Severe acute malnutrition (SAM) is a life-threatening condition that requires immediate and structured medical intervention, especially when complicated by other illnesses. The World Health Organization's (WHO) 10-step management plan is a crucial framework for healthcare providers to treat affected children effectively, reducing mortality rates significantly. The process is divided into two distinct phases: stabilization and rehabilitation.
The Stabilization Phase (Steps 1-7)
This initial phase focuses on treating immediate, life-threatening symptoms and restoring metabolic function. It typically lasts for the first 1-7 days of treatment.
Step 1: Treat and Prevent Hypoglycemia
Hypoglycemia, or low blood sugar, is a constant risk in severely malnourished children and often a sign of infection. It must be treated immediately with a 10% glucose or sucrose solution administered orally or via nasogastric (NG) tube. Frequent feeding, day and night, is essential for prevention.
Step 2: Treat and Prevent Hypothermia
Hypothermia, a low body temperature, is common and is treated by re-warming the child through skin-to-skin contact with the mother or with a radiant heater. Frequent feeding and keeping the child warm and covered at all times are key preventative measures.
Step 3: Treat and Prevent Dehydration
Dehydration is difficult to assess in SAM children, so it should be assumed in those with watery diarrhea. The WHO recommends a low-sodium rehydration solution for malnutrition (ReSoMal), administered cautiously and slowly over a period of hours. Intravenous fluids should be avoided unless the child is in shock.
Step 4: Correct Electrolyte Imbalance
Severely malnourished children have deficiencies in potassium and magnesium, which can contribute to oedema. Extra potassium and magnesium are added to the therapeutic feed. Restricting sodium intake is vital, and diuretics should never be used to treat oedema.
Step 5: Treat and Prevent Infection
As signs of infection like fever are often absent in SAM, it is assumed that all children have an infection. Broad-spectrum antibiotics are given routinely upon admission. Specific infections like pneumonia or dysentery are treated as appropriate.
Step 6: Correct Micronutrient Deficiencies
All children with SAM have vitamin and mineral deficiencies. This step involves providing Vitamin A and daily doses of folic acid, zinc, and copper. Iron supplementation is intentionally delayed until the rehabilitation phase to avoid worsening infections.
Step 7: Start Cautious Feeding
Feeding begins carefully during the stabilization phase with a low-lactose, low-osmolarity formula, such as F-75. Feeds are given frequently (every 2-3 hours) in small volumes to provide basic energy needs without overloading the fragile metabolic system.
The Rehabilitation Phase (Steps 8-10)
This phase begins once the child is medically stable, has regained appetite, and any oedema is disappearing. The focus shifts to restoring nutritional status and promoting rapid weight gain.
Step 8: Achieve Catch-up Growth
Once stabilization is achieved, the child transitions to a higher-energy, higher-protein formula like F-100 or ready-to-use therapeutic food (RUTF). This catch-up feeding is crucial for rapid weight gain. Iron supplementation is started at this point, typically after a few days on the catch-up formula.
Step 9: Provide Sensory Stimulation and Emotional Support
Starvation can lead to delayed mental and behavioral development. Providing a stimulating environment, tender loving care, and structured play therapy is vital for recovery. Maternal involvement is encouraged to support the child's emotional and psychological well-being.
Step 10: Prepare for Follow-up and Discharge
The final step involves preparing the child for discharge and preventing relapse. Criteria for discharge include the resolution of oedema for at least two weeks and reaching a target weight-for-height or significant weight gain. Caregivers are counseled on proper feeding practices and the importance of regular follow-up.
Comparison of Treatment Phases
| Feature | Stabilization Phase | Rehabilitation Phase |
|---|---|---|
| Primary Goal | Treat life-threatening issues, restore metabolic function. | Achieve rapid catch-up growth and full recovery. |
| Duration | Approximately 1-7 days. | Can last several weeks. |
| Feeding Formula | Cautious, frequent feeds of low-energy F-75. | High-energy, high-protein F-100 or RUTF. |
| Iron Supplementation | Withheld to prevent exacerbating infection. | Administered to correct anaemia after weight gain starts. |
| Key Interventions | Treat hypoglycemia, hypothermia, dehydration, infection, correct electrolyte imbalances. | Intensive feeding, sensory stimulation, discharge planning. |
Essential Supplies for SAM Treatment
Successful management of SAM relies on a consistent supply of critical items. Key supplies typically include:
- Ready-to-use therapeutic food (RUTF)
- Amoxicillin and other broad-spectrum antibiotics
- ReSoMal oral rehydration solution
- Folic acid and Vitamin A capsules
- MUAC (mid-upper arm circumference) tapes
- Thermometers
- Weighing scales
- Soap for handwashing
Conclusion
The WHO's 10-step protocol provides a standardized and effective approach to managing complicated severe acute malnutrition in children. By addressing acute medical issues first during the stabilization phase and then focusing on nutritional rehabilitation and psychological support, the protocol significantly improves survival rates and promotes better long-term health outcomes. Consistent application of these guidelines, both in facilities and at the community level, is essential for tackling this major global health challenge. Following these steps ensures comprehensive care that can prevent relapse and contribute to full recovery.
