Severe acute malnutrition is due to an imbalance between food intake and needs of the individual. This is usually a deficit in both quantitative (number of kilocalories / day) and qualitative (vitamins, minerals, etc.).
In children over 6 months:
The two major clinical forms of severe malnutrition are:
– The slump: large muscle and fat melting, appearance “skeletal”
– Kwashiorkor: bilateral leg edema / edema of the face, often associated with cutaneous signs (shiny or cracked skin lesions with the burning appearance, bleached hair and brittle).
Both forms can be associated (marasmus-kwashiorkor).
In addition to these characteristic signs, severe acute malnutrition associated with severe pathophysiological disturbances (metabolic disorders, anemia, immune depression promoting the development of often difficult to diagnose infections, etc.).
The complications are numerous and can be life-threatening.
Mortality can be elevated in the absence of in suitable supported.
The criteria for admission / exit of a severe malnutrition treatment program are both anthropometric and clinical:
• MUAC (PB) is the measurement of the circumference of the arm, conducted in the middle of the relaxed left arm in children 6 to 59 months (or measuring 65-110 cm).
PB measure the importance of muscle wasting. A BP <110 mm indicates severe malnutrition and a significant risk of death.
• The index weight / height (P / T) measures the importance of underweight by comparing the weight of malnourished children to the median weight of non-malnourished children of the same size.
Severe malnutrition is defined by an index P / T <- 3 Z under the new child growth standards of WHO (Some national programs NCHS reference to determine the anthropometric criteria for admission and exit, with thresholds expressed in % of the median.).
• The presence of bilateral edema of the lower limbs always corresponds to a severe acute malnutrition irrespective of the index P / T and PB (not eliminate other causes of edema).
The admission criteria are usually: BP <110 mm (in children over 59 months or over 110 cm, the PB is no longer used as an admission criterion) or P / T <- 3 Z2 or presence of bilateral edema of the lower extremities.
output criteria (healing) are usually: P / T> – 2 Z2 and absence of bilateral edema (two consecutive measurements at one-week intervals) and lack of uncontrolled acute pathology. PB is not used as an exit criterion.
The support arrangements (hospitalization or outpatient treatment) depend on the presence or absence of serious complications:
• Children with anorexia or major medical complications, p. ex. severe anemia, severe dehydration or severe infection (complicated acute malnutrition) must be hospitalized “By rule, a malnourished child with serious medical complications should initially be hospitalized, even though he suffers from moderate malnutrition (p. ex. P / T > – 3 Z) “.
• Children without major medical complications (uncomplicated acute malnutrition) can track their outpatient treatment with a weekly medical supervision.
Treatment:
1) Diet therapy:
Recharge based on the use of therapeutic foods fortified with vitamins and minerals:
– Therapeutic Milk (for hospitalized patients):
• The F-75 therapeutic milk, low protein, sodium and calories (0.9 g of protein and 75 kcal per 100 ml) is used in the initial phase of treatment in patients suffering from complicated acute malnutrition. It is administered to cover the basic needs while the complications are supported medically. The daily amount is administered in 8 meals.
• Therapeutic milk F-100, the density of protein and calories is higher (2.9 g of protein and 100 kcal per 100 ml), replaces after a few days once the patient is stabilized (Resume appetite, clinical improvement; melting of edema at least initiated). The objective is to rapidly gain weight in children. It can be given in combination with, or replaced by, RUTF.
– The RUTF (ready-to-use therapeutic food) as food consumer loans (.. Eg of milk peanut paste, like Plumpy’nut), are used in children treated as outpatients and in hospitalized children. The nutritional characteristics of RUTF are close to those of milk F-100, but the iron content is significantly higher. They are designed to rapidly gain weight (about 500 kcal per 100 g). These are the only therapeutic food used as an outpatient.
Furthermore, it is important to give water, without food, especially if the outside temperature is high or if the child has a fever.
For school-age children be breastfed, keep breastfeeding.
2) systematic medical treatment:
Apart from any particular complication, it is recommended to always perform the following treatment (outpatient or inpatient treatment)
– For infections:
• Vaccination against measles, upon admission.
• Antibiotic broad spectrum from J1 (amoxicillin PO: 70 to 100 mg / kg / day in 2 divided doses for 5 days) “In case of specific infection signs, adjust antibiotic therapy and length of treatment.”
• In areas endemic for malaria: quick test to J1 and treatment based on the results.
Without test, systematic antimalarial treatment (page 131).
• anthelmintic treatment on Day 1 or Day 8:
albendazole PO
Children> 6 months and adults: 400 mg single dose (200 mg in children> 6 months but <10 kg)
– For micronutrient deficiencies:
The use of therapeutic foods corrects most of them.
Some supplements are however necessary:
• A dose of vitamin A is given routinely on admission, retinol
(Vitamin A) “Only patients with clinically detectable ocular lesions receiving a complete cure by vitamin A”:
Children from 6 months to 1 year: 100 000 IU single dose
Children over 1 year: 200 000 IU single dose
• A dose of 5 mg of folic acid PO is given routinely on admission.
3) Support for common complications:
– Diarrhoea and dehydration
Diarrhea is often associated with malnutrition. Therapeutic foods used to reconstruct the digestive mucosa and boost production of stomach acid, digestive enzymes and bile juice. Amoxicillin systematic treatment reduces the bacterial load effectively. Most diarrhea stop without further treatment. Watery diarrhea may however be related to the presence of another disease (otitis media, pneumonia, malaria, etc.), to look for.
The child receives simple, non-oral rehydration salts water after each loose stool. Oral rehydration salts are administered in case of dehydration established.
If an etiological treatment is necessary, see page 83.
Dehydration is more difficult to assess than in healthy children, p. ex. in case of stagnation, signs “skin fold” or “sunken eyes” are present even if the child is not dehydrated.
Diagnosis is watery diarrhea history of recent onset accompanied by a weight loss corresponding to the water loss since the onset of diarrhea. Chronic and persistent diarrhea does not require rapid rehydration.
The hydration protocol is different from the standard protocol:
• In the absence of hypovolemic shock, rehydration is done orally (possibly by nasogastric tube) using specific oral rehydration salts “Except in cases of cholera, in this case using standard rehydration salts” (ReSoMal) containing less of sodium and potassium of more than standard rehydration salts.
ReSoMal should be administered under close medical supervision (clinical evaluation and weighing every hour). The dosage was 10 ml / kg / hour for the first 2 hours and then 5 ml / kg / hour, until the weight loss
– Known or estimated – is corrected.
In practice, it is useful to determine the target weight before starting rehydration. The target weight is the weight prior to the onset of diarrhea. In a child who is improving clinically and shows no signs of fluid overload, rehydration continued until the return to the previous weight.
When weight loss can not be measured (newly admitted child p. Ex.), The latter is estimated at 2-5% of current weight.The target weight should not exceed more than 5% the current weight (p. Ex. If the child weighs 5 kg before starting rehydration, the target weight should not exceed 5.250 kg).
Whatever the target weight, the appearance of water overload signs requires stopping rehydration.
• The intravenous route has a significant risk of fluid overload and heart failure. It is only used in case of hypovolemic shock (weak or absent radial pulse, cold extremities, impaired consciousness, associated with recent weight loss, if known):
Ringer lactate: 15 to 20 ml / kg over 30 minutes to an hour, under strict medical supervision. Reassess every 15 minutes and monitor aparition signs of fluid overload.
– If the clinical condition improved after 30 minutes (recovery of consciousness, hit pulse), continue the infusion at a rate of 15 to 20 ml / kg for one hour then move to the mouth with ReSoMal: 10 ml / hour for 2 hours.
– If the clinical condition has not improved or worsened (overload signs) after the first hour of treatment, slowing the infusion (vein guard) and treat sepsis.
– Bacterial Infections
Lower respiratory infections, ear infections, skin and urinary tract infections are common but sometimes difficult to diagnose (no fever, specific symptoms). The presence of infection should be suspected in a sluggish or sleepy child.
The presence of hypothermia or hypoglycemia is suspected severe infection. The site of infection is difficult to determine, a broad spectrum antibiotic, combining two antibiotics is recommended.
– Hypothermia and hypoglycaemia
The hypothermia (rectal temperature <35.5 ° C or axillary <35 ° C) is a common cause of death during the first days of hospitalization.
To prevent this, keep the child against the mother’s body (kangaroo), give blankets. In case of hypothermia, warm the child as above, monitor temperature, treat underlying hypoglycemia and infection.
In case of suspected or confirmed hypoglycemia (dipstick), administer glucose PO if the child is conscious (50 ml sugar water [50 ml water + a teaspoon of sugar] or 50 ml milk) ; if the child is unconscious, 1 ml / kg of 50% glucose IV. Treating an underlying infection.
– Oral candidiasis
A systematic search because it interferes with feeding, see treatment page 92.
– Skin lesions of kwashiorkor
• In dry areas: ointment of zinc oxide 2 times / day.
• If oozing or extensive lesions: gentian violet, 2 applications / day (to avoid on the face).
• If superinfection: treat as impetigo (page 105).
If at the end of a medical and nutritional treatment behaved well the child does not recover, think of another disease: tuberculosis, HIV infection, etc.
In adolescents and adults:
Clinical examination (sudden loss of weight, reduced mobility due to muscle wasting, cachexia, presence of edema of the lower limbs to the exclusion of other causes of edema) is essential for diagnosis and a medical care, nutrition and sometimes social adapted.
The admission and discharge criteria are (indicative):
– Admission Requirements:
In adolescents: the same as in children (but the PB is not used).
Adults: BP <160 mm or bilateral leg edema (grade 3 or higher, having excluded other causes of edema) or MUAC <185 mm in a patient in poor general condition (inability to stand , apparent dehydration, p. ex.).
As in children, while malnourished patient with severe medical complications is initially hospitalized, regardless of anthromopétriques criteria above.
– Exit criteria:
In adolescents: the same as in children.
Adults: weight gain> 10 to 15% and bilateral leg edema <Grade 2 and good condition.
Dietary treatment follows the same principles as for the child, but caloric intake is less important.
Routine treatments are similar to those of the child but:
• The vaccine against measles is administered in adolescents (up to age 15 years).
• No systematic antibiotics, search and treat if infection present.
For more information on the treatment of malnutrition in infants, children and adults, visit the Nutrition guide, MSF.
