1.14 CME

Managing Severe Acute Malnutrition: Facility & Community-Based Approaches

Speaker: Dr. Mettu Pradeep Reddy

Professor of Pediatrics, Maheshwara Medical College & Hospital and Malla Reddy Medical College for Women

Summary

Nutrition, distinct from food, supports life by providing energy for growth, development, and metabolic activities. Nutritional deficiencies can hinder growth, immunity, and contribute to increased morbidity and mortality, especially in children under 5. Conversely, excess intake can lead to obesity, diabetes, and cardiovascular issues.
Nutrients are categorized into macronutrients (fats, proteins, and carbohydrates) and micronutrients (vitamins and minerals). Macronutrients, required in large quantities, form the body's building blocks, while micronutrients, needed in smaller amounts, are crucial for metabolic pathways. Energy balance involves intake and expenditure, with components including basal metabolic rate, digestion, physical activity, and growth (especially in children).
Fats, diverse esters of fatty acids, are energy-dense and crucial for cell membrane structure, hormone production, and vitamin absorption. Proteins, the second most abundant substance in the body, play structural and functional roles in cells, tissues, enzymes, and hormones. Carbohydrates, the main energy source, are divided into simple and complex types, with excess amounts being converted to glycogen or fat. Fiber, a type of carbohydrate, aids fermentation, dilutes toxins, regulates sugar absorption, and lowers cholesterol.
Malnutrition encompasses both undernutrition and overnutrition. Globally, one in four children is malnourished, with higher rates in developing countries. Protein-energy malnutrition (PEM) manifests in forms like kwashiorkor and marasmus, each with distinct clinical features.
Classifications of malnutrition have evolved, using parameters like weight-for-age, weight-for-height, and mid-upper arm circumference (MUAC). The World Health Organization (WHO) defines malnutrition based on edema, weight-for-height, and height-for-age, leading to categories like moderate and severe wasting or stunting. MUAC provides a quick screening method, especially when age is unknown.
Causes of malnutrition are multifaceted, including conditioning influences, socio-economic factors, and cultural practices. Poverty, ignorance, illiteracy, and cultural taboos contribute significantly. The free radical theory suggests that food deprivation releases toxic oxygen radicals, damaging cells and increasing susceptibility to infections.
Clinical manifestations of PEM vary. Marasmus presents with severe muscle wasting and an "old man" appearance, while kwashiorkor is characterized by edema, irritability, and skin changes. Mixed forms also exist. Immunity is compromised in PEM, increasing susceptibility to infectious diseases.
Inpatient treatment of severe acute malnutrition involves a stabilization and rehabilitation phase. The ten steps in the stabilization phase are: Prevent/Treat Hypoglycemia, Prevent/Treat Hypothermia, Treat Dehydration, Correct Electrolyte Imbalance, Treat Infection with Antibiotics, Correct Micro-nutrient Deficiencies, Start Cautious Feeding, Achieve Catch Up Growth, Provide Sensory Stimulation and Emotional Support, Prepare for Follow Up After Recovery and Discharge. Cautious feeding with F-75 formula gradually progresses to F-100 as appetite returns. Emergency treatment addresses shock and severe anemia. Discharge criteria include weight gain, resolution of edema, and caregiver competence. If discharged early, frequent feeding, high-energy snacks, and ongoing education are essential.