What is Severe Acute Malnutrition (SAM)?
Severe Acute Malnutrition (SAM) is a life-threatening condition resulting from insufficient energy and nutrient intake, often combined with infectious diseases. It causes extreme wasting, a skeletal appearance (marasmus), or nutritional edema (kwashiorkor). While historically categorized as separate conditions, their treatment is largely similar and based on the underlying severity of malnutrition.
SAM has profound metabolic and physiological consequences, including impaired immune function, organ damage, and altered body composition. It affects approximately 19 million children under five worldwide and is responsible for a significant number of preventable child deaths each year.
The Importance of Early Identification
Early and accurate identification of SAM is paramount. Timely treatment can dramatically reduce the case fatality rate and improve long-term health outcomes. Community-based management, using tools like Ready-to-Use Therapeutic Foods (RUTFs), has proven highly effective for treating uncomplicated cases in outpatient settings, provided they are identified early.
How to Identify Sam: Diagnostic Criteria
Diagnosis of SAM relies on a combination of anthropometric and clinical criteria, primarily based on the World Health Organization (WHO) guidelines. These assessments can be performed by trained health workers in clinical settings and, in some cases, by community volunteers using simplified methods like Mid-Upper Arm Circumference (MUAC) measurements.
Anthropometric Indicators
Anthropometry involves taking physical measurements to assess nutritional status. For children aged 6 to 59 months, the key indicators are:
- Weight-for-Height Z-score (WHZ): This measure compares a child's weight to the weight of a healthy reference child of the same height and sex. A WHZ below -3 standard deviations (SD) of the median indicates severe wasting, a form of SAM.
- Mid-Upper Arm Circumference (MUAC): This simple measurement uses a color-coded or numbered tape to assess muscle mass. A MUAC of less than 115 mm indicates SAM in children aged 6-59 months and signals a significant mortality risk. MUAC is particularly useful for rapid community screening due to its simplicity and strong correlation with risk of death.
For infants under 6 months, the criteria focus on weight-for-length z-scores below -3 SD and the presence of bilateral pitting oedema.
Clinical Signs
Clinical assessment involves observing physical symptoms that indicate severe malnutrition. The most critical sign is:
- Bilateral Pitting Oedema: This is a key clinical sign of nutritional oedema (kwashiorkor). It is tested by applying gentle pressure with a thumb for a few seconds to both feet. The presence of a lasting indentation, or "pit," indicates oedema. The presence of bilateral pitting oedema is an independent diagnostic criterion for SAM, regardless of other anthropometric measurements.
Other notable clinical signs, which may indicate medical complications, include:
- Severe palmar pallor (severe anemia)
- Lethargy, irritability, or an altered mental state
- Hypothermia or hypoglycemia
- Dermatosis or skin changes
- Eye signs of vitamin A deficiency
- Signs of infection, which can be masked in severely malnourished children
Comparison of Clinical Manifestations of SAM
While both are forms of SAM, marasmus and kwashiorkor present with distinct clinical features that aid in identification, though treatment protocols are often similar.
| Feature | Marasmus | Kwashiorkor | Combined Marasmic-Kwashiorkor |
|---|---|---|---|
| Appearance | Wasted, "skin and bones" appearance. Loss of muscle mass and subcutaneous fat. | Oedema (swelling) obscures wasting. Puffy, bloated look. | Combination of severe wasting and oedema. |
| Oedema | Absent. | Present (bilateral pitting oedema). | Present. |
| Hair | Normal or brittle. | Discolored, brittle, sparse, and easily pulled out. | May show similar changes to Kwashiorkor. |
| Skin | Wrinkled due to fat loss. | Cracks, peels, and can develop a dark, "flaky paint" dermatosis. | May show similar changes to Kwashiorkor. |
| Mental State | Often anxious and irritable. | Apathetic and miserable. | Can present with mixed or more severe symptoms. |
Screening and Assessment Process
A systematic approach is necessary for identifying and managing SAM. This process involves several steps:
- Community Screening: Volunteers or health workers use MUAC tapes to quickly screen all children aged 6-59 months. Any child with a MUAC below 115mm or obvious bilateral oedema is identified for further assessment.
- Referral to Health Facility: Identified children are referred to a health centre for a full clinical examination.
- Appetite Test: At the clinic, a health worker performs an appetite test using Ready-to-Use Therapeutic Food (RUTF) to determine if the child is fit for outpatient care. Children who eat well and have no medical complications can be treated at home. A failed appetite test or other danger signs necessitate inpatient admission.
- Medical Complications Assessment: For children requiring hospital care, a thorough assessment for common complications like hypothermia, hypoglycemia, severe dehydration, or infections is performed. These are urgently treated according to WHO guidelines.
Nutritional and Dietetic Implications
The identification of SAM leads directly to specialized nutritional interventions. Dietetic management is divided into two phases:
- Stabilization Phase: For inpatient care, this phase focuses on correcting fluid, electrolyte, and metabolic imbalances. Feeds are frequent, small, and low-sodium, using special therapeutic milk formulations like F-75.
- Rehabilitation Phase: Once the child is stabilized, the focus shifts to catch-up growth. A higher-energy formula, like F-100, or RUTF is used to facilitate rapid weight gain. RUTF is particularly effective for outpatient management of uncomplicated SAM due to its high nutrient density, palatability, and stability.
For long-term recovery, dietary education for caregivers is crucial to prevent relapse. This includes promoting nutrient-dense foods and continued breastfeeding for young children.
Conclusion
Timely and accurate identification of Severe Acute Malnutrition (SAM) is essential for effective intervention and reducing child mortality. The process involves using a combination of anthropometric tools, like MUAC and WHZ, and clinical observations, such as checking for bilateral pitting oedema. Early detection allows for prompt treatment with specialized nutritional products like RUTF, often in a community-based setting, reserving inpatient care for complicated cases. By understanding how to identify SAM and implementing a systematic assessment protocol, health workers and communities can work together to save lives and improve long-term health outcomes for children.
For more in-depth information on managing SAM, visit the World Health Organization (WHO) website: Management of severe acute malnutrition requiring inpatient care in children 6–59 months of age.
