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PHM15: Management of Childhood Severe Acute Malnutrition


 

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

  • Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
  • Micronutrient deficiencies in SAM;
  • Specific things to look for when treating SAM using rehydration and refeeding protocols;
  • Definitions and classification of malnutrition states; and
  • The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

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