Medical Science Optional daily answer writing practice for CSE 2023 – Dec 15

managing severe acute malnutrition:

1. Stabilization Phase:

• Admission and medical care: Assess airway, breathing, circulation, treat dehydration with IV fluids, correct electrolyte imbalances.
• Broad spectrum antibiotics: IV/IM ampicillin and gentamicin to cover common organisms like Salmonella, Shigella etc.
• Therapeutic feeds: Start F-75 feeds (75kcal/100ml) via NG tube every 3 hours. F-75 helps gut rehabilitation and prevents refeeding syndrome.
• Monitoring: Check for hypoglycemia, hypothermia,convulsions. Monitor blood glucose, electrolytes.

2. Transition Phase:

• Switch to F-100 feeds once stable on F-75. F-100 provides 100kcal/100ml.
• Monitor weight gain: Weigh daily, expect >5g/kg/day gain to achieve discharge criteria.
• Monitor for complications: Convulsions, recurrent diarrhea, sepsis, respiratory distress etc. Treat promptly.

3. Rehabilitation Phase:

• Continue F-100 feeds 200-400ml/kg/day. Gradually introduce family foods.
• Supplements: Vit-A, zinc, iron-folic acid. Manage underlying conditions.
• Screen for complications: marasmus, kwashiorkor, sequelae like blindness etc. Treat accordingly.

4. Outpatient Care & Follow up: Details discussed earlier in the question.

Timely identification and appropriate management of each phase is crucial for effective rehabilitation of severe acute malnutrition. Close monitoring helps prevent complications and achieves recovery.

More detailed answer

Characteristic physical signs

• In marasmus: skeletal appearance resulting from significant loss of muscle mass and subcutaneous fat.
• In kwashiorkor:
  • Bilateral oedema of the lower limbs sometimes extending to other parts of the body (e.g. arms and hands, face).
  • Discoloured, brittle hair; shiny skin which may crack, weep, and become infected.

Diagnostic and admission criteria

Diagnostic criteria for SAM are both anthropometric and clinical:

• Mid-upper arm circumference (MUAC) a measures the degree of muscle wasting. MUAC < 115 mm indicates SAM and significant mortality risk.
• Weight-for-height z-score (WHZ) indicates the degree of weight loss by comparing the weight of the child with the median weight of non-malnourished children of the same height and sex. SAM is defined as WHZ < –3 with reference to the WHO Child Growth Standards b 
  .
• The presence of bilateral pitting oedema of the lower limbs (when other causes of oedema have been ruled out) indicates SAM, regardless of MUAC and WHZ.

Admission criteria for SAM treatment programmes vary with context. Refer to national recommendations.

Medical complications

• Children with any of the following severe medical conditions should receive hospital-based medical management:
  • Pitting oedema extending from the lower limbs up to the face;
  • Anorexia (observed during appetite test);
  • Other severe complications: persistent vomiting, shock, altered mental status, seizures, severe anaemia (clinically suspected or confirmed), persistent hypoglycaemia, eye lesions due to vitamin A deficiency, frequent or abundant diarrhoea, dysentery, dehydration, severe malaria, pneumonia, meningitis, sepsis, severe cutaneous infection, fever of unknown origin, etc.
• In the absence of these conditions, children should be treated as outpatients with regular follow-up.

Nutritional treatment

• All children with SAM should receive nutritional treatment.
• Nutritional treatment is based on the use of specialised nutritious foods enriched with vitamins and minerals: F-75 and F-100 therapeutic milks, and ready-to-use therapeutic food (RUTF).
• Nutritional treatment is organised into phases:
  • Phase 1 (inpatient) intends to restore metabolic functions and treat or stabilize medical complications. Children receive F-75 therapeutic milk. This phase may last 1 to 7 days, after which children usually enter transition phase. Children with medical complications generally begin with phase 1.
  • Transition phase (inpatient) intends to ensure tolerance of increased food intake and continued improvement of clinical condition. Children receive F-100 therapeutic milk and/or RUTF. This phase usually lasts 1 to 3 days, after which children enter phase 2.
  • Phase 2 (outpatient or inpatient) intends to promote rapid weight gain and catch-up growth. Children receive RUTF. This phase usually lasts 1 to 3 days when inpatient, after which children are discharged for outpatient care. Children without medical complications enter directly into this phase as outpatients. The outpatient component usually lasts several weeks.
• Breastfeeding should be continued in breastfed children.
• Drinking water should be given in addition to meals, especially if the ambient temperature is high, or the child has a fever or is receiving RUTF.

Routine medical management 

The following should be provided to all inpatients and outpatients with SAM:

Antibiotic treatment	From D1, unless specific signs of infection are present:amoxicillin PO: 50 mg/kg (max. 1 g) 2 times daily for 5 to 7 days
Malaria	On D1, rapid diagnostic test in endemic areas and treatment for malaria according to results or if testing is not available (see Malaria, Chapter 6).
Intestinal parasites	In transition phase or upon outpatient admission, albendazole PO:Children 12 to 23 months: 200 mg single dose Children 24 months and over: 400 mg single dose
Vaccination	In transition phase or upon outpatient admission, measles vaccine for children 6 months to 5 years, unless a document shows that the child received 2 doses of vaccine administered as follows: one dose at or after 9 months and one dose at least 4 weeks after the first dose. Children vaccinated between 6 and 8 months should be re-vaccinated as above (i.e. with 2 doses) once they reach 9 months of age, provided that an interval of 4 weeks from the first dose is respected.Other vaccines included in the EPI: check vaccination status and refer the child to vaccination services at discharge.
Tuberculosis (TB)	At D1 then regularly during treatment, screen for TB. For a child screening positive, perform complete diagnostic evaluation.For more information, refer to the guide Tuberculosis, MSF.
HIV infection	Perform HIV counselling and testing (unless the mother explicitly declines testing).Children under 18 months: test the mother with rapid diagnostic tests. For a mother testing positive, request PCR test for the child.Children 18 months and over: test the child with rapid diagnostic tests.