign & symptom.
4. Detailed history –A child feeding practice
_ poor weaning practice.
_ Hx on the socio cultural
& other risk factors.
• Recommended criteria for SAM and Admission to TFP
• All children who fulfill any of the following criteria have
SAM and they should be admitted to a Therapeutic
Feeding Program (In-patient care (TFU) or Out-Patient
Treatment Program (OTP)):
1. Infants less than six months or less than 3 Kg:
• Weight –for- Length (WFL) less than 70% or < -3Z score
OR
• Presence of pitting edema of both feet
OR
• Visible Severe Wasting if it is difficult to determine WF
2. Children 6 months to 5 years:
• Weight –for- Length (WFL) / WFH less than 70 %
or < -3Z score OR
• Presence of pitting edema of both feet OR
• MUAC <11.5 cm for child length greater than 65
cm
 Admission and discharge criteria for severely
malnourished
Age Admission criteria Discharge criteria
<6 Infants to weak to
month suck effectively  Gaining wt.
old Wt. For ht. < 70% If no medical
Or wt or < -3Z score problem
less than No wt. Gain at home.
3 Kg Mother does not
have enough milk to
feed her child.
Presence of bilateral
edema.
Age Admission criteria Discharge criteria
6 month
up to  Wt. /Ht. <70%  Wt/ ht.> 85% for two
18 or < -3Z score consecutive wts.
Years old.  Presence of bilateral  No edema for 10 days.
edema.  MUAC>12.5 c.m
 MUAC < 11.5c.m
> 18 year  BMI< 16 k.g / m2  Wt/ ht> 85% for two
old  The presence of consecutive wts.
bilateral edema  No edema for 10 days
 Wt. /Ht. <70%
 Recommended Admission Criteria and
Admission Procedure
Out-patient Treatment Program (OTP):
• Children with SAM and has no medical complications, and
• who pass the appetite test
• are classified as uncomplicated SAM and they are treated in
OTP with RUTF and routine medicines.
• These are taken at home, and the child attends the outpatient
care site every one week.
In-patient care (TFU):
All children with SAM need to be treated in an in-patient care
facility until they are well enough to continue treatment in OTP if
they fulfill any one of the following:
• Infants below six months of age with SAM OR
• Children 6 months to 5 years with SAM who have
 Any one of the medical complications or
 Failed appetite test OR
 Referred from OTP for in-patient care OR
 OTP is not available in your working area or
 where the care taker lives or if the care taker’s choice is
inpatient care, all SAM children need to be admitted for
inpatient care even if they do not fulfill the In-patient
admission criteria.
• A child who fulfills any of the first three criteria is
classified as severe complicated acute malnutrition
 visible severe wasting
A child with visible severe wasting has lost fat and muscle
and has a “skin and bones” appearance.
• Another term used for this condition is marasmus
• To look for severe wasting, remove the child‟s clothes.
• Look at the front view of the child
• Is the outline of the child‟s ribs easily seen?
• Does the skin of the upper arms look loose?
• Does the skin of the thighs look loose?
• Look at the back view of the child:
o Are the ribs and shoulder bones easily seen?
o Is flesh missing from the buttocks?
• When wasting is extreme, there are folds of skin on the
buttocks and thighswrinkle
• It looks as if the child is wearing “baggy pants”.
 Edema
Edema is swelling from excess fluid in the tissues.
• edema is usually seen in the feet and lower legs and arms.
• In severe cases it may also be seen in the upper limbs and face.
• To check for edema, grasp both feet so that they rest in your
hand with your thumbs on top of the feet.
• Press your thumbs gently for three seconds or count
101,102,103.
• The child has edema if a pit (dent) remains in both feet when
you lift your thumbs .
• To be considered a sign of severe malnutrition, edema must
appear in both feet.
• If the swelling is only in one foot, it may just be a sore or
infected foot.
Note
• edema is a characteristic of kwashiorkor, which
is a form of severe malnutrition
 Dermatosis
• Dermatosis is a skin condition.
• In severe malnutrition, it is more common in children who
have edema than in wasted children.
• A child with dermatosis may have patches of skin that is

 abnormally light or dark in color,

 shedding of skin in scales or sheets, and
ulceration of the skin of the perineum, groin, limbs,
behind the ears, and in the armpits.
• There may be weeping lesions.
• There may be severe rash in the nappy areaሽንት ጨርቅ.
The extent of dermatosis can be described in the following
way:
• + mild: discoloration or a few rough patches of skin
• + + moderate: multiple patches on arms and/or legs
• + + + severe: flaking skin, raw skin, fissures (openings
in the skin)
11/18/2024 23
 Eye signs
• Children with severe malnutrition may have signs of eye infection
and/or vitamin A deficiency.
• Bitot’s spots – superficial foamy white spots on the conjunctiva
(white part of the eye).
These are associated with vitamin A deficiency.
• Pus and inflammation (redness) are signs of eye infection.
• Corneal clouding is seen as an opaque appearance of the cornea
(the transparent layer that covers the pupil and iris).
It is a sign of vitamin A deficiency.
• Corneal ulceration is a break in the surface of the cornea.
• It is a severe sign of vitamin A deficiency.
• If not treated, the lens of the eye may push out and cause blindness.
• Corneal ulceration is urgent and requires immediate treatment
with vitamin A and atropine (to relax the eye).
 Micronutrient deficiency

11/18/2024 25
 Measure length/height
• For children less than 85 cm in length, or children too weak
to stand, measure the child’s length while supine (lying
down).
• For children 85 cm or more, measure standing height.
• Note: Length is usually greater than standing height by 0.5 cm.
• This difference has been accounted for in the weight-for-
height table in the chart booklet and on your Weight-for-
Height Reference Card.
• If the child is 85 cm or more but cannot be measured
standing, subtract 0.5 cm from the supine length.
• Whether measuring length or height, the mother should be
nearby to help sooth and comfort the child.
• If a child is 6 months to 5 years and has check for the serious
medical complications that will determine the choice of
treatment modalities (In-patient (TFU) or (OTP)):
a. Unable to breast feed or drink
b. Vomiting everything
c. Very Weak, Lethargic or unconscious
d. Convulsions
e. Pneumonia/severe pneumonia:
 Chest in-drawing
 Fast breathing:
Birth-2 month>=60
 For child 2 month to 12 months: >=50 bpm
 For a child 12 months up to 5 years: >=40bpm
For child> 5 years>=30bpm
f. Hypothermia: axillary temp <35 0C or rectal < 35.5 0C
g. Fever >39 0C
h. Shock
i. Dehydration
j. Hypoglycemia
k. Severe anemia: Hgb < 4 gm./dl
l. Extensive skin lesions/infection (+++ dermatosis)
m. Dysentery
n. Jaundice
o. Bleeding Tendencies
Common medical complications in SAM
• Hypoglycemia
• Hypothermia
• Shock
• Severe anemia
• Corneal clouding and ulceration
• Watery diarrhoea and/or vomiting and dehydration
• Heart failure
• Infections
• Abdominal distension
• High grade fever
• Extensive skin lesions
• Significant weight loss for HIV positive patients
• OIs
1 Feeding Management of SAM
F-75 and F-100 Formulas and RUTF
• F-75 is the "starter" formula to use during phase 1,
beginning as soon as possible and continuing for 2-7 days
until the child is stabilized.
• Severely malnourished children cannot tolerate usual amounts
of protein and sodium at this stage, or high amounts of fat.
• They may die if given too much protein or sodium.
• They also need glucose, so they must be given a diet that is
low in protein and sodium and high in carbohydrate
• F-75 is specially made to meet the child‟s needs without
overwhelming the body‟s systems in the initial stage of
treatment.
• Use of F-75 prevents deaths.
• F-75 contains 75 kcal and 0.9 g protein per 100 ml.
• As soon as the child is stabilized on F-75, F-100 is used as a
"catch-up" formula to rebuild wasted tissues during transition
phase and phase 2.
• F-100 contains more calories and protein: 100 kcal and 2.9
g protein per 100 ml.
RUTF
• high-energy, nutrient-dense food used for nutrition
rehabilitation during phase 2 of In patient care and in
outpatient care (OTP).
• It does not need to be cooked or mixed with water
• It is similar in composition to F100 (except RUTF contains
iron and is about five times more energy nutrient dense).
• The RUTF Plumpy‟nut has a caloric value of 545
kilocalories (kcal) per 100 g of product.
• There are two types:
– soft lipid-based paste (Plumpy‟nut®) or
– crushable nutrient bar (BP100).
• The principle behind the recipes is to provide the energy
and protein needed for stabilization and catch-up.
Children 6 months to 5 years
Phase I Feeding
• Feed the child with F-75 and Determine frequency of feeds
 On the first day, feed the child a small amount of F-75 every 3 hours (8
feeds in 24 hours, including through the night).
 If the child is hypoglycemic, give ¼ of the 3-hourly amount every half-hour
for the first 2 hours or until the child‟s blood glucose is at least 54 mg/dl (3
mmol/l).
 Night feeds are extremely important. Many children die from
hypoglycemia due to missed feeds at night.
 After the first day, increase the volume per feed gradually so that the
child's system is not overwhelmed.
 The child will gradually be able to take larger, less frequent feeds (every 3
or 4 hours).
 Five feeds per day are given where there are few staffs at night.
 Give eight feeds per day where there are sufficient staffs to prepare and
distribute the feeds at night
Transition Phase (Feeding the child in transition)
• It may take 2-7 days for the child to stabilize on F-75.
• When the child has stabilized, transfer into transition
phase and offer F-100, the higher calorie, higher protein
“catch-up” feed intended to rebuild wasted tissues.
• In terms of feeding, it is the same as phase I except F-
100 or RUTF is given rather than F-75.
• Eventually the child will be offered F-100 freely.
• However, it is extremely important to make the transition
to free feeding on F-100 or RUTF gradually and monitor
carefully.
• If transition is too rapid, heart failure may occur.
• Usually a child stays in transition phase for 2-3 days.
Recognize readiness for transition phase
• Look for the following signs of readiness to progress
from Phase 1 to transition phase:
• Return of appetite (easily finishes the F-75 feeds) and
• Reduced edema or minimal edema (++ or less) and
• No IV line, No NGT
• The child may also smile at this stage.
• Note; children with +++ oedema should wait in phase I at
least until their oedema has reduced to ++ oedema.
• These children are particularly vulnerable to fluid
overload and heart failure.
 Begin giving F-100 or RUTF
• Transition takes 3 days, during which F-100 or RUTF should be
given according to the following schedule:
• First 48 hours (2 days):
A. Give RUTF (Plumpy’Nut rather than F100) if the child is going
to continue treatment as outpatients (OTP) with take-home treatment.
• The full day‟s amount of RUTF should be given to the mother and
the amount taken checked five times during the day.
• Children that are not taking sufficient RUTF should be given
F100 to make up any deficit in intake.
• No other food should be given to the patient during this period.
• They should be offered as much water to drink as they will take
during and after they have taken some of the RUTF.
• When the children are taking this amount they should be discharged
to continue their treatment at home as OTP.
B. Give F-100 every 5 hours in the same amount as
you last gave F-75 if children can‟t take RUTF or
are not going to continue treatment in OTP.
Give F-100 based on your F-100 reference card for
Transition Phase or the F-100 reference of the
chart booklet.
Do not increase this amount for 2 days.
• If the child is breastfeeding, encourage the mother
to breastfeed before and on demand between feeds
of F-100.
Phase 2 (Feed freely with F-100 or RUTF)
• Criteria to move from transition phase to phase 2 feeding
• Transition takes 2-3 days.
 After transition, the child is in the phase 2 ("rehabilitation"
phase).
 A child is ready for phase 2:
• If he/she has good appetite. This means taking at least 90% of the
RUTF or F100 prescribed for Transition Phase.
• Edematous patients should remain in Transition Phase until there is a
definite and steady reduction in oedema (now at + level):
 For those who are going to remain as inpatients they should
normally remain in Transition Phase until they have lost their
oedema entirely.
 For those who are going to continue as OTP they can go when their
appetite is good and they have reduced their oedema to ++ or +.
Feed with F-100 or RUTF and determine amount to Give
• During phase 2, a child can feed freely F-100 to an
upper limit of 220 kcal/kg/day (This is equal to 220
ml/kg/day.) or RUTF.
• Most children will consume at least 150
kcal/kg/day; any amount less than this indicates
that the child is not being fed freely or is unwell.
• There is F-100 or RUTF reference table that shows
the amount to give for children of different weights
up to 40 - 60 Kg.
Adjust feeding plan as necessary
• During Phase II, the child is expected to gain weight rapidly,
and the amount of F-100 or RUTF given should be increased
as the child gains.
• The more energy that is packed in, the faster the child will grow.
• To plan feeds for the next day:
Use the child‟s current weight to determine the amount of F-
100 or RUTF each day.
Choose a starting amount within the range. Base the starting
amount on the amount taken in feeds during the previous day. If
the child finished most feeds, offer a bit more. If he did not
finish most feeds, offer the same amount as the day before.
Do not exceed the maximum in the range for the child‟s current
weight.
Criteria to move back from transition phase to phase1
Move the child back to Phase 1:
• If the patient gains weight more rapidly than 10g/kg/d (this
indicates excess fluid retention)
• If there is increasing oedema
• If a child who does not have oedema develops oedema
• If there is a rapid increase in the size of the liver
• If any other signs of fluid overload develop.
• If tense abdominal distension develops
• If the patient gets significant re-feeding diarrhea so that there is
weight loss.
• If patient develops medical complication
• If Naso-Gastric Tube is needed
• If patient takes less than 75% of the feeds in Transition Phase even
after interchange between RUTF and F100
Criteria to move back from phase 2 to phase 1
• A child who has any one of the following should
be returned to Phase 1:
• develops any signs of a complication
• Increase/development of oedema
• Development of re-feeding diarrhea sufficient to
lead to weight loss.
• Weight loss for 2 consecutive weighing
• Static weight for 3 consecutive weighing
• Fulfilling any of the criteria of “failure to respond
to treatment”
Feeding Infants less than 6 months
• Malnourished infants should always be treated in inpatient facilities.
• The management of complication is the same as children 6 moths to
5 years as explained in the treatment of complication section.
• The feeding of infants is different from older children and it is also
different for infants on breast feeding or with a caretaker willing to
breast feed and for infants who can not be breast-fed.
• RUTF is not suitable for them, as the reflex of swallowing is not
present yet.
Infants below six months (with a female caretaker)
• Infants who are malnourished are weak and do not suckle strongly
enough to stimulate adequate production of breast milk.
• The mother often thinks that she has insufficient milk and is
apprehensive about her ability to adequately feed her child.
• The objective of treatment of these children is to return them to full
exclusive breastfeeding.
Phase 1 – Transition – Phase 2
• The objective is to supplement the child while stimulating production of
breast milk.
• This is achieved through the Supplementary Suckling (SS) technique:
• Breastfeed every three hours for at least 20 minutes (more if the child cries
or demands more)
• Between one and a half hours after a normal breastfeed give maintenance
amounts of F100-diluted using the SS technique.
• Diluted F100 is given at 130 ml/kg/day, distributed in 6 meals .
• If the infant has no edema, there are not separate phases in the treatment of
infants with the SS technique.
 There is no need to start with F75 and then switch to F100 diluted unless
the infant has oedema.
• If the infant presents with oedema, start treatment with F75 instead of F100
diluted.
After resolution of oedema, change to F100 diluted.
Note: F100 undiluted is never used for small infants (less than 3kg)
Preparation of F 100 diluted
• One packet of F100 is diluted in 2.7 liters of water, instead of 2
liters.
- To make small quantities of F100 diluted,
• Use 100ml of F100 already prepared and add 35ml of water, then
you will get 135ml of F100diluted.
Discard any excess waste. Don‟t make smaller quantities.
• If you need more than 135ml, use 200ml of F100 and add 70ml of
water, to make 270ml of F100 diluted and discard any excess waste.
Supplementary suckling technique
• The mother holds a cup with the F100 diluted. The end of a NG
tube (size nº8) is put in the cup, and the tip of the tube on the
breast, at the nipple. The infant is offered the breast in the normal
way. The cup is placed 5 – 10 cm below the level of the nipple for
easy suckling. When the child suckles more strongly it can lowered
to up to 30 cm
Infants below six months who can not be breast-fed
• The following only applies to malnourished infants for whom
there is no prospect of being breastfed (e.g. no mother, no
wet-nurse) and are less than 6 months of age or less than 3 kg,
with weight-for-length < 70 % or bilateral oedema.
Feeding
• Standard protocols are followed except that F100 is given
diluted in the phase 1 (stabilization phase) (instead of F75) for
children without edema.
• Children with oedema are fed with F75.
• In transition and phase 2 use Diluted F100 (RUTF is not
suitable for these children) at inpatient facility.
• During Transition Phase, the amount of diluted F100 in phase
1 is increased by one third.
 Provide potassium and restrict sodium
• Normally the body uses a lot of energy maintaining the
appropriate balance of potassium inside the cells and sodium
outside the cells.
• This balance is critical to maintaining the correct distribution
of water inside the cells, around the cells and in the blood.
• In reductive adaptation, the “pump” that usually controls the
balance of potassium and sodium runs slower.
• As a result, the level of sodium in the cells rises and the
potassium leaks out of the cells and is lost (for example, in
urine or stools).
• Fluid may then accumulate outside of the cells (as in edema)
instead of being properly distributed through the body.
• All severely malnourished children should be given potassium to
make up for what is lostthey should also be given magnesium,
which is essential for potassium to enter into the cells and be
retained.
• The commercially prepared F-75 and F-100 have enough
potassium and magnesium and there is no need to supplement.
• However, if you use the F-75 and F-100 recipe that are prepared by
the health facility/ locally, Combined Mineral Vitamin mixes (CMV)
should be given to supplement potassium, Magnesium, and other
important minerals and vitamins.
• Malnourished children already have excess sodium in their cells, so
sodium intake should be restricted.
• If a child has diarrhea, a special rehydration solution called
ReSoMal should be used instead of regular WHO ORS.
• ReSoMal has less sodium and more potassium than regular WHO
ORS.
 Mineral mix
• Mineral mix is included in each recipe for F-75 and F-100.
• It is also used in making ReSoMal.
• The mix contains potassium, magnesium, and other essential
minerals.
• It must be included in F-75 and F-100 to correct electrolyte
imbalance.
• The mineral mix may be made in the pharmacy of the hospital or a
commercial product called Combined Mineral Vitamin Mix (CMV)
may be used to provide the necessary minerals.
Vitamins
• Vitamins are also needed in or with the feed.
• Vitamin mix cannot be made in the hospital pharmacy because
amounts are so small.
• Thus, children are usually given multivitamin drops as well. The
multivitamin preparation should not include iron
 Important things NOT to do and why
Do not give diuretics to treat edema.
• The edema is partly due to potassium and magnesium
deficiencies that may take about 2 weeks to correct.
• The edema will go away with proper feeding including a
mineral mix containing potassium and magnesium.
• Giving a diuretic will worsen the child‟s electrolyte
imbalance and may cause death.
Do not give iron during phase 1 and transition phase.
Add iron only when the child is in phase 2 (usually during week 2).
giving iron early in treatment can have toxic effects and
interfere with the body‟s ability to resist infection.
 Do not give high protein formula (over 1.5 g protein per
kg body weight daily).
• Too much protein in the first days of treatment may be
dangerous because the severely malnourished child is
unable to deal with the extra metabolic stress involved.
• Too much protein could overload the liver, heart, and
kidneys and may cause death.
Do not give IV fluids routinely.
• IV fluids can easily cause fluid overload and heart failure
in a severely malnourished child.
• Only give IV fluids to children with signs of shock.
• Be sure that personnel in the emergency treatment area of
the hospital know these important things NOT to do, as
well as what to do.
 What is Hypoglycemia?
• Hypoglycemia is a low level of glucose in the blood.
• In severely malnourished children, the level considered low is
less than <54 mg/dl (< 3 mmol/litre).
• The hypoglycemic child is usually hypothermic (low
temperature) as well.
• Other signs of hypoglycemia include lethargy, limpness, and
loss of consciousness.
• Another sign of hypoglycemia is eye-lid retraction due to
overactive sympathetic nervous system, thus a child sleep
with eyes slightly open.
• Sweating and pallor may not occur in malnourished children
with hypoglycemia.
• Often the only sign before death is drowsiness.
• The short-term cause of hypoglycemia is lack of food.
• Severely malnourished children are more at risk of
hypoglycemia than other children and need to be fed more
frequently, including during the night.
• Malnourished children may arrive at the hospital hypoglycemic
 if they have been vomiting,
if they have been too sick to eat, or
 if they have had a long journey without food.
• Children may develop hypoglycemia in the hospital if they are
kept waiting for admission, or if they are not fed regularly.
• Hypoglycemia and hypothermia are also signs that the child has
a serious infection.
• Hypoglycemia is extremely dangerous.
• The child may die if not given glucose (and then food) quickly,
or if there is a long time between feeds.
 What is Hypothermia?
• Hypothermia is low body temperature.
• A severely malnourished child is hypothermic if the
 rectal temperature is below 35.5 oc or
 if the auxiliary temperature is below 35 0 c.
• Severely malnourished children are at greater risk of
hypothermia than other children and need to be kept warm.
• The hypothermic child has not had enough calories to
warm the body.
• If the child is hypothermic, he is probably also
hypoglycemic.
• Both hypothermia and hypoglycemia are signs that the
child has a serious systemic infection.
• Rectal temperatures are preferred because they
more accurately reflect core body temperature.
• If axillary temperatures are taken, convert them to
rectal by adding 0.5 0c.
 Maintain temperature (prevent hypothermia)
Important measures for all severely malnourished children:
• Cover the child, including his head.
• Stop draughts(መንፈስ፣መጎተት) in the room. Move the child
away from windows.
• Maintain room temperature of 28 and 32 0C (82.4-89.6 0F)
if possible.
• Keep the child covered at night.
• Warm your hands before touching the child.
• Avoid leaving the child uncovered while being examined,
weighed, etc.
• Promptly change wet clothes or bedding.
• Dry the child thoroughly after bathing.
 Signs of Dehydration to follow
Lethargic
• A lethargic child is not awake and alert when he should be.
• He is drowsy and does not show interest in what is happening
around him.
Restless, irritable
The child is restless and irritable all the time, or whenever he is
touched or handled.
Sunken eyes
The eyes of a severely malnourished child may always appear sunken,
• regardless of the child‟s hydration status. Ask the mother if the child‟s
eyes appear unusual.
Thirsty
See if the child reaches out for the cup when you offer ReSoMal. When
it is taken away, see if the child wants more.
What is ReSoMal?
• ReSoMal is a rehydration solution for children with SAM.
• It is a modification of the standard (ORS) recommended by WHO.
• ReSoMal contains less sodium, more sugar, and more potassium
than standard ORS and is intended for severely malnourished
children with diarrhea.
• It should be given by mouth or by nasogastric tube.
• Do not give standard ORS to severely malnourished children.
• ReSoMal is available commercially in some places, but it may also
be prepared from standard ORS and some additional ingredients.
Contents of ReSoMal as prepared from standard ORS:
• Water 2 liters
• WHO-ORS one 1 liter packet
• sugar 50 g
• mineral mix solution* 40 ml or one leveled scoop CMV
• *The mineral mix solution is the same that is
used in making F-75 and F-100.
• Composition of mineral mix is described below.
• It may be prepared by the hospital pharmacy.
• Alternatively, a commercial product, called
Combined Mineral Mix (CMV), may be used.
• If CMV or mineral mix is not available, prepare
with out the mixes
 Prepare ReSoMal
If using commercial ReSoMal, follow the package instructions.
If preparing ReSoMal from standard ORS and mineral mix
solution, prepare as follows:
• Wash hands.
• Empty one 1-litre standard ORS packet into container that holds
more than 2 liters.
• Measure and add 50 grams of sugar. (It is best to weigh the sugar
on a dietary scale that weighs to 5 g.)
• Measure 40 milliliters or one leveled scoop of CMV in a graduated
medicine cup or syringe; add to other ingredients.
• Measure and add 2 liters cooled boiled water.
• Stir until dissolved.
• Use within 24 hours.
Signs of improving hydration status
• Fewer or less pronounced signs of dehydration,eg:
• less thirsty
• less lethargic
• Slowing of rapid respiratory and pulse rates
• Passing urine
• Gaining weight with clinical improvement
If a child has three or more of the above signs of improving
hydration status, stop giving ReSoMal.
• When the child has three or more signs of improving
hydration (see above), stop giving ReSoMal routinely
in alternate hours.
• However, watery diarrhoea may continue after the child is
rehydrated. If diarrhoea continues, give ReSoMal after each
watery diarrhoea to replace stool losses and prevent
dehydration:
• Oedematous Children: give 30 ml after each watery
stool.
• Non-edematous children:
o < 2 years: give 50-100 ml after each watery stool
o 2 years and older: give 100 -200 ml after each watery stool.
Base the amount given in these ranges on the child‟s
willingness to drink and the amount of stool loss.
 Signs to check

• Respiratory rate - Count for a full minute

• Pulse rate - Count for 30 seconds and multiply by two
• Weight
• Urine frequency – Ask: Has the child urinated since last
checked?
• Liver size: mark before any infusion
• Stool or vomit frequency – Ask: Has the child had a stool
or vomited since last checked?
• Signs of hydration – Is the child less lethargic or irritable?
 Signs of Over hydration

Stop ReSoMal if any of the following signs appear:

Increased respiratory rate by five breaths and pulse
rate by 25 beats per minute (Both must increase to be
considered a problem.)
Jugular veins engorged. (Pulse wave can be seen in the
neck.)
• Sudden increase in liver size and tenderness
• Increasing oedema (e.g., puffy eyelids).
• Increasing weight with clinical deterioration
Manage a severely malnourished child with shock
What is shock?
• Shock is a dangerous condition with severe weakness,
lethargy, or unconsciousness, cold extremities, and fast,
weak pulse.
• It is caused by:
– diarrhea with severe dehydration,
– hemorrhage,
– burns, or
– sepsis.
• In severely malnourished children, some of the signs of shock
may appear all the time, so it is difficult to diagnose.
• Thus, IV fluids are given in severe malnutrition only if the
child meets the following criteria:
 The severely malnourished child 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 ,fast or absent radial or femoral pulses and
• absence of signs of heart failure in an edematous child
• To check capillary refill: Press the nail of the thumb or big
toe for two seconds to produce blanching of the nail bed.
• Count the seconds from release until return of the pink
colour. If it takes longer than three seconds, capillary
refill is slow.

• For a child 2 -12 months of age, a fast pulse is 160 beats

or more per minute.
• For a child 12 mnth-5 years of age, a fast pulse is 140
beats or more per minute.
If the child is in shock :
• Give oxygen.
• Give sterile 10% glucose 5 ml/kg by IV .
• Give IV fluids .
• Keep the child warm.
Giving IV fluids
• Shock from dehydration and sepsis are likely to coexist
in severely malnourished children.
• They are difficult to differentiate on clinical signs alone.
• Children with shock due to dehydration will respond to
IV fluids.
• Those with septic shock and no dehydration will not
respond.
• The amount of IV fluids given must be guided by the
child's response.
• Over hydration can cause heart failure and death.
• If no improvement with IV fluids, give blood
transfusion
• If the child fails to improve after the first hour of IV
fluids, then assume that the child has septic shock.
• 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, and
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.
What is severe Anemia?
• Anemia is a low concentration of hemoglobin in the
blood.
• Very severe anemia is a hemoglobin concentration of <
4 g/dl (or packed cell volume <12%).
• If it is not possible to test hemoglobin, rely on clinical
judgment.
• For example, you can judge the degree of anemia
based on paleness of gums, lips, palm, and inner
eyelids.
• Severe anemia can cause heart failure and must be
treated with a blood transfusion.
 • As malnutrition is usually not the cause of severe
anemia, it is important to investigate other possible
causes such as malaria and intestinal parasites
(hookworm).
• Mild or moderate anemia is very common in severely
malnourished children and should be treated later with
iron, after the child has stabilized.

• (Do NOT give iron during phase 1and transition phase as

it can damage cell membranes and make infections
worse.)
• Symptoms of moderate and severe anemia may appear between
day two and day 14 of treatment of malnutrition, due to the
movement of fluids from tissues (edema and intracellular
water) to vascular space.
• This temporary excess of fluids will produce dilutional anemia
(i.e. pseudo anemia) that should never be treated with
transfusions (this risks aggravating the problem and inducing
cardiac overload and death).
• Pseudo-anemia normally resolves spontaneously after 2 or 3
days when kidney function recovers and excess fluids can be
eliminated.
• For these reasons, transfusion is not recommended between
48 hours and day 14 unless there is heart failure and the
cause is other than dilutional anemia.
If hemoglobin < 4g/dl, give blood transfusion
• If hemoglobin is less than 4 g/dl, (or packed cell volume
is less than 12 %) in the first 48 hours, give a blood
transfusion.
1. Stop all oral intake and IV fluids during the transfusion.
2. Look for signs of congestive heart failure such as
 fast breathing,
 respiratory distress,
 rapid pulse,
 engorgement of the jugular vein,
 cold hands and feet,
 cyanosis of the fingertips and under the tongue.
3. Give a diuretic to make room for the blood. Furosemide
(1 mg/kg, given by IV) is the most appropriate choice.

4. If there are no signs of congestive heart failure,

transfuse whole fresh blood at 10 ml/kg slowly over 3
hours.

5. If there are signs of heart failure, give 10 ml/kg

packed cells over 3 hours instead of whole blood.
 Heart failure
• Physical deterioration with
 weight gain,
 sudden increase in liver size and tenderness,
 increased respiratory rate,
 „grunting‟ breathing,
 crepitation's in lungs,
 prominent superficial and neck veins,
 engorgement of the neck veins when the abdomen is pressed,
 increased edema or reappearance of edema, among other
clinical signs and symptoms.
• It progresses to marked respiratory distress with rapid
pulse, cold hands and feet, edema and cyanosis and sudden
death from cardiac shock.
• Heart failure and pneumonia may be difficult to tell
apart as they can be clinically similar.
• When weight gain precedes or is associated with signs
of respiratory distress, heart failure should be the
first diagnosis.
• If there is loss of weight, consider pneumonia
instead.
• Note: Children with edema do not necessarily present
weight gain during heart failure if the expanded
circulation is due to mobilization of edema fluid from
the tissues to vascular space.
Treatment
• Stop all intakes of oral or IV fluids
No fluid or food should be given until heart failure
has improved (even if this takes 24 to 48 hours).
Small amounts of sugar-water can be given orally
to prevent hypoglycemia.
• Give Furosemide (1 mg/kg) single dose, repeat if
necessary.
• Digoxin can be given in a single dose (5
microgram/kg, lower than the normal dose).
Select antibiotics and prescribe regimen
• Selection of antibiotics depends on the presence
or absence of complications.
• Complications include :
septic shock
 hypoglycemia
 hypothermia
 skin infections
dermatosis (+++ with raw skin/fissures),
 respiratory or urinary tract infections, or
lethargic/sickly appearance.
• If no complications, give first line antibiotics:
 oral Amoxicillin (preferred) or Cotrimoxazole if Amoxicillin is
not available.
• If complications present, give second line antibiotics:
o If the child has shock, respiratory distress , unconsciousness,
and very sick Give, Gentamicin, plus IV Ampicillin for 2 days
followed by oral Amoxicillin.
o If the child has complications other than mentioned above, give
oral Amoxicillin and I.M. Gentamicin.
• If the child fails to improve within 48 hours, add chloramphenicol
or Ceftriaxone)
• Almost all children improve on Gentamicin plus amoxicillin, and
it is rare that chloramphenicol is needed.
• If specific infections are identified which require a specific
antibiotic not already being given, give an additional antibiotic to
address that infection.
1. If the child is not passing urine, Gentamicin may
accumulate in the body and cause deafness.
Do not give the second dose until the child is
passing urine.
2. If amoxicillin is not available, give Ampicillin,
50 mg/kg orally every 6 hours for 5 days.
Give folic acid
• Folic acid is a vitamin important for treating and
preventing anemia and repairing the damaged gut.
• There is sufficient folic acid in commercially
manufactured F75, F100 and RUTF to treat mild folate
deficiency.
• CMV should be added in locally prepared F75 and F100.
• On the day of admission, one single dose of folic acid (5 mg)
can be given to children with clinical signs of anemia.
Give vitamin A
• Severely malnourished children are at high risk of blindness
due to vitamin A deficiency.
• Thus, vitamin A should be given orally to all children with SAM
on the day of admission (on Day 1),
• except :
– those with oedema or
– those who received vitamin A in the past 6 months.
• However, for children with edema, it should be given once the
oedema subsides.
• Give a second dose on discharge if the child finishes the
treatment in in-patient care.
• Don't give the discharge dose of vitamin A when transferred to
OTP since it will be given at the OTP site on the fourth week.
 Timing and oral dosages of vitamin A
Targets Timing Age Dosage
All children* Day 1 <6 months 50 000 IU
6 – 12 months 100 000 IU
> 12 months 200 000 IU

All children who are Day 15 or day of

not discharge
transferred to OTP Same age-specific dose
All children who On the 4 th week
will be of treatment
transferred to OTP
Children Day 1,2 and 15
with eye signs or
has
measles or had *Unless vitamin A is given in the last 6
measles in months or if a child has edema
the past 3 months
Give Measles Vaccine
• All children from 9 months who are not vaccinated should
be given measles vaccine both on:
– admission
– discharge after Phase 2.
• The first measles dose often does not give a protective
antibody response.
• It is given because it ameliorates the severity of incubating
measles and partially protects from nosocomial measles
• The second dose is given to provoke protective
antibodies.
 Give Deworming tabs
• Worms are common in older children who play
outside, and they can be a problem in severely
malnourished children.
• They can cause dysentery and anemia Albendazole
or Mebendazole is given at the start of phase 2 for
children greater than 1 year that will remain as in-
patient.
• For those transferred to outpatient Albendazole or
Mebendazole is given at the second outpatient visit
(after 7 days).
 Give Iron
• Even if the child is anemic, he/she should not be given
iron until he is recovering and he/she is in phase 2.
• If given earlier, iron can have toxic effects and reduce
resistance to infection.
• Provide iron to a child who is in phase 2. Add 1 crushed
tablet of ferrous sulphate (200 mg) to each 2 to 2.4 liters
of F100.
• For lesser volumes: 1000 to 1200 ml of F100, dilute one
tab of ferrous suphate (200 mg) in 4 ml of the solution.
• For 500 ml to 600 ml of F100, add 1ml of the solution

Don't give iron to a child who is taking RUTF because it

already has the required amount of iron.
 Do not give iron early in treatment
• Due to reductive adaptation, the severely malnourished
child makes less hemoglobin than usual.
• Iron that is not used for making hemoglobin is put into
storage.
• Thus, there is “extra” iron stored in the body, even though
the child may appear anemic.
• Giving iron early in treatment will not cure anemia, as the
child already has a supply of stored iron.
• Giving iron early in treatment lead to “free iron” in the body.
• Free iron can cause problems in three ways:
1) Free iron is highly reactive and promotes the formation
of free radicals, which may engage in uncontrolled
chemical reactions with damaging effects.
2) Free iron promotes bacterial growth and can make some
infections worse.
3) The body tries to protect itself from free iron by converting
it to ferritin. This conversion requires energy and amino acids
and diverts these from other critical activities.
• Later, as the child recovers and begins to build new tissue
and form more red blood cells, the iron in storage will be
used and supplements will be needed.
 Danger signs
 In addition to watching for increasing pulse or respirations and
changes in temperature, watch for the following danger signs and
alert a physician if any of these danger signs appear.
• anorexia (loss of appetite)
• change in mental state (e.g., becomes lethargic)
• jaundice (yellowish skin or eyes)
• cyanosis (tongue/lips turning blue from lack of oxygen)
• difficult breathing
• difficulty feeding or waking (drowsy)
• abdominal distention
• new oedema
• large weight changes (> 20 gm during phase 1)
• increased vomiting
• petechial (bruising)
• If the child has edema, allow more space for
weight loss (up to 30%) by placing the starting
weight higher on the axis.
• As a general guideline, allow for up to:
– 1 kg weight loss if mild (+) or moderate (++)
edema
– 2 kg weight loss if severe (+++) edema and
child is ≤ 7 kg
– 3 kg weight loss if severe (+++) edema and
child is > 7 kg
 Discharge Criteria
• The discharge criteria differ for children age 6-
59 months and less than 6 months.
i. Children age 6-59 months and who will complete
their phase 2 treatments as inpatient should be
discharged from in-patient care if they fulfill the
following criteria:
Age Discharge Criteria

Option 1 • weight-for-length or height

>=85% and no oedema for
10 days (In-patient) or
Option 2 • Target weight gain achieved if
the child is admitted
with MUAC
Age Discharge Criteria

6 months on • Infant gaining weight on breast

breastfeeding or milk alone
with a • No medical problem
caretaker willing to • Mother is adequately supplemented
breast feed with vitamins and minerals
• There are no anthropometric criteria
for discharge of the fully breast-fed
infant who is gaining weight.
Age
• <6 months who can not be breast-fed
Discharge Criteria
• When they reach 85% weight for length and
they can be switched to infant formula or
animal milk.