The World Health Organization's (WHO) 10-step protocol is a crucial framework for the inpatient treatment of children suffering from Severe Acute Malnutrition (SAM). This systematic approach, developed to combat the high mortality rates associated with SAM, is divided into two distinct phases: stabilization and rehabilitation. By addressing the most immediate life-threatening issues first, and then focusing on nutritional recovery, the protocol provides a comprehensive path to health for the most vulnerable children.
The Stabilization Phase (Initial 1–2 Days)
The first phase of treatment is dedicated to managing the life-threatening medical complications that often accompany SAM, such as infection, dehydration, and electrolyte imbalances. Immediate and cautious care is paramount to prevent further deterioration.
Step 1: Treat Hypoglycaemia (Low Blood Sugar)
Severely malnourished children have depleted glycogen stores and are at high risk of hypoglycaemia. On admission, a 10% glucose or sucrose solution should be given orally or via a nasogastric tube to prevent and treat this condition. Frequent feeding is also initiated immediately to prevent recurrence.
Step 2: Treat and Prevent Hypothermia
These children are often unable to maintain their body temperature. They must be kept warm, preferably in a draught-free area, and wrapped in warm blankets. Skin-to-skin contact with the caregiver (the Kangaroo technique) is highly effective for infants. Hypoglycaemia and infection should also be actively checked for whenever hypothermia is present, as they often occur together.
Step 3: Treat and Prevent Dehydration
Dehydration in SAM requires a specialized and cautious approach. Standard oral rehydration solution (ORS) is not suitable due to its high sodium content. Instead, a low-sodium solution known as ReSoMal is used and administered slowly to avoid fluid overload, which is a significant risk.
Step 4: Correct Electrolyte Imbalance
SAM children almost always have severe potassium and magnesium deficiencies. Supplementation with these minerals is crucial. Simultaneously, excess body sodium must be corrected, and no salt should be added to food. Oedema, a common sign of SAM, should not be treated with diuretics as it can be fatal.
Step 5: Treat Infection
Infection signs are often masked in severely malnourished children due to a weakened immune system. Therefore, broad-spectrum antibiotics are routinely administered upon admission to treat or prevent potential infections. A measles vaccine is also given to children over six months who are not already vaccinated.
Step 6: Correct Micronutrient Deficiencies
All SAM children have vitamin and mineral deficiencies. Supplements including vitamin A, zinc, copper, and folic acid are provided. Iron is withheld during this initial phase, as it can worsen infection.
Step 7: Start Cautious Feeding
Initial feeding begins with a low-protein, low-energy formula called F-75. Feeds are given frequently in small, measured amounts to allow the child's digestive system to recover. Nasogastric tube feeding is used if the child refuses to eat or is too weak.
The Rehabilitation Phase
Once the child is stabilized, has a good appetite, and any oedema is resolving, they move to the rehabilitation phase, where the focus shifts to restoring weight and health.
Step 8: Achieve Catch-up Growth
This is the phase of rapid weight gain. The F-75 formula is gradually replaced with a higher-energy and higher-protein formula, F-100, or Ready-to-Use Therapeutic Food (RUTF). Feedings become less frequent and larger in volume, with the goal of providing enough energy for significant catch-up growth. Iron supplementation can be started during this phase.
Step 9: Provide Sensory Stimulation and Emotional Support
Children with SAM often suffer from developmental delays. Providing a stimulating and loving environment is vital for their emotional and mental recovery. Play therapy, physical activity, and affectionate care are encouraged daily. Caregivers are trained and empowered to participate in this process.
Step 10: Establish Follow-up Plan
Before discharge, a comprehensive plan for continued care is developed. Caregivers receive education on preparing nutritious foods, recognizing danger signs, and maintaining good hygiene at home. Regular follow-up visits are scheduled to monitor the child's progress and prevent relapse.
Comparison of Stabilization and Rehabilitation Phases
| Feature | Stabilization Phase | Rehabilitation Phase |
|---|---|---|
| Primary Goal | Treat life-threatening medical conditions; stabilize metabolism. | Achieve rapid catch-up growth; restore nutrient stores. |
| Therapeutic Food | F-75 (low energy, low protein). | F-100 or RUTF (high energy, high protein). |
| Feeding Frequency | Small, frequent feeds (every 2-3 hours), day and night. | Larger, less frequent feeds (every 4 hours), allowing for rest. |
| Micronutrient Focus | All except iron; high-dose Vitamin A given if signs present. | Addition of iron supplementation for building up stores. |
| Environment | Controlled, warm, medical setting, constant monitoring. | Encouraged sensory and emotional stimulation with the caregiver. |
Conclusion
The WHO 10 step protocol for SAM has revolutionized the management of severe malnutrition, shifting the focus from simply feeding to treating the underlying physiological complications that lead to high mortality. By dividing the process into stabilization and rehabilitation phases, the protocol systematically addresses the complex medical needs of severely malnourished children. Its success relies on consistent adherence, skilled healthcare workers, and active caregiver involvement, ultimately providing these children a chance at a healthy future. For more detailed information on implementation, consult the official WHO publications on inpatient management of severe acute malnutrition.
