Understanding Severe Acute Malnutrition
Severe acute malnutrition (SAM) is a life-threatening condition characterized by very low weight-for-height or mid-upper arm circumference (MUAC), or the presence of nutritional edema. The fragility of a severely malnourished child's physiological state makes them highly susceptible to fatal complications like hypothermia, hypoglycemia, and infections. To address this, the World Health Organization developed a comprehensive 10-step protocol for inpatient management, divided into two distinct phases: stabilization and rehabilitation. Adherence to this protocol has proven critical in reducing mortality and enabling long-term recovery.
The Two Phases of the WHO Protocol
The 10 steps are sequentially implemented over two main phases to address the immediate and longer-term needs of a severely malnourished child. The initial phase, or stabilization, focuses on treating life-threatening medical issues. This is followed by the rehabilitation phase, which is dedicated to nutritional recovery and sustained growth. Emotional and sensory stimulation is recommended throughout both phases to support the child's development.
The Stabilization Phase (Steps 1-7)
This initial phase, typically lasting 1-2 days, is designed to correct immediate metabolic and clinical complications. Nutritional intake is carefully managed to avoid putting excess strain on the body, a condition known as refeeding syndrome, which can occur when feeding is introduced too quickly.
- Treat/Prevent Hypoglycemia: All severely malnourished children are at risk for low blood sugar. Treatment involves giving an immediate dose of 10% glucose or sucrose solution and starting frequent, small feedings of F-75 starter formula every two to three hours, day and night.
- Treat/Prevent Hypothermia: Malnourished children are often unable to regulate their body temperature. They should be kept warm at all times through skin-to-skin contact with their caregiver (Kangaroo mother care), warming devices, and blankets. Hypothermia often indicates a serious underlying infection.
- Treat/Prevent Dehydration: Rehydration must be done slowly to avoid fluid overload, which can lead to congestive heart failure. A specialized low-sodium rehydration solution for malnutrition (ReSoMal) is used, administered orally or via nasogastric tube. Intravenous fluids are typically avoided except in cases of shock.
- Correct Electrolyte Imbalance: Severely malnourished children have excess body sodium but dangerously low levels of potassium and magnesium. Supplements of potassium and magnesium are added to the feed, and foods are prepared without added salt. Diuretics are not used to treat edema.
- Treat/Prevent Infection: The usual signs of infection, such as fever, are often absent in severely malnourished children. Therefore, all admitted children are presumed to have an infection and are given broad-spectrum antibiotics.
- Correct Micronutrient Deficiencies: Malnourished children have multiple vitamin and mineral deficiencies. Multivitamins, folic acid, zinc, and copper are administered daily. High-dose vitamin A is given, but iron is withheld until the rehabilitation phase, as it can worsen infections.
- Start Cautious Feeding: Feeding begins slowly and frequently with a low-protein, low-lactose starter formula called F-75. This provides just enough energy and protein for basic metabolic functions and helps stabilize the child's fragile state.
The Rehabilitation Phase (Steps 8-10)
Once stabilized, the child progresses to this longer phase focused on rebuilding wasted tissues and achieving rapid catch-up growth.
- Achieve Catch-up Growth: The child is transitioned from the F-75 formula to a higher-energy, higher-protein therapeutic food, either F-100 or a Ready-to-Use Therapeutic Food (RUTF). RUTF is a nutrient-dense paste that is easier for caregivers to administer at home for uncomplicated cases, allowing for outpatient management.
- Provide Sensory Stimulation and Emotional Support: This step is crucial for mental and behavioral development, which is often delayed in severely malnourished children. It involves providing a cheerful, stimulating environment, structured play therapy, and encouraging caregiver involvement.
- Prepare for Follow-up After Recovery: Before discharge, caregivers are trained on nutrition-dense foods using local ingredients, continued stimulation, and the importance of regular follow-up appointments to prevent relapse. Discharge criteria are met when the child reaches a healthy weight-for-length and is free of edema.
Inpatient vs. Outpatient Management
The management of a child with severe acute malnutrition is determined by the presence of complications and appetite. Children with any medical complication (like infection, hypothermia, etc.) or a poor appetite require intensive, inpatient care, where all 10 steps are implemented in a facility. For children with uncomplicated SAM who have a good appetite, the rehabilitation phase using RUTF can be managed at home under outpatient supervision. The successful implementation of Community-based Management of Acute Malnutrition (CMAM) relies heavily on effectively transitioning children between these two care settings.
Comparison of Inpatient and Outpatient Nutritional Care for SAM
| Feature | Inpatient Stabilization Phase | Outpatient Rehabilitation Phase |
|---|---|---|
| Goal | Correct life-threatening complications, stabilize patient. | Achieve rapid weight gain, promote catch-up growth. |
| Therapeutic Food | F-75 milk formula (low energy, low protein). | F-100 formula or RUTF (high energy, high protein). |
| Feeding Schedule | Small, frequent feeds (every 2-3 hours). | Less frequent feeds, as appetite improves (e.g., 8 times per day with RUTF). |
| Electrolyte Management | Initial correction of electrolyte imbalances (potassium, magnesium). | Continued supplementation. |
| Iron Supplementation | Withheld to avoid exacerbating infection. | Initiated once weight gain begins. |
| Location | Facility-based, requiring close medical monitoring. | Community-based, managed at home with caregiver supervision. |
Long-Term Impact and Prevention
The success of the WHO 10 steps extends beyond immediate survival, aiming to prevent long-term developmental delays often associated with early childhood malnutrition. The protocol emphasizes the importance of sustained nutritional support and psychosocial stimulation. For prevention, broader nutrition-sensitive interventions are needed to address underlying factors such as food security, clean water, and access to healthcare. These interventions aim to break the intergenerational cycle of poor nutrition and disease.
Conclusion
The WHO malnutrition 10 steps protocol provides a structured, evidence-based approach to managing severe acute malnutrition. By systematically addressing life-threatening complications and then fostering nutritional rehabilitation, it has become a cornerstone of global efforts to reduce child mortality and improve developmental outcomes. The protocol’s focus on cautious initial feeding, correction of deficiencies, and the crucial transition to high-energy therapeutic foods marks a significant advancement in pediatric nutrition, offering a path to recovery for the most vulnerable children. The integration of sensory stimulation further underscores the holistic nature of this life-saving treatment plan.
