Severe Acute Malnutrition (MSF guidelines)

Question 1

what is marasmus?

Answer 1

form of severe malnutrition characterized by inadequate energy intake in all forms (including protein)

Question 2

what is kwashiorkor?

Answer 2

form of severe malnutrition characterized inadequate protein intake

Question 3

marasmus: physical sign?

Answer 3

skeletal appearance (due to loss of muscle and fat)

Question 4

kwashiorkor: physical signs?

Answer 4

• bilateral edema of lower limbs (may extent into other part of the body, e.g. arms and hands, face)
• discolored brittle hair, shiny skin which may crack/become infected

Question 5

diagnostic criteria for SAM? name 3

(SAM = severe acute malnutrition)

Answer 5

• Mid-upper arm circumference (MUAC): degree of muscle waisting (<115 mm indicates SAM)
• Weight-for-height Z-scores (WHZ): degree of weight loss compared to non-malnourished children. (<-3SD indicates SAM)
• Bilateral pitting edema of lower limbs indicates SAM, regardless of MUAC/WHZ

Question 6

When should children with SAM be admitted to the hospital?

Answer 6

• pitting edema extending from lower limbs to face
• severe complications such as: shock, sepsis, altered mental status, seizures, vomiting, severe diarrhea, dysentery (diarrhea w blood/slime), severe anemia, persistent hypoglycemia, eye lesions due to vit A def, malaria, pneumonia, meningitis, severe cutaneous infection, fever of unknown origin, etc.
• in absence of these conditions -> outpatients with regular follow-up

Question 7

SAM: with types of treatment?

Answer 7

nutritional, and routine medical (medicines, tests, etc.)

Question 8

SAM: what is the nutritional treatment based on?

Answer 8

specialized foods enriched with vitamins and minerals: therapeutic milks (F-75 and F-100), ready-to-use therapeutic food (RUTF)

Question 9

what do F-75 and F-100 therapeutic milks consist of? what’s the difference?

Answer 9

F-75: “starter” formula. 75 kcal/100ml.
F-100: the “catch-up” formula. 100kcal/100ml.

Both high in energy, fat, protein, vitamins. May be prepared by mixing with water.

There are lactose free variants (in case of persistent diarrhea).

Question 10

what is the first phase of nutritional treatment in SAM?

(where, goal, treatment, how long)

Answer 10

Phase 1 (inpatient):
- restore metabolic functions and treat complications
- F-75 therapeutic milk
- 1-7 days

Question 11

what is the transition phase of nutritional treatment in SAM?

(where, goal, treatment, how long)

Answer 11

Transition phase (inpatient):
- ensure tolerance of increased food intake, continued improvement of clinical condition
- F-100 therapeutic milk and/or RUTF
- 1-3 days

Question 12

what is the second phase of nutritional treatment in SAM?

(where, goal, treatment, how long)

Answer 12

Phase 2 (inpatient or outpatient):
- promote rapid weight gain/growth
- RUTF
- 1-3 days inpatient, then discharged

Question 13

children with SAM without complications: which treatment phase do they start?

Answer 13

the second phase as outpatients

Question 14

SAM treatment: should breastfeeding be continued?

Answer 14

yes

Question 15

SAM treatment: should drinking water be promoted next to treatment?

Answer 15

yes

Question 16

SAM routine medical treatment: what are the 6 routine medication and tests that should be done?

Answer 16

• give antibiotics
• parasite medication
• vaccines, especially measles
• malaria test
• TB screening
• HIV counseling and testing

(both to outpatient and inpatient)

Question 17

SAM routine medical treatment: which antibiotics? when?

Answer 17

amoxicilline 5-7 days

start at day 1
2dd 50mg/kg (max 1g)

(unless specific signs of infection are present)

Question 18

SAM routine medical treatment: malaria testing?

Answer 18

a rapid diagnostic test on day 1

Question 19

SAM routine medical treatment: intestinal parasites treatment?

Answer 19

give albendazole per os

<2 yrs: 200 mg single dose
>2 yrs: 400 mg single dose

during transition phase or upon outpatient admission

Question 20

SAM routine medical treatment: vaccination?

Answer 20

• give measles vaccine, unless they already had 2 shots (after 9 months of age + >4 weeks later)

during transition phase or upon outpatient admission

• other vaccines: check EPI vaccination status, refer to services at discharge

Question 21

what are the EPI vaccines?

Answer 21

EPI = Essential Programme on Immunization by WHO

now included: diphteria, pertussis, polio, tetanus (DKTP), measles, rubella ((B)MR), HepB, HiB, pneumokokken, rotavirus, HPV, BCG

COVID-19 voor volwassenen

Question 22

SAM routine medical treatment: TB screening?

Answer 22

screen for TB at day 1 (Mantoux or IGRA)

if positive screen -> complete diagnostic evaluation

Question 23

SAM routine medical treatment: HIV counselling/screening?

Answer 23

counsel and test for HIV (unless mother declines):
- <18 months: test mother with rapid test. if mother positive -> PCR child
- >18 months: test child with rapid test