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Severe Acute Malnutrition (SAM) : Causes, Types, Criteria, Symptoms, & Treatment

Severe Acute Malnutrition (SAM) : Definition, Etiology, Pathophysiology, Types, Criteria, Signs, Symptoms, Complications, Management, & Prevention

Definition

Severe Acute Malnutrition (SAM) is said to be there if any one out of three are present

  1. Severe wasting (Weight for height <70% or < -3 standard deviation)
  2. Mid upper arm circumference (MUAC) < 11.5 cm
  3. Decrease in weight for age with symmetrical edema

Types

Criteria Kwashiorkor Marasmus
Edema Edematous SAM Non-edematous SAM
Cause Moderate to severe deficiency of calories   +  Severe deficiency of protein + Free radical damage Severe deficiency of calories & protein But no free radical damage
Features Hallmark features (PEM-G)   P: Psychomotor changes (irritability, apathy) E: Edema (e.g. ascites, effusion) M: Muscle wasting G: Growth retardation (stunting) Other features Hepatomegaly Hypoalbuminemia Poor appetite Hair changes (FLAG sign) Skin changes (Flaky paint dermatosis OR Crazy pavement dermatosis) Increased infections No edema No CNS changes No hair changes No skin changes Alopecia Wrinkles on face (Old man look OR Monkey child look) Baggy pants appearance due to fat loss from thigh & buttocks Voracious appetite
Prognosis Poor Better outcome

Hormones in SAM

Increase Decrease
Serum cortisol Serum growth hormone
Serum insulin Serum IGF-1 (Somatomedins)

Complications

Mnemonic: SHIELDED

  • S: Sugar deficiency i.e. hypoglycemia
  • H: Hypothermia
  • I: Infections
  • EL: Electrolyte disturbances
  • DE: Dehydration
  • D: Diarrhea → Death

Management

Hospitalize

2 phases

Stabilization (0-7 days)

Rehabilitation (2nd to 6th week)

Following guideline is followed:

A. Stabilization phase (0-7 days)

Treat & prevent

  • Hypoglycemia (First 2 days)
  • Hypothermia (First 2 days)
  • Dehydration (First 2 days)
  • Infections (All days)

Initiation of feeds

  • Day 1

75-80 Kcal/kg/day

0.8-1 g/kg/day of proteins

↓Slowly increase

  • Day 7

100-110 Kcal/kg/day (Never by ≥ 130 Kcal/kg/day)

2-3 g/kg/day of proteins

  • Type of food: F-75 feed
  • Timing: Feed every 2-3 hourly

Micronutrients

  • All micronutrients are needed (except: Oral iron in stabilization phase)

1. Vitamin A (orally)

  • < 6 months: 50000/IU
  • 6-12 months: 1 lakh/IU
  • > 12 months: 2 lakh/IU

2. Folic acid

  • Day 1: 5 mg
  • Later on: 1 mg/day

3. Zinc

  • 2 mg/kg/day

4. Copper

  • 0.2 mg/kg/day

B. Rehabilitation phase (2-6 weeks)

Give micronutrients as before

+

Oral iron 3 mg/kg/day

  • Calorie: 175-200 Kcal/kg/day
  • Protein: 4-6 g/kg/day
  • F-75 → F-100

Failure of therapy

A. Primary failure to respond

  • Failure to regain appetite by day 4 OR
  • Failure to start losing edema by day 4 OR
  • Presence of edema on day 10 OR
  • Failure to gain at least 5 gm/kg/day by day 10

B. Secondary failure to respond

  • Failure to gain at least 5 gm/kg/day by day for 3 consecutive day during rehabilitation phase.

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