Severe Acute Malnutrition (SAM): Model Clinical Case and Viva Q&A

SAM
Clinical Case of Protein-Energy Malnutrition (SAM)

A 2-year-old boy, Rahul, is brought to the pediatric emergency department by his mother. She reports that Rahul has been lethargic, irritable, and has had poor appetite for the past few weeks. His condition has worsened in the last 3 days with the onset of diarrhea.

History:

  • Exclusive breastfeeding for 2 months, followed by irregular feeding with diluted cow's milk and occasional solid foods
  • Recent history of measles infection 1 month ago
  • Low socioeconomic background with limited access to healthcare

Physical Examination:

  • Weight: 6.5 kg (severe underweight, below -3 SD on WHO growth chart)
  • Height: 75 cm (stunted, below -2 SD on WHO growth chart)
  • Visible severe wasting of muscles, especially in the buttocks and thighs
  • Skin changes: dry, scaly skin with areas of hyperpigmentation and depigmentation
  • Hair changes: sparse, thin, and easily pluckable hair with reddish discoloration
  • Bilateral pitting edema up to the knees (+2)
  • Abdominal distension with hepatomegaly
  • Signs of dehydration: sunken eyes, decreased skin turgor

Laboratory Findings:

  • Hemoglobin: 8.5 g/dL
  • Serum albumin: 2.1 g/dL
  • Blood glucose: 58 mg/dL
  • Serum electrolytes: Hypokalemia (2.8 mEq/L) and hyponatremia (128 mEq/L)

Diagnosis:

Based on the clinical presentation and anthropometric measurements, Rahul is diagnosed with Severe Acute Malnutrition (SAM) with complications, specifically Kwashiorkor-Marasmus mixed type.

Management Plan:

  1. Immediate stabilization: Treat dehydration, hypoglycemia, and electrolyte imbalances
  2. Initiate F-75 therapeutic milk for initial nutritional rehabilitation
  3. Monitor for refeeding syndrome
  4. Treat infections: Broad-spectrum antibiotics and antimalarial if endemic
  5. Gradual transition to F-100 milk and RUTF (Ready-to-Use Therapeutic Food)
  6. Provide supplements: Vitamin A, Folic acid, Zinc, and other micronutrients
  7. Educate the mother on proper feeding practices and hygiene
  8. Plan for long-term follow-up and community-based management

Clinical Presentations of Protein-Energy Malnutrition (SAM)

Clinical Presentations of Severe Acute Malnutrition

  1. Marasmus

    • Severe wasting of muscles and subcutaneous fat
    • Appearance of "old man" face
    • Skin hangs in loose folds, especially around the buttocks ("baggy pants")
    • Alert and irritable behavior
    • Absence of edema

  2. Kwashiorkor

    • Generalized edema, often starting in the feet and legs
    • "Moon face" appearance due to facial edema
    • Skin changes: Hyperpigmentation, hypopigmentation, desquamation, and "flaky paint" dermatosis
    • Hair changes: Thin, sparse, and easily pluckable hair with color changes (flag sign)
    • Hepatomegaly due to fatty infiltration
    • Apathetic and irritable behavior

  3. Marasmic Kwashiorkor (Mixed SAM)

    • Features of both marasmus and kwashiorkor
    • Severe wasting with some degree of edema
    • Skin and hair changes similar to kwashiorkor
    • Variable behavior, often apathetic

  4. Nutritional Dwarfism (Stunting)

    • Chronic malnutrition leading to significantly reduced height-for-age
    • Delayed motor and cognitive development
    • Relatively normal body proportions, but overall small stature
    • May not show acute signs of malnutrition

  5. Cachexia

    • Severe wasting with significant loss of muscle mass
    • Often associated with chronic diseases (e.g., HIV, tuberculosis, cancer)
    • Disproportionate loss of lean body mass compared to fat mass
    • Biochemical inflammation markers are often elevated

  6. Micronutrient Deficiency Syndromes

    • Vitamin A deficiency: Night blindness, Bitot's spots, keratomalacia
    • Iron deficiency: Pallor, koilonychia, glossitis
    • Zinc deficiency: Growth retardation, delayed wound healing, dermatitis
    • Iodine deficiency: Goiter, cretinism in severe cases
    • Often coexist with protein-energy malnutrition

  7. Refeeding Syndrome

    • Occurs when nutrition is reintroduced too quickly in severely malnourished individuals
    • Characterized by severe electrolyte imbalances, particularly hypophosphatemia
    • Can lead to cardiac arrhythmias, seizures, and respiratory failure
    • Requires careful monitoring during initial phases of nutritional rehabilitation


Knowledge Check: Question and Answers for Medical Students & Professionals

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

Question 1 of 30


Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.



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