Understanding the WHO's 10-Step Approach
The World Health Organization has established a critical, evidence-based 10-step protocol for the inpatient management of severe acute malnutrition (SAM). This comprehensive guideline is designed to systematically address the complex medical and nutritional needs of severely malnourished children, significantly improving their chances of survival and recovery. The protocol is divided into two distinct phases: the initial Stabilization Phase, which focuses on immediate life-threatening conditions, and the Rehabilitation Phase, which promotes rapid weight gain and recovery.
The Stabilization Phase: Steps 1-5
During this critical initial period, the focus is on correcting life-threatening conditions that are common in severely malnourished children. These steps are carried out over the first 1-2 days of hospital admission.
- Treat or Prevent Hypoglycemia: Low blood sugar is a common and dangerous complication. It is managed by providing a 10% glucose or sucrose solution immediately, followed by frequent feeding with specialized formulas like F-75.
- Treat or Prevent Hypothermia: Malnourished children have poor temperature regulation. They must be kept warm and dry, often using warm blankets or skin-to-skin contact with a caregiver. Hypothermia and hypoglycemia often occur together and must be addressed simultaneously.
- Treat or Prevent Dehydration: Standard oral rehydration solutions are too high in sodium for severely malnourished patients. The WHO recommends a low-sodium, high-potassium solution called ReSoMal, administered slowly and cautiously.
- Correct Electrolyte Imbalance: Malnutrition often causes imbalances like high sodium and low potassium and magnesium levels. Feeds are prepared without added salt, and supplements of potassium and magnesium are given.
- Treat or Prevent Infection: Signs of infection can be subtle in malnourished children. All severely malnourished children are therefore routinely treated with broad-spectrum antibiotics upon admission.
The Rehabilitation Phase: Steps 6-9
Once the child is stabilized, the focus shifts to restoring nutritional status and promoting catch-up growth. This phase begins when the child's appetite returns and life-threatening issues are resolved.
- Correct Micronutrient Deficiencies: All severely malnourished children have vitamin and mineral deficiencies. Vitamin A is given on day one. A multi-vitamin, folic acid, zinc, and copper regimen is started, but iron supplementation is delayed until the child is gaining weight (usually the second week) to avoid exacerbating infections.
- Start Cautious Feeding: Feeding is initiated as soon as possible, using a starter formula like F-75, which is low in protein and calories but high in essential micronutrients. Frequent, small feeds are given initially, often every two to three hours.
- Achieve Catch-up Growth: Once the child's appetite returns, the feeding formula is changed to a higher-energy formula, such as F-100, or a Ready-to-Use Therapeutic Food (RUTF). The volume is increased daily to encourage rapid weight gain.
- Provide Sensory Stimulation: Malnutrition can lead to developmental delays. The WHO protocol emphasizes providing a loving and stimulating environment, including play therapy and physical activity, and encouraging maternal involvement.
Preparing for Follow-up: Step 10
The final step ensures the child's long-term health and prevents relapse.
- Prepare for Follow-up After Recovery: Before discharge, caregivers receive counseling on feeding practices, hygiene, and the importance of continued sensory stimulation at home. Regular follow-up appointments are scheduled, and immunization status is checked.
Comparison of Treatment Phases for Severe Malnutrition
| Feature | Stabilization Phase | Rehabilitation Phase |
|---|---|---|
| Primary Goal | Treat life-threatening medical complications | Restore nutritional status and achieve catch-up growth |
| Therapeutic Feed | F-75 starter formula (low protein/calorie) | F-100 or RUTF (high protein/calorie) |
| Micronutrient Focus | All micronutrients except iron, which is withheld | All micronutrients, including iron after weight gain starts |
| Fluid Management | Slow rehydration with ReSoMal, not standard ORS | Normal oral fluid intake and increased feeding |
| Feeding Frequency | Frequent, small feeds every 2-3 hours | Less frequent, larger feeds as appetite increases |
| Monitoring | Frequent checks for hypoglycemia, hypothermia, fluid balance | Monitoring weight gain and appetite progression |
The Role of Therapeutic Foods
Specialized therapeutic foods are the cornerstone of the WHO protocol. These products are carefully formulated to address the unique needs of severely malnourished individuals without overwhelming their fragile systems.
- F-75 Starter Formula: Used during the stabilization phase, this milk-based formula has low protein, lactose, and osmolality. This makes it easier for the compromised digestive system to tolerate while providing essential electrolytes and minerals needed to correct imbalances.
- F-100 Catch-up Formula: Once the child is stabilized, F-100 is introduced to provide a much higher energy and protein density. This fuel is crucial for the rapid catch-up growth that is the hallmark of the rehabilitation phase.
- Ready-to-Use Therapeutic Foods (RUTF): These are energy-dense, micronutrient-fortified pastes that do not require cooking or refrigeration. They are used for the rehabilitation phase and for home-based management of uncomplicated cases, facilitating broader access to treatment.
Conclusion
The WHO's 10-step protocol is a lifesaving, evidence-based strategy that has dramatically improved outcomes for severely malnourished children worldwide. By methodically addressing the medical complications first and then supporting nutritional recovery, the protocol provides a clear, effective pathway to health. It emphasizes not only the physiological needs but also the psychological and developmental aspects of recovery, highlighting the importance of a holistic approach. For healthcare professionals and caregivers, understanding these steps is vital for delivering the best possible care. For further in-depth details on the medical management, consult the WHO's Pocket Book of Hospital Care for Children.
