1. Severe Acute Malnutrition (Protein-Energy Malnutrition)

2. Protein-energy malnutrition (PEM) is manifested primarily by inadequate dietary intakes of protein and energy, either because the dietary intakes of these 2 nutrients are less than required for normal growth or because the needs for growth are greater than can be supplied by what otherwise would be adequate intakes.

3. the most severe forms of malnutrition, 1.marasmus (nonedematous malnutrition with severe wasting) and 2.kwashiorkor (edematous malnutrition), 3.marasmic kwashiorkor, has features of both disorders (wasting and edema)

4. -- CLINICAL SIGNS OF MALNUTRITION

9. Investigation R.B.S C.B.P S.electrolyte C-Reactive Protein Total s.protein & s.albumin S.Creatinine Urinalysis Stool Examination for the presence of parasite

10. Treatment includes 3 phases: 1.stabilization phase (1-7 days):it involve Rx.&Pv of infection,hypoglycemia, hypothermia,dehydration,anemia&correc tion of electrolyte disturbances as well as vitamins&micronutrient deficiency(except iron)

11. The initial phase of oral treatment is with the F75 diet (75 kcal or 315 kJ/100 mL), Feedings are initiated with higher frequency and smaller volumes; over time, the frequency is reduced from 12 to 8 to 6 feedings per 24 hr. The initial caloric intake is estimated at 80-100 kcal/kg/day.

12. If diarrhea starts or fails to resolve and lactose intolerance is suspected, a non– lactose-containing formula should be substituted. If milk protein intolerance is suspected, a soy protein hydrolysate formula may be used.

13. N.B Because of the difficulty of estimating hydration, oral rehydration therapy is preferred If IV therapy is necessary, estimates of dehydration should be reconsidered frequently, particularly during the first 24 hr of therapy.

14. N.B Iron therapy usually is not started until this phase of treatment; iron can interfere with the pt's host defense mechanisms. There also is concern that free iron during the early phase of treatment might exacerbate oxidant damage, precipitating infections (malaria), clinical kwashiorkor, or marasmic kwashiorkor in a child with clinical marasmus. Some recommend treatment with antioxidants.

15. 2. Rehapilitation phase (wk 2-6) may include continued antibiotic therapy with appropriate changes, if the initial combination was not effective, and introduction of the F100 or RUTF diet with a goal of at least 100 kcal/kg/day. At any time, if the infant is unable to take the feedings from a cup, syringe, or dropper, administration by a nasogastric tube rather than by the parenteral route is preferred.

16. ready to use therapeutic foods (RUTFs) is a mixture of powdered milk, peanuts, sugar, vitamins, and minerals. RUTFs reduce mortality in a cost-effective manner, it is an oil-based paste that has little water content which make it less susceptible to bacterial contamination It also has a similar nutrient profile but a higher calorie density and is equally palatable to F100

17. 3. follow-up phase, which consists of feeding to cover catch-up growth as well as providing emotional and sensory stimulation In all phases, parental education is crucial for continued effective treatment as well as preventing additional episodes

18. Refeeding syndrome can complicate the acute nutritional rehabilitation of children who are undernourished from any cause The hallmark of refeeding syndrome is the development of severe hypophosphatemia after the cellular uptake of phosphate during the 1st week of starting to refeed

19. Refeeding syndrome Other featurts of refeeding S. include: hypokalemia, hypomagnesemia, Na retention, hyper glycemia and vitamin deficiency esp. thiamin If Serum phosphate levels of ≤0.5 mmol/L can produce weakness, rhabdomyolysis, neutrophil dysfunction, cardiorespiratory failure, arrhythmias, seizures, altered level of consciousness, or sudden death

20. Tx.Of Refeeding syndrome : 1.pt. at risk check S.k,S.ca,S.ph,S.mg during the 1 st 2 wk. of Tx. 2.Before start feeding administer thiamine(200- 300)mg daily vitamin B 1-2 tab 3 times daily or give full dose I.V vitamin B & multi vitamin or trace element e daily 3.Slowly increase feeding over 4-7 days 4.Rehydrate carefully and supplement&/or correct level of K ( give 2-4 mmol/kg/day) ph ( 0.3-0.6 mmol/kg/day) Mg (0.2mmol/kg/day if IV, OR 0.4 mmol/kg/day if orally)

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