Severe acute malnutrition
Beyond the basic ABC, severe acute malnutrition (SAM) requires particular protocols:
- Remember that at triage, any child with emergency signs should be immediately attended to
- Any child with severe wasting (buttocks) or oedema is a priority case and should be assessed and treated at the front of the queue
SAM for children is defined as MUAC <115 mm or Weight for Height Z score <3" with or without bilateral oedema.
Inpatient treatment is required for:
- Abrupt or progressive weight loss
- Appearance of oedema
- Failure of the appetite test
You must assess for clinical complications such as:
- Diarrhoea with dehydration
- High fever
- Pneumonia or respiratory distress
- Hypoglycaemia with lethargy
- Severe anaemia
- Other severe infections
The presence of anorexia is a key indicator and sign of complications.
Select the Types of SAM tab to continue.
Types of SAM
There are three types of SAM:
| Type | Description |
|---|---|
| Marasmus |
Weak, emaciated, brief rapid weight loss, apathetic,
inconsolable with severe acute wasting |
| Kwashiorkor | Cardinal sign of symmetric bilateral pitting oedema beginning in the feet, to legs, to body and face. The acute development of oedema in children in LMIC is very specific for kwashiorkor |
| Marasmic kwashiorkor | Features of both types. These children are the most ill with the highest risk of death and often have concomitant illness |
Question: Which type of SAM does the child in Fig 1 appear to have?
There are three types of SAM:
| Type | Description |
|---|---|
| Marasmus |
Weak, emaciated, brief rapid weight loss, apathetic,
inconsolable with severe acute wasting |
| Kwashiorkor | Cardinal sign of symmetric bilateral pitting oedema beginning in the feet, to legs, to body and face. The acute development of oedema in children in LMIC is very specific for kwashiorkor |
| Marasmic kwashiorkor | Features of both types. These children are the most ill with the highest risk of death and often have concomitant illness |
Question: Which type of SAM does the child in Fig 1 appear to have?
Answer: He appears to have marasmus kwashiorkor malnutrition, because although his upper arms are thin, his forearms are oedematous. His stomach is swollen and he has visible severe wasting.
Question: What are the WHO 10 steps of management of SAM?
There are three types of SAM:
| Type | Description |
|---|---|
| Marasmus |
Weak, emaciated, brief rapid weight loss, apathetic,
inconsolable with severe acute wasting |
| Kwashiorkor | Cardinal sign of symmetric bilateral pitting oedema beginning in the feet, to legs, to body and face. The acute development of oedema in children in LMIC is very specific for kwashiorkor |
| Marasmic kwashiorkor | Features of both types. These children are the most ill with the highest risk of death and often have concomitant illness |
Question: Which type of SAM does the child in Fig 1 appear to have?
Answer: He appears to have marasmus kwashiorkor malnutrition, because although his upper arms are thin, his forearms are oedematous. His stomach is swollen and he has visible severe wasting.
Question: What are the WHO 10 steps of management of SAM?
Answer: The WHO 10 steps of management of SAM are:
- Hypoglycaemia
- Hypothermia
- Dehydration
- Electrolytes
- Infection
- Micronutrients
- Initiate feeding
- Catch-up growth
- Sensory stimulation
- Discharge preparation
The first seven (the 'rescue phase') need to be assessed, prevented or treated at admission
Select the Inpatient treatment tab to continue.
Inpatient treatment
For inpatient treatment you should follow the WHO protocols, including those that address complications and underlying diseases, and seek specialist advice.
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IV fluids
IV fluids should be only given if absolutely necessary, for:
- Severe dehydration
- Shock or
- No oral intake possible due to surgical reasons
The risk of a hyperhydration and cardiac failure is very high in malnourished children.
Outcome
Worse outcomes are associated with:
- Low sodium
- Low MUAC
- Bacteraemia
- Hypoxia
- Hypokalaemia
- Oedema
Chronic disease
You should treat other underlying chronic diseases:
- Worms
- Malaria
- Measles
- Vitamin A deficiency
- TB
- HIV, with appropriate testing and counselling
RUTF and iron
Therapeutic milks must be used first, i.e. F-75, F-100, and after stabilization, PPN is introduced.
In the presence of a complication, you should not give iron or PPN, but give therapeutic feed first with folic acid, and then start iron after recovery.
If the child has diarrhoea, ORS should not be used as the rehydration solution. Malnourished children often have problems with their electrolytes, e.g. low potassium or high sodium, so ReSoMal or dilute ORS should be used, i.e. 1 sachet in 1.5 L of water instead of 1 L.
Signs of improvement
Signs of improvement include:
- Return of appetite and no need for parenteral treatment
- Ascending weight curve between two weight measurements
- Significant reduction to oedema+ or absence of oedema
- Medical complications under control, i.e. is asymptomatic
- No need of IV or IM treatment