Mcn - Sam

Front 1

Outpatient Therapeutic Programme(OTP)

Back 1

Those with severe acute malnutrition (SAM) with no medicalcomplications are treated in an Outpatient Therapeutic Programme(OTP), which provides ready–to–use therapeutic food (RUTF) androutine medicines to treat simple medical conditions. These are takenat home, and the child attends an OTP site weekly for check upsand more supplies of RUTF


Routine med – Trehan et al, 2013: antibiotics with SAM cases

Front 2

inpatient stabilisation centre (SC)

Back 2

Those who are acutely malnourished and have medical complicationsare treated in an inpatient stabilisation centre (SC) until they are wellenough to continue with outpatient care.

Front 3

electrolyte imbalance

Back 3

Electrolyte disorders result in an imbalance of minerals in the body. For the body to function properly, certain minerals need to be maintained in an even balance.
Electrolytes play a vital role in maintaining homeostasis within the body. They help to regulate eg heart and neurological function, fluid balance. Need to correct this w/in first few weeks of MAM/SAM treatment.

Electrolytes refer to minerals that include calcium, chloride,magnesium, phosphate, potassium, and sodium. They are present in your blood,body fluids, and urine.

Front 4

Sunken fontanelles

Back 4

A sign of dehydration in infants.

The skull bones are not joined together firmly at birth. In an infant, the space where two sutures (the areas where the skull bones join together) join forms a membrane–covered "soft spot" called a fontanelle. The fontanelles allow the brain and skull to grow during an infant's first year.There are normally several fontanelles on a newborn's skull.

The fontanelle in the back of the head (posterior fontanelle) most often closes by the time an infant is 1 or 2 months old.
The fontanelle at the top of the head (anterior fontanelle) most often closes within 7 to 19 months.

The fontanelles should feel firm and should curve inward slightly to the touch. A noticeably sunken fontanelle is a sign that the infant does not have enough fluid in his or her body.

Front 5

Explain the triad of hypothermia, hypoglycemia and infection

Back 5

Often SAM kids present with hypothermia and hypoglycemia.

Brain needs continuous supply of glucose. This will be made available from liver if person not eatig.

In infection: if try fight it, you have certain white cells which are dependent on energy which comes from the oxidation of glucose. If you have infection you use glucose even faster. If liver has problem it'll make glucose even slower.

Brain has a competitive demand from infection. When not enough glucose, hard to keep warm.

Therefore triad of hypothermia, hypoglycemia is indicative of a silent infection.

When SAM kids have infection they dont raise temperature, they get hypothermic. Hypothermia on its own is an important warning sign that child has hypoglycemia and/or (most likely and) infection. Managing these in the acute phase is massively important!

Front 6

According to IMAM guidelines, how to treat Those with moderate acute malnutrition and no medicalcomplications

Back 6

They are supported in a supplementary feedingprogramme (SFP) which provides dry take–home rations.

Front 7

According to IMAM guidelines, how to treat

Those with severe acute malnutrition (SAM) with no medicalcomplications

Back 7

Those with severe acute malnutrition (SAM) with no medicalcomplications are treated in an Outpatient Therapeutic Programme(OTP), which provides ready–to–use therapeutic food (RUTF) androutine medicines to treat simple medical conditions. These are takenat home, and the child attends an OTP site weekly for check upsand more supplies of RUTF

Front 8

According to IMAM guidelines, how to treat Those who are acutely malnourished and have medical complications

Back 8

Those who are acutely malnourished and have medical complicationsare treated in an inpatient stabilisation centre (SC) until they are wellenough to continue with outpatient care.

Front 9

What happens in reductive adaptation?

Back 9

Reduced mass – body compostion
Reduced work (intl & extl) – metabolic and physiological changes.



Loss of reserve tissue and functional capacity


Loss of reserve capacity (focus on staying alive): hepatic, renal, thermoregulation, cardiovascular, immune


Energy – loss of mass, increased efficiency


Increased susceptibility to stress, infeciton


Loss of homeostatis


Loss of inflammatory response, immune response altered


Hypothermia, hypoglycemia



NaK ATPase not function well

Front 10

Explain evidence for using antibiotics in SAM

Back 10

Trehan et al 2013


SAM mortality %

4.8% Amoxicillin
4.1% Cefdinir
7.4 % placebo


Placebo vs Amoxicillin: RR 1.55 (1.07–2.24)Placebo vs Cefdinir: RR 1.80 (1.22–2.64)

Front 11

Na+/K+–ATPase

Na+/K+ pump

sodium–potassium pump

Back 11

is an enzyme found in the plasma membrane of all animal cells. The Na+/K+–ATPase enzyme is a solute pump that pumps sodium out of cells while pumping potassium into cells, both against their concentration gradients. This pumping is active (it uses energy from ATP) and is important for cell physiology. An example application is nerve conduction.

In SAM – excess Na, less P – cell bloating and death

Front 12

4 common examples of SAM mismanagement

Back 12

Diuretics for oedema 41% (1993)

Treat kwashiorkor as protein deficiency 56%Specific treatment for “acute” phase not recognized 41%

Anaemia treated with iron from admission

Front 13

WHO 10 steps to SAM treatment

Back 13

General treatment 2 phases:

stabilisation days 1–2; days 3–7
Rehabilitation weeks 2–6
(Follow–up weeks 7–26 )



Treat or prevent:

hypoglycaemia

hypothermia

dehydration
Correct electrolyte imbalance
Treat infection

Correct micronutrient deficiencies
Begin initial feeding
Increase feeding to recover lost weight (“catch–up growth”)
Stimulate emotional and sensorial development
Prepare for follow–u

Front 14

Explain dual presence of dehydration and pitting oedema

Back 14

Dehydration: decreased intravascular volume,increased interstitial volume
Oedema: excess fluid in interstitium.



so child has too much water in between cells and too little in vasculature.Water is in wrong space.



WHYmechanisms that control distribution of fluid b/w one space to another isn't working properly. Mechanisms are complex.– a problem of control. (but we dont know exactly..)


Fix fluid and electrolyte disburbances early

Front 15

Give examples of reductive adaptation

Back 15

Thermoregulation becomes dependant on the environment.

If no limiting nutrients e.g. iron to act as co–factor, enzyme functions are affected and compromised.

NaK ATPase dysfunction: cells keep Na and swell and die – K stays outside.

Front 16

Explain role of AAs in SAM children

Back 16

Two roles: AA function can be limited due to

1. limiting nutrients: substrates
2. limiting nutrients: co–factors


1. Consequences of lacking 1 essential AA:
– we cant make a polypeptide. evidence: existence of essential AAs in animal studies. If those werent included in diet, bad consequences.

– We have excess precursors that need to get rid of in a safe way. (Break AAs down in 2 cycles: Krebs cycle: make C skeleton and oxidise to get atp, the amino group goes to urine cycle. enzymes that break down these but cant make them. cannot get rid of precursors which you're constrained bec limited metabolic ability.



2. enzyme co–factors are e.g. thiamine, riboflavin, pyridoxineiron, zinc, copper.

Poor status in these leads to defect functioning in enzymes. They dont need substrates given to them that they cant deal with. Part of reductive adaptation: they can deal with some but not all.


Need to recover tissues but ORDER is imp. you cant rebuild tissue with sick cells.

Front 17

Diagnosis of SAM

Back 17

■ weight–for–length/height < –3SD(wasted) (see p. 386) or

■ mid–upper arm circumference< 115 mm or

■ oedema of both feet (kwashiorkorwith or without severe wasting).