SEVERE ACUTE MALNUTRITION IN INFANTS lt; 6 MONTHS
Severe acute malnutrition infant below 6 months is less likely in children with exclusive breastfeeding, usually seen in top-fed infants and diagnosis rests on following criteria:
• Weight/height lt; 3 SDS or z-score, or
• Bilateral symmetrical edema or visible wasting
MUAC cannot be used for diagnosis of SAM in infants lt;6 months and use of wasting for diagnosis of SAM should be made with utmost caution.
Management of SAM in infants lt;6 months is similar to management in older children with following considerations:
• All these infants should preferably be hospitalized irrespective clinical status, unless there are overriding barriers.
• In view of the high-risk of underlying sepsis, all these infants should receive parenteral antibiotics in initial days of hospitalization or a course of oral antibiotics, e.g. Amoxicillin, if cannot be hospitalized.
• Breastfed children should continue breastfeeding with assessment of local breast/nipple problems, position, attachment and adequate intake. Mother should be encouraged for frequent breastfeeding after proper lactation counseling.
• In non-breast infants (in order of preference).
- Attempt should be made re-initiate lactation, using supplementary sucking techniques (discussed below), or
- Provide expressed breast milk or milk from human milk banking or
- Use a generic infant milk formula or started F-75 diet or diluted catch-up F-100 diet (by adding 30% water), either alone or in addition to the breast milk. Undiluted catch-up diet should not be used due to high solute load.
• Assess the physical and mental status of mother, with appropriate counseling and support.
Supplementary sucking techniques (SST) aim to re-establish breast milk output in mothers who have stopped BF due to some reason before consultation and includes:
• Non-nutritive sucking, i.e.
to place the baby on the breast at least 8-10 times/day for 10-15 minutes every time, even in the absence of milk output.• Drip and drop method, in which a nasogastric tube connected to milk/formula filled cup (~100-130 ml) is fixed with an adhesive tape over the nipple and baby is encouraged to suck on nipple while milk is gradually dripped over it. Cup is kept 5-10 cm below the nipple level so the milk does not flow too quickly. Sucking efforts by the baby stimulate prolactin reflex to reestablish BM output. Gradually the cup should be lowered further to encourage stronger sucking efforts. SST should initially be done on both breasts 4-6 times
a day along with intermittent katori/spoon feeding and the frequency should be reduced gradually over next 7-14 days. If the baby does not finish supplementary feed after few days but is gaining weight, it means that breast milk output is increasing.
Discharge: Infant lt;6 months with SAM should be discharged only if weight for height has reached gt;-2 z-score, though early discharge may be considered in cases with: (a) continuous weight gain (gt; 5 gm/kg/day) for gt; 2 weeks, (b) good appetite (c) absence of medical complications, (d) availability of effective alternative supervision.
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