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PRINCIPLES OF MANAGING A CHILD

WITH SAM.

OBJECTIVES
At the end of this session, you should
be able to:
1. Define SAM
2. Know Principles of Management of
SAM

Definition of SAM
Features:
(i) Presence of edema of both feet
(ii) severe wasting (wt for height < -3
SD or MUAC < 11.5 cm)

Complicated vs Uncomplicated SAM


COMPLICATED SAM

UNCOMPLICATED SAM

Have poor appetite

Have a good appetite

Not alert

Clinically well and alert

Have Severe Edema (+++)

No edema

May have one or more


medical complications
(shock, hypoglycaemia,
hypothermia, respiratory or
urinary tract infections,
dermatosis (flaky paint
dermatosis)

Have no any medical


complications.

Principles of the management of


SAM.
General treatment involves 10 steps
divided into phases:
the initial stabilization phase
the Rehabilitation phase and
follow-up

Adapted from Nelson Textbook of pediatrics 19th Ed

Phase one : stabilization


phase.
Correct hypoglycemia, dehydration,
manage hypothermia, control
infections, initiate feeding, correct
electrolyte imbalance, supply
micronutrients without iron, sensory
stimulation.

Hypoglycemia.
When blood glucose is <3mmol/litre
(<54mg/dl) in a malnourished child
Children with acute malnutrition are
at risk of hypoglycemia.
If it can not be measured, assume
that the child with SAM is
hypoglycemic and give treatment.

Management of
Hypoglycemia
Give 50 ml of sugar water (1 teaspoon sugar in
50ml water) give 50ml of 10% glucose or
sucrose solution orally or by NGT.
Initiate the first feed ASAP with F- 75
therapeutic milk, continue every 2hrs for 24hrs.
If unconscious consider other routes:
Bolus IV 10% glucose at 5ml/kg, if IV access not
quickly established give by NGT. If IV glucose not
available give one teaspoon of sugar moistened
with one/two drops of water sublingually, repeat
every 20 mins

Management of hypoglycaemia
contd..
Monitor RBG every 30 mins and Start
Antibiotics

Hypothermia.
Common in malnourished children
and may indicate infection or
hypoglycemia.
Axillary temp < 35C or rectal
temp < 35.5C.
Management : Feed, give antibiotics,
rewarm the child (clothing, skin to
skin contact with mother).

Dehydration
Assume that all children with watery
diarrhea or reduced urine output
have some dehydration.
Management: Give 5ml /kg of
ReSoMal every 30mins for the first
2hrs and then 5 10 ml / kg per hr
for the next 4 10 hrs orally or by
NGT.
Dont use IV route unless in shock.

Electrolyte imbalance
Malnourished children have
deficiency of potassium and
magnesium
Management:
1. Give extra potassium (3-4 mmol/kg
per day)
2. Give extra magnesium (0.4-0.6
mmol/kg per day) in feed
preparation
. May take up to 2 weeks to correct.

Infections
Children with SAM may have
infections without signs like fever.
Assume that all have an infection
and treat with antibiotics
immediately.
For uncomplicated SAM give oral
Amoxicillin 25-40 mg kg 8hrly for 5/7
For complicated SAM give
parenteral antibiotics:

Infections ctd
Benzylpenicillin or ampicillin IM/IV for
2 days, then oral amoxicillin for 5
days PLUS Gentamicin od for 7days.
If any evidence of other infections,
treat appropriately.

Micronutrient deficiencies.
If child is receiving pre- mixed
therapeutic foods containing
vitamins and minerals, there is no
need of additional doses.
If not , give :
FA 5 mg on day 1; then 1 mg
daily.
multivitamin syrup 5ml
zinc 2 mg/ kg/ day and
copper 0.3 mg/ kg/ day.

Micronutrients ctd
Give vitamin A on day 1 and repeat
on day 2 and 14 if child has signs of
vitamin A deficiency like corneal
ulceration or has a history of
measles.
Start iron at 3mg/ kg/ day during the
rehabilitation phase, after 2 days
on F- 100. NB: Dont give iron if on
RUTF or in the stabilization phase.

2nd phase: rehabilitation


phase
Continue with antibiotic therapy,
catch - up feeding, iron therapy,
sensory stimulation.

Feeding
There are two ways of feeding:
1.Initial Refeeding (Day 1- 7),
Stabilization Phase
2.Catch up Feeding (From 2 weeks),
Rehabilitation Phase

Initial re-feeding.
Should be frequent( every 2-3hrs )
The starter formula commonly used is F- 75.
that begin as soon and continuing for 2-7 days
Treatment in the initial phase aimed at
providing calories at 100kcal/kg pday, Protein
at 1-1.15g/kg pday and liquid at 130ml/kg
pday
If child is breastfed, encourage continued
breastfeeding . Just make sure the starter
formula prescribed amount is given.

Refeeding Schedule

DAYS

FREQUENCY

VOL/KG/FEED

VOL/KG/DAY

1-2

2 hourly

11ml

130ml

3-5

3hourly

16ml

130ml

6 onwards

4hourly

22ml

130ml

Types of Formulas
F-75 starter:
F-75 Starter
used
cereal based

F-100 Catch
up

Dried skimmed
milk (g)

25

25

80

Sugar (g)

70

100

50

Cereal flour (g)

35

Vegetable oil
(g)

27

27

60

Electrolyte/min
eral soln (ml)

20

20

20

Water: make up

1000

1000

1000

CONTENTS per
100mls

F-75 (cereal
based)

F-75
(starter)

F-100 (Catch
up)

Energy (kcal)

75

75

100

Protein (g)

1.1

0.9

2.9

Lactose (g)

1.3

1.3

4.2

Potassium (mmol)

4.2

4.3

6.3

Sodium (mmol)

0.6

0.6

1.9

Magnesium
(mmol)

0.46

0.43

0.73

Zinc (mg)

2.0

2.0

2.3

Copper (mg)

0.25

0.25

0.25

% energy from
protein

12

% energy from fat

32

32

53

Osmolality
(mOsm/l)

334

413

419

Catch-up growth feeding


Involves Transition from F-75 to F-100
Signs that a child has reached rehabilitation for
catch-up growth are:
i. Return of Appetite
ii. No episodes of hypoglycaemia
iii. Reduced/ disappearance of all edema
. Treatment in the initial phase aimed at providing
calories at 150-220kcal/kg pday, Protein at 46d/kg pday and liquid at 200ml/kg pday

Catch Up growth feeding


Replace starter F-75 with equal amount
of F-100 for 2days.
On day 3, increase each successive
feed by 10ml until some feeds remain
uneaten.
Monitor for early signs of CHF and
reduce the volume of the feed.
After transition assess progress by rate
of weight gain.

Weight gain
Is calculated every 3 days as g/kg
per day
-Poor if <5g/kg/d
-Moderate if 5-10g/kg/d
-Good if >10 g/kg/d
Adequate weight gain is when the
child has a weight gain of
>5gm/kg/day for at least 3
successive days.

Sensory stimulation.
Prevent permanent psychosocial
effects of starvation with
psychomotor stimulation.
Provide the child with tender loving
care, a cheerful stimulating
environment, physical activity as
soon as the child is well enough.
Provide toys and play activities for
the child.

Common Associated
conditions
1. Eye Problems: mainly due to vitamin A
deficiency.
2. Severe Anaemia.
3. Skin lesions in Kwashiorkor: Hypo- or
hyperpigmentation, Ulceration,
Exudative lesions, Desquamation of skin.
4. Continuing Diarrhoea: Check stool,
Lactose intolerance, Osmotic diarrhea.
5. Tuberculosis.

Discharge and follow-up.


The child should be discharged from
hospital to outpatient or nutritional
program when:
-they have completed parenteral
antibiotic therapy and are clinically
well and alert,
-medical complications are
resolved,
-their appetite has fully
recovered and they are eating well

Discharge and follow-up


The child should be discharged from
the nutritional treatment program
when only when:
-wt for height -2 SD score
and they have had no edema for at
least 2 weeks,
or MUAC 12.5cm and they
have had no edema for at least 2
weeks.

Follow-up
After the child has been discharged to
outpatient, a plan should made follow-up
until full recovery.
The child should be weighed weekly after
discharge
If they fail to gain weight over a 2 week
period or loses weight btn 2
measurements or develops loss of appetite
or edema, should be referred back to
hospital for further assessment.

References
1. Pocket book of hospital care for
children, WHO
2. Nelson Textbook of pediatrics 19th Ed
3. National guideline for the
Management of Acute malnutrition in
Tanzania.

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