national guideline nepal IMAM

1. TOPIC PRESENTATION
Approach to child with malnutrition
Dr. Bishal Sapkota
1st year Resident
MDGP & EM
PAHS

2. Protein Energy Malnutrition

3. Content
• Definition
• Epidemiology
• Indicators
• Classification
• Etiology
• Clinical features
• IMAM – objectives, principles and structure
• Assessment of Acute Malnutrition
• Criteria for Admission
• Management SAM
• Outpatient and Inpatient

4. Definition
According to WHO Malnutrition refers to deficiencies, excesses, or imbalances in a person’s
intake of energy and/or nutrients.
• Addresses 3 broad groups of conditions:
• Undernutrition –
• wasting (low weight-for-height)
• stunting (low height-for-age) and
• underweight (low weight-for-age)
• micronutrient-related malnutrition
• micronutrient deficiencies (a lack of important vitamins and minerals)
• micronutrient excess.
• overweight, obesity and diet-related noncommunicable diseases
such as heart disease, stroke, diabetes and some cancers

5. Epidemiology

6. Epidemiology

7. Epidemiology

8. Epidemiology
Trends in nutritional status of children, NEPAL 1996-2016
Nepal demographic and health survey 2016

9. Indicators
indicators
Wasting Low weight for height • Acute malnutrition,
• result of more recent food deficit or
illness
Stunting Low height for age • Chronic malnutrition
• result of prolonged food deprivation
and/or disease or illness
Under weight Low weight for age Both acute and chronic

10. Classification
Age Dependent parameters Age Independent parameters
1. Gomez’s classification
2. Waterlow’s classification
3. Wellcome Trust classification
4. WHO classification
5. Indian Academy of Pediatrics
(IAP)
1. Mid upper arm
circumference (MUAC)
1. Bangle test
2. Skin fold thickness
3. Ratios
• Mid-arm /height ratio
• Chest/head-circumference ratio
• Mid-arm/head circumference ratio

11. WHO classification
Malnutrition Moderate
Z-scores
Severe
Z-scores
Symmetrical
oedema
No Yes
Wt/ht
(wasting)
-2 to ≥ 3SD ≤ 3 SD
Ht/age
(stunting)
-2 to≥ 3SD ≤ 3 SD

12. ETIOLOGY
Immediate cause
Underlying cause
Basic cause

13. Recent evidence clarifies that the period of greatest vulnerability to nutritional
deficiencies begins during pregnancy.

14. Clinical features
Marasmus
• Head that appears large relative to the
body, with staring eyes
• Emaciated and weak appearance
• Irritable and fretful affect
• Bradycardia, hypotension, and
hypothermia
• Thin, dry skin
• Shrunken arms, thighs, and buttocks
with redundant skin folds caused by
loss of subcutaneous fat
• Thin, sparse hair that is easily plucked

15. Kwashiorkor
Clinical features
• Symmetrical pitting edema
• Starts from dependent part and proceeds cranially
• Apathetic, listless affect.
• moon-face
• Pursed mouth
• Thin, dry, peeling skin with confluent areas of
hyperkeratosis and hyperpigmentation
• Dry, dull, hypopigmented hair that falls out or is easily plucked. Flag
sign
• Hepatomegaly (from fatty liver infiltrates).
• Distended abdomen with dilated intestinal loops.
• Bradycardia, hypotension, and hypothermia.

16. Differences between Marasmus and Kwashiorkor
Features Marasmus Kwashiorkor
Face
Edema
Wasting
Growth retardation
Mental changes
Drawn in monkey like
None
Marked
Present
Less common
Edematous
Present
Present
Present
Common (irritable)
Appetite
Skin change
Hair change
Poor
Uncommon
Less common
Good
Common (flaky paint)
Common ( flag sign)
Anemia
Liver
Less severe
Normal or atrophic
Severe
Fatty infiltrates
Occurrence
Infection
Recovery
Mortality
More common
Less prone
Early
Less than kwashiorkor
Less common
More prone
Slow
High in early stage

17. Integrated Management of Acute Malnutrition(IMAM)
Acute malnutrition occurs when an individual suffers from
• severe nutritional restrictions,
• a recent bout of illness,
• inappropriate child care practices or a
• combination of these factors
The result is sudden weight loss or the development of bilateral pitting
edema, which can be reversed with appropriate treatment

18. The primary objectives of IMAM are:
• To reduce mortality & morbidity risks in children under five due to acute
malnutrition.
• To rehabilitate children with acute malnutrition to a state of health in
which they are able to sustain their nutritional status upon discharge as
cured.
• To prevent the condition of children with acute malnutrition from
deteriorating thus requiring more intensive treatment.
• Contribute to the prevention of acute malnutrition in young children in
the critical 1000 day window
• Prevent micro-nutrient deficiency disorders among under five year old
children associated with acute malnutrition
Objectives of IMAM

19. Principles of IMAM
IMAM is based on the following principles -
• Maximum coverage and access :- accessible and acceptable
• Timeliness – Early detection and treatment before complications
develop.
• Appropriate care –
• outpatient care
• inpatient treatment.
• Care for as long as it is needed –
• By improving access to treatment and
• integrating the service into the existing structures and health
system
• until they have been cured

20. Structure of IMAM
• Community mobilisation:
• identification at the community level
• early detection & referral before complication.
• Inpatient Therapeutic Care (ITC) : complicated cases of SAM
• Outpatient Therapeutic Care (OTC): non-complicated cases of
SAM
• Management of Moderate Acute Malnutrition (MAM)

21. Assessment of Acute Malnutrition
Acutely malnourished children are identified by :
• Determine the age :- ( 6 – 59 months)
• Measuring the mid – upper arm circumference (MUAC) :-
<11.5cm - SAM and
≥11.5 - <12.5cm - MAM
• Checking for bilateral pitting edema
• Taking weight and height of children
• Weight for Height Z-scores
• < -3 for SAM
• ≥ -3 <-2 for MAM
Assessment of appetite and medical complications
• CB-IMNCI
• Inpatient care, Outpatient care, MAM programme

22. At community level – CB-IMNCI At facility level
look for the danger signs :
- had convulsions / is unconsciousness
/is apathetic, lethargic /not alert
- vomits everything
- severe diarrhea and/or dehydration
- hypothermia
- high fever
- rapid breathing
- not able to drink or breastfeed and/or
eat
- severe edema (+++ Grade 3)
- severe anemia (severe palmar pallor)
• Assess the appetite- Test with Rea
dy to Use Therapeutic Food (RUTF)
• Take history- for Diarrhoea,
Vomiting, Stool, Urine, Cough,
Appetite, Breastfeeding, Swelling,
and edema. Duration of the
symptoms.
• Carry out medical assessment -
• Take weight/height measurement
as a baseline for weight monitoring
during follow- up visits

23. Criteria for admission
Inpatient management of
SAM
Outpatient management of
SAM
Management of MAM
Severe acute malnutrition with
complications
Severe acute malnutrition without
complications
Moderate acute malnutrition
Children 6-59m
Nutritional oedema +++
Children 6-59m
Nutritional oedema +& ++
Children 6-59m
(<11.5cm with any
grade of oedema)
MUAC <11.5 cm Or
WHZ <-3 Z Score
MUAC 11.5cm- < 12.5cm Or
WHZ <-2 MUAC>11.5cm where
facility capacity exists
MUAC <11.5cm Or
WHZ<-3 Z Score

24. Inpatient management of SAM Outpatient management of SAM Management of MAM
with any of the following
complications:
- Anorexia, no appetite
- Increased respiration rate
- High fever
- Severe dehydration
- Severe anaemia
- Not alert (very weak,
lethargic, unconscious,
convulsions)
- Hypothermia
- Intractable vomiting
- Severe diarrhoea
- Hypoglycaemia
AND
• Appetite- good
• Clinically well Alert
AND
• No bilateral pitting oedema
• Appetite- good
• Clinically well Alert
Referral from OTC Due to
deterioration or non- response
Referral from ITC After stabilisation Referral from OTC
2 months SFP regardless of MUAC
or W/H

25. Management of SAM
A. Outpatient Therapeutic Care
1. Medical management
• IRON and FOLIC ACID:
• NOT to be given routinely
may increase the risk of
severe infections
• The child’s immunization
status should be checked &
referred to the monthly
immunization clinic
• Other medical conditions/
symptoms – eye infections,
ear discharge, mouth
ulcers,minor skin infections
and lesions – should be
treated according to the CB-
IMNCI guidelines

26. 2. Nutrition Management
Ready-to-use therapeutic food (RUTF).
• Energy dense mineral/vitamin enriched food
• Nutritionally equivalent to F100,
• It is an oil-based paste usually made of peanuts, oil, sugar and milk, with
low water activity
• Microbiologically safe and can be kept for months in simple packaging
• Complete diet with the exact balance of micronutrients and electrolytes
• The amount of RUTF - 200 kcal/ kg/ day.
• Do not double supplement with multi micronutrients

27. Non Responders
- No weight gain for five weeks
- Weight loss for three weeks
- Increased edema or development of edema
Referral
• Inpatient from outpatient treatment
• HIV counselling and testing
• TB testing counselling and testing
Discharge from Outpatient care
Discharge Cured Criteria
- Minimum LOS of 6 weeks AND MUAC >11.5cm AND
- No oedema for two consecutive visits AND
- Weight gain for last two consecutive visits AND
- Clinically well and alert

28. Criteria for referral to inpatient from outpatient treatment during follow-up

29. B. Inpatient Therapeutic Care
Delivered from tertiary level facilities
• 24 hour care
• treatment of complications.
WHO steps for management of SAM

30. Step 1- Treat/prevent hypoglycemia
Blood sugar <54mg/dl or 3mmol/l
CONCIOUS CHILD
-50ml 10% glucose or sucrose oral or via NG.
-Followed by starter diet ( F-75) every 30mins for 2 hrs. thereafter
2hrly.
UNCONCIOUS/ LETHARGIC/ CONVULSING
-5ml/kg 10% glucose iv
- Followed by 50ml 10%glucose or sucrose oral or via NG.
- Repeat blood sugar after 30 mins – if still low, repeat bolus.

31. Step 2- Treat/prevent hypothermia
• Axillary temperature is <35⁰C
• Rectal temperature is <35.5⁰c(<95.9⁰f)
• Start feeding immediately
• Treat infections
• Active rewarming - kangaroo technique
- Overhead warmer or radiant heater
• Severe hypothermia ( rectal temperature <32⁰C)
- Warm humidified oxygen
- 10% glucose bolus
- Slow rewarming using radiant warmer

32. Monitor-
• Body temperature: during rewarming ,take rectal temperature hourly (take
half-hourly if heater is used)
• Ensure the child is covered at all times, especially at night
• Blood glucose level: check for hypoglycaemia whenever hypothermia is
found
• Stop rewarming when rectal temperature is >36.5⁰C ( 97.7⁰F)

33. Step 3- Treat/prevent dehydration
 Difficult evaluation
 All children having watery diarrhea should be assumed to have some dehydration.
 Weak pulse and oliguria - septic shock or severe dehydration.
Reliable signs Unreliable signs
Increased thirst
Recent sunken appearance
Weak pulses
Cold extremities
Decreased urine output
Mental state
Mouth, tongue and tears
Skin elasticity
Edema and hypovolemia may coexist

34. DO NOT USE IV FLUID EXCEPT IN PRESENCE OF SHOCK.
WHO recommended low osmolarity ORS/ ReSoMal Soln
• 5ml/kg every 30mins for 2hrs orally or via NG.
• Then 5-10ml/kg every alternate hours with F75 for 10hrs based on child’s
willingness to drink and amount of ongoing loss.
Replace ORS with F-75 at 4,6,8 and 10hrs if rehydration is continuing.
ReSoMal2 should not be given cholera- give standard ORS
Signs of Overhydration
- increase in RR by 5 /min
- increase in PR by 15/min
- increasing Oedema
- Periorbital puffiness
Diuretics must never used in this setting

35. Composition of Standard and RO -ORS
STANDARD
ORS
mmol/L
RO-ORS
mmol/L
Re-SoMal
mmol/L
GLUCOSE 111 75 125
SODIUM 90 75 45
POTASSIUM 20 20 40
CHLORIDE 80 65 70
CITRATE 10 10 7
OSMOLARITY 311 245

36. Composition : ReSoMal
ReSoMal
( mmol/L
GLUCOSE 125
SODIUM 45
POTASSIUM 40
CHLORIDE 70
MAGNESIUM 3
ZINC 0.3
COPPER 0.045
CITRATE 7
OSMOLARITY 300

37. PRESENCE OF SHOCK.
weigh child, give oxygen, correct hypoglycemia and hypothermia
IV or IO RL with 5% D or ½ NS with 5% D at 15 ml/kg/hour for the first hour
*Do not use 5% dextrose alone
Continue monitoring every 5-10 min
Assess after 1 hour
If no improvement or worsening If improvement (pulse ↓/faster capillary refill / ↑BP)consider
septic shock severe dehydration with shock
Repeat Ringers Lactate 15 ml/kg over 1 h
Assess
If accepts orally start ORS Clinically better but not
accepting orally give 10ml/kg/h
till accepts orally

38. Step 4- Correct electrolyte balance
• Prepare food without salt
• Supplemental potassium at 3-4mEq/kg/day for at least 2 weeks
• Serum k+ < 2meq/l with ECG changes ( ST-depression , T-wave inversion ,
presence of U wave) ,start 0.3-0.5mEq/kg /hr infusion of KCL intravenous
fluid.
• On day 1- 50% of MgSo4(4mEq/ml) at 0.3ml/kg i.m maximum 2ml.Then
0.4-0.6 mEq/kg/day given orally.

39. Step 5- Treat/prevent infection
• Localizing signs of infection
• Hypoglycemia and hypothermia :marker of severe infection
• All children with SAM require antibiotics.
• Out patient- oral amoxicillin for 5 days
• Inpatient- ampicillin/ 3rd generation cephalosporin plus
aminoglycoside
• If fails to improve within 48hrs add chloramphenicol.
• If persistent diarrhea add metronidazole for 7 days.
• If specific infections identified add antibiotics appropriately.

40. Step 6- Correct micronutrient deficiencies
Vitamin A orally in single dose stat
• < 6 months : 50,000 IU (if clinical signs of
deficiency are present).
• 6-12 months : 1 lakh IU.
• Older children: 2 lakh IU.
Children < 8kg irrespective of age should receive
1 lakh IU orally.
Give same dose on Day 0,1 and 14 if there is clinical
evidence of vitamin A deficiency
Other micronutrients should be given daily for at
least 2 weeks and twice RDA:
 Multivitamin supplements
 Folic acid: 5mg on day 1, then 1mg/day.
 Zinc : 2mg/kg/day.
 Vit. K 2.5mg on day 1
 Copper 0.3mg/kg/day
 Iron 3mg/kg/day can be added after 2 weeks
Anemia
 If Hb <4g /dl or if respiratory distress 4-6g/dl whole blood transfusion 10ml/kg is given with iv furosemide
1mg/kg
 If sign of cardiac failure is present PCV 5-7ml/kg is given.

41. Step 7- Start cautious feeding ( 0-7 days)
• Start as soon as possible
• Initial Phase – F 75 starter (per 100ml- 75kcal, 0.9gm protein)
• Weight of day 1 should be used.
• Frequent and small amounts
• Orally or NG feeding
• Fluid at 130 ml/kg/day(100 ml/kg in edema)
• Calorie- At least 80-100 Kcal/kg per day
• Protein- 1-1.5g/kg/day
• Gradually increase volume and decrease frequency
Days Frequency Vol/kg/feed Vol/kg/day
1-2 2 hourly 11ml 130ml
3-5 3 hourly 16ml 130ml
6 onwards 4 hourly 22ml 130ml

42. Step 8- Transition to catch-up diet
STARTER FEEDS to CATCH UP FEEDS
Readiness to shift to F-100 ( per
100ml- 100kcal, 2.9gm ptn)
1. Return of appetite
(easily finishes 4 - hourly feeds of
starter formula)
2. Most /all of the edema has gone.
3. No episodes of hypoglycemia
or hypothermia
Calorie- 150-200kcal/kg/day
Protein- 4-5g/kg/day
Aim- weight gain >10g/kg/day
First 48hrs- replace same amount of F-
100 as F-75 every 4hrs.
On 3rd day- increase each feed by 10ml
If child is BF continue breastfeeding.

43. Step 9- Provide sensory stimulation and emotional support
 Tender loving care.
 A cheerful stimulating environment.
 Structured play therapy for 15-30 min a day.
 Physical activity as soon as child is well.
 Maternal involvement as much as possible (eg. comforting, feeding, play).

44. Step 10- Prepare for follow-up after stabilisation
Criteria for transferring children from inpatient to outpatient care
The decision should be determined by their clinical condition and not on the basis of
specific anthropometric outcomes such as a specific MUAC or weight-for-height/length
• Appetite normal ( eats at least 75% of therapeutic food)
• Resolved medical complications
• No edema
• Weight gain at least 5g/kg/day for 3 consecutive days.
• Minimum length of stay is 5 days.
Follow up every 15 days for 2 months then monthly till W/H reaches -1SD or above

45. Criteria for discharging children from treatment
• weight-for-height/length is ≥–2 Z-score and they have had no
oedema for at least 2 weeks, or
• mid-upper-arm circumference is ≥125 mm and they have had no
oedema for at least 2 weeks.

46. Failure to respond to treatment
PRIMARY FAILURE
Failure to gain appetite Day 4
Failure to start to losing oedema Day 4
Oedema still persists Day 10
Failure to gain at least 5gm/kg/day
weight
Day 10
SECONDARY FAILURE
Failure to gain at least 5
gm/kg/day body weight
during rehabilitation
during 3 successive days.

47. Complications
1. Pseudotumor cerebri:
• Due to over energetic nutritional correction
• Benign, self limiting, transient increase in ICP
2. Nutritional recovery syndrome: Due to increased level of estrogen and variety of hormones produce by
pituitary gland.
• Hepatomegaly
• splenomegaly
• Ascites
• Parotid swelling
• Prominent Thoraco-abdominal veins
• Hypertrichosis
• Gynecomastia and eosinophilia.

48. 3. Encepalitis like syndromes: Due to too much protein in diet.
drowsy, coarse tremor, parkinsonian rigidity, bradykinesia, myoclonus. Condition is self
limiting
4. Refeeding syndrome: Hallmark of syndrome due to develpoment of severe
hypophosphatemia .( Weakness, Rhabdomyolysis, Neutrophilic dysfunction, Arrhythmias,
Seizure, Alter level of consciousness, Sudden death)
Manage by monitoring phosphate level and administered during refeeding

49. References
• Nelson Textbook of Paediatrics, 19th edition
• Ghai Essentials Pediatrics, 8th edition
• Park’s textbook of preventive and social medicine, 22th edition
• https://www.who.int/news-room/fact-sheets/detail/malnutrition
• https://www.who.int/nutgrowthdb/2018-jme-brochure.pdf?ua=1
• Nepal demographic and health survey 2016
• NEPAL Integrated Management of Acute Malnutrition (IMAM)
Guideline Draft 7: 8 February 2016
• WHO. Guideline: Updates on the management of severe acute
malnutrition in infants and children. Geneva: World Health
Organization; 2013.