Understanding the Phases of Management of Acute Malnutrition

December 24, 2025 •

3 min read

Globally, severe acute malnutrition (SAM) affects millions of children under the age of five and is a major contributor to child mortality, necessitating a structured and phased treatment approach. The World Health Organization (WHO) outlines a clear, systematic process designed to address the complex medical and nutritional needs of severely malnourished individuals.

Quick Summary

The management of severe acute malnutrition follows distinct phases: stabilization to treat life-threatening conditions, followed by rehabilitation for rapid weight gain, and long-term follow-up to prevent relapse. Specialized therapeutic foods and close medical monitoring are essential throughout the process.

Key Points

Stabilization First: The initial management phase prioritizes treating immediate life-threatening conditions like hypoglycemia, hypothermia, and infection before aggressive nutritional rehabilitation.
Gradual Refeeding: Inpatient feeding begins cautiously with low-protein F-75 therapeutic milk to avoid the dangers of refeeding syndrome.
Rehabilitation for Catch-Up Growth: Once medically stable, the patient transitions to higher-energy F-100 or RUTF to promote rapid weight gain.
Monitoring and Follow-up: Post-discharge follow-up is crucial for preventing relapse and ensuring sustained recovery, with caregivers receiving guidance on diet and care.
Medical Complications Determine Care Setting: Patients with complications or poor appetite require intensive inpatient care, while uncomplicated cases can be managed through community-based outpatient programs.
Delayed Iron Supplementation: Iron is not given during the initial stabilization phase to avoid exacerbating infections.
Psychosocial Stimulation is Important: Engaging the patient through play and stimulation is an integral part of the treatment plan, especially for children.

Overview of the Phased Approach

Effective management of acute malnutrition, especially severe cases (SAM), requires a systematic, phased approach crucial for high recovery rates and reduced mortality. This model, used in inpatient or community settings, starts with stabilizing the patient, moves to nutritional rebuilding, and ends with preparation for sustained health at home. Without this careful progression, patients, particularly children, risk refeeding syndrome and other issues.

Phase 1: Stabilization

This initial phase focuses on correcting immediate, life-threatening medical problems, usually in an inpatient setting. The priority is metabolic stability, not rapid weight gain. Key actions include treating hypoglycemia with glucose, addressing hypothermia by rewarming and treating infection, cautiously correcting dehydration with ReSoMal, administering broad-spectrum antibiotics for likely infections, correcting electrolyte imbalances with supplements, and initiating cautious refeeding with F-75 therapeutic milk to prevent refeeding syndrome. Iron is withheld initially as it can worsen infections.

Phase 2: Rehabilitation

Once medically stable and with a returned appetite, patients enter rehabilitation to promote rapid weight gain. This can be inpatient or shifted to community-based outpatient care for less complicated cases. This phase involves transitioning to higher-energy formulas like F-100 or RUTF, starting iron supplementation, providing psychosocial support, treating other conditions like parasites, and potentially transitioning to outpatient care with RUTF for clinically well patients with good appetite and no severe edema.

Phase 3: Follow-up and Long-Term Prevention

After discharge with a stable weight-for-height, follow-up is vital to prevent relapse. This includes regular weight monitoring, counseling caregivers on a nutrient-rich home diet, potentially continuing micronutrient support, and linking families to public health services like immunizations and hygiene education.

Inpatient vs. Outpatient Management

Deciding between inpatient and outpatient care depends on the severity and complications of acute malnutrition. Patients are triaged to determine the appropriate setting.


Feature	Inpatient Management (Complicated Cases)	Outpatient Management (Uncomplicated Cases)
Goal	Correct life-threatening complications and stabilize the patient.	Promote rapid weight gain and full nutritional recovery.
Setting	Stabilization Centre or hospital ward.	Community-based Outpatient Therapeutic Program (OTP).
Admission Criteria	Severe edema (+++), poor appetite (failed appetite test), medical complications (e.g., shock, lethargy).	No medical complications, good appetite, can tolerate oral RUTF.
Nutritional Formula	Starts with low-protein F-75, transitions to F-100 or RUTF.	Primarily uses Ready-to-Use Therapeutic Food (RUTF).
Medication	Broad-spectrum antibiotics, ReSoMal, micronutrients (no iron initially).	Oral antibiotics, RUTF, iron supplementation starts after appetite test is passed.
Monitoring	Frequent, intensive monitoring of vital signs and feeding tolerance.	Regular, often weekly, visits to the clinic for follow-up.

Conclusion

The phased approach to managing acute malnutrition is a systematic process prioritizing stability before recovery. It accounts for the physiological challenges of malnourished patients and the risks of sudden nutritional changes. By addressing immediate threats, promoting controlled weight gain, and providing follow-up, this method significantly improves recovery and saves lives, particularly in resource-limited areas. Smooth transitions between inpatient and outpatient care, guided by protocols like those from the WHO, are crucial for successful treatment.

For additional information and guidelines, consult the World Health Organization (WHO) resources on managing severe acute malnutrition.

The Role of Community-Based Management

Community-Based Management of Acute Malnutrition (CMAM) is a key advancement, decentralizing care and allowing treatment of uncomplicated cases at the community level. Community health workers screen and refer children, and caregivers receive RUTF and training to monitor their child at home with regular health facility check-ins. CMAM is effective and cost-efficient, enabling hospitals to focus on severe cases. Strong connections between community outreach and facility care are vital for success and ensuring appropriate treatment.

Frequently Asked Questions

Inpatient treatment is for complicated cases with medical issues like shock, severe edema, or poor appetite, and occurs in a hospital. Outpatient treatment is for uncomplicated cases where the patient has a good appetite and no complications, managed in the community with RUTF.

Iron supplementation is delayed until the rehabilitation phase and is not given during stabilization. This is because iron can exacerbate infections, and malnourished patients are highly susceptible to them.

Refeeding syndrome is a dangerous and potentially life-threatening metabolic complication that can occur when severely malnourished individuals are fed too aggressively. It is prevented by starting with small, frequent feeds of a specific low-energy formula like F-75.

ReSoMal is a special low-sodium oral rehydration solution designed specifically for malnourished patients. It is used to correct dehydration slowly and carefully, avoiding the fluid overload that could lead to heart failure with standard solutions.

RUTF is a nutrient-dense, shelf-stable paste used during the rehabilitation phase and for outpatient care. It helps promote rapid weight gain and can be safely administered at home by caregivers.

Discharge criteria include the resolution of medical complications, a healthy weight-for-height or mid-upper arm circumference (MUAC), and the absence of edema for at least two weeks.

Early signs can include low body weight, visible wasting of fat and muscle, bilateral pitting edema, low mid-upper arm circumference (MUAC), and frequent infections.