Diagnosing Severe Acute Malnutrition (SAM)
Accurate diagnosis is the crucial first step in applying the WHO guidelines for severe malnutrition. The 2013 WHO guidelines define severe acute malnutrition (SAM) based on specific anthropometric and clinical indicators for children aged 6 to 59 months. The three primary diagnostic criteria are:
- Low weight-for-height/length: A weight-for-height/length Z-score below -3 standard deviations (SD) of the median WHO Child Growth Standards. This condition is also known as severe wasting and indicates a recent and severe weight loss.
- Low Mid-Upper Arm Circumference (MUAC): A MUAC measurement of less than 115 millimeters is an independent criterion for diagnosis. The threshold was increased from 110mm to 115mm to capture more high-risk children.
- Bilateral Pitting Oedema: The presence of bilateral pitting oedema, swelling caused by fluid retention, is a clinical sign of SAM. No distinction is made between kwashiorkor and marasmic kwashiorkor for treatment purposes, as their management is similar.
These criteria help healthcare workers identify and classify children for appropriate management, which can occur in either inpatient or outpatient settings depending on the child's condition.
Inpatient vs. Outpatient Management
One of the key principles of the WHO approach is differentiating between complicated and uncomplicated SAM to determine the appropriate care setting.
- Inpatient Care: Hospital admission is required for children with complicated SAM. These are children who exhibit medical complications or danger signs, such as a poor appetite, severe oedema (Grade III), lethargy, shock, hypothermia, or hypoglycaemia. Inpatient treatment follows a structured 10-step plan to stabilize the child's condition before moving to rehabilitation.
- Outpatient Care: Children with uncomplicated SAM—meaning they have a good appetite and no medical complications—can be managed in a community-based setting. This approach, supported by community health workers, allows children to be treated at home, increasing access to care and reducing costs. These children receive Ready-to-Use Therapeutic Foods (RUTF) and regular follow-up visits.
The 10-Step Inpatient Management Protocol
The comprehensive management protocol is divided into three distinct phases: stabilization, rehabilitation, and follow-up.
Phase 1: Stabilization (Steps 1–5)
This initial phase focuses on correcting immediate life-threatening conditions during the first 1–2 days. The priority steps include:
- Treat Hypoglycaemia: Give a 10% glucose or sucrose solution immediately, followed by frequent feeding with F-75 therapeutic milk.
- Treat Hypothermia: Re-warm the child immediately using skin-to-skin contact or radiant heat and feed promptly.
- Treat Dehydration: Use ReSoMal (Rehydration Solution for Malnutrition) orally or via nasogastric tube slowly. Standard oral rehydration solution (ORS) is not suitable due to its high sodium content.
- Correct Electrolyte Imbalance: All severely malnourished children have deficiencies in potassium and magnesium, which are corrected with specific supplementation added to feeds.
- Treat Infection: Administer broad-spectrum antibiotics, such as oral amoxicillin for uncomplicated cases or parenteral antibiotics like gentamicin for complicated cases.
Phase 2: Rehabilitation (Steps 6–9)
Once the child is stabilized, the focus shifts to restoring nutritional status and promoting weight gain. This typically begins a few days into treatment.
- Catch-up Feeding: Gradually introduce high-energy, high-protein foods like F-100 or RUTF to promote rapid weight gain. Dosage is increased as the child's appetite returns.
- Micronutrient Supplementation: Provide multivitamins, folic acid, zinc, and copper daily for at least two weeks. Iron supplementation should only be started in this phase, after the initial stabilization.
- Sensory Stimulation: Provide a supportive environment with play and physical activity to aid emotional and intellectual development, which is often impaired by prolonged malnutrition.
- Prepare for Follow-up: Educate caregivers on home care, including appropriate feeding, hygiene, and danger signs.
Discharge and Follow-up
Discharge occurs when the child has reached target weight criteria and is medically stable. Follow-up is critical to prevent relapse, with ongoing monitoring and support provided by community health workers.
Comparison of Inpatient and Outpatient Management
| Feature | Inpatient Management | Outpatient Management |
|---|---|---|
| Indication | Complicated SAM (medical complications, poor appetite, severe oedema) | Uncomplicated SAM (good appetite, no medical complications) |
| Location | Hospital or specialized nutrition unit | Home or community-based facility |
| Initial Treatment | Intensive medical stabilization (hypoglycaemia, hypothermia, etc.) | Initial screening and appetite test |
| Feeding | Therapeutic milk formulas (F-75, then F-100) in small, frequent feeds | Ready-to-Use Therapeutic Food (RUTF) provided for home use |
| Antibiotics | Broad-spectrum (e.g., Gentamicin and Amoxicillin) | Oral amoxicillin |
| Monitoring | Frequent, intensive clinical and anthropometric checks | Regular, scheduled follow-up visits with health workers |
Conclusion
The WHO guidelines for severe malnutrition offer a systematic and evidence-based framework for managing this life-threatening condition. By focusing on initial stabilization, followed by a phased approach to rehabilitation and subsequent follow-up, the guidelines significantly improve recovery rates and reduce mortality in malnourished children. The differentiation between inpatient and outpatient care enables efficient use of resources, ensuring that the most critically ill children receive the intensive medical attention they need, while others can recover within their communities supported by specialized therapeutic foods. This comprehensive approach is essential for combating malnutrition globally and is a core component of achieving health and development goals.
Further Information: For detailed clinical procedures, refer to the WHO's Pocket Book of Hospital Care for Children.
