Defining Severe Acute Malnutrition (SAM)
Severe acute malnutrition is a life-threatening condition defined by specific clinical signs and anthropometric measurements. According to the WHO, a child under 5 years old can be diagnosed with SAM if they present with any of the following indicators:
- A weight-for-length/height score below -3 standard deviations (SD)
- A mid-upper arm circumference (MUAC) less than 115mm (for children aged 6 to 60 months)
- The presence of bilateral pitting oedema (swelling of both feet), often associated with kwashiorkor
No distinction is made between the different clinical manifestations of severe wasting or oedema during treatment, as the management is largely similar. It is crucial to determine if a child has any complicating factors, as this dictates whether they can be treated as an outpatient or require inpatient care. Complicating factors include poor appetite, serious medical conditions, and severe oedema.
The WHO 10-Step Inpatient Protocol
For children with complicated SAM requiring inpatient care, the WHO has established a comprehensive 10-step protocol, divided into two phases: stabilization and rehabilitation.
Phase 1: Stabilization (Days 1–7)
This initial phase focuses on addressing the most immediate life-threatening issues, without trying to achieve rapid weight gain.
- Treat and prevent hypoglycemia: Severely malnourished children are highly susceptible to low blood sugar. Treatment begins with a 10% glucose solution orally, followed by frequent, small feeds.
- Treat and prevent hypothermia: Keeping the child warm is critical, as hypothermia often signals infection. Skin-to-skin contact with the mother is recommended.
- Treat or prevent dehydration: Intravenous fluids are generally avoided, except in cases of shock. Slow oral rehydration using a special low-sodium solution, ReSoMal, is preferred.
- Correct electrolyte imbalance: All SAM children have potassium and magnesium deficiencies. These are corrected through mineral-rich feeds like F-75.
- Treat infection: Because signs of infection may be absent in malnourished children, broad-spectrum antibiotics are administered to all complicated cases upon admission.
- Correct micronutrient deficiencies: Supplements of vitamins and minerals, including Vitamin A, folic acid, zinc, and copper, are given. Iron is withheld until the rehabilitation phase.
- Initiate cautious feeding: Feeding starts gradually using a low-osmolality, low-lactose starter formula (F-75) to prevent refeeding syndrome.
Phase 2: Rehabilitation (Weeks 2–6)
Once the child is stabilized, the focus shifts to restoring weight and health.
- Achieve catch-up growth: Feeds transition to a higher-energy formula (F-100) or Ready-to-Use Therapeutic Food (RUTF) to support rapid weight gain. Iron supplements are also introduced.
- Provide sensory stimulation and emotional support: This includes play, a loving environment, and maternal involvement to promote recovery.
- Prepare for follow-up and discharge: The family is prepared for continued care at home.
Community-Based Management of Acute Malnutrition (CMAM)
For children aged 6 to 59 months with uncomplicated SAM, CMAM allows for treatment at home using RUTF. This decentralized approach has been shown to achieve high recovery rates, reduce hospital stays, and lower costs for caregivers.
Key CMAM Components:
- Community Outreach: Community health workers screen children using MUAC tapes to identify cases of malnutrition.
- Outpatient Therapeutic Programme (OTP): Uncomplicated cases receive RUTF and regular monitoring in the community.
- Supplementary Feeding: Children with moderate acute malnutrition (MAM) may receive nutritional support to prevent deterioration.
Management for Infants Under 6 Months (MAMI)
WHO guidelines released in 2023 include specific recommendations for managing SAM in infants under 6 months (MAMI), an age group with higher mortality rates. A key priority is establishing or re-establishing effective, exclusive breastfeeding by supporting the mother-infant dyad. Infants with complicating factors are admitted for inpatient care. For those without complications, outpatient care with feeding support and follow-up is provided.
Key Updates from 2023
In 2023, the WHO released significant updates to its acute malnutrition guidelines, aiming to strengthen and streamline care.
- Expanded CMAM Role: Community health workers can now be trained to manage and monitor cases, expanding access to treatment in remote areas.
- Supplementary Food Hierarchy: A priority list for supplementary foods during crises was introduced, favoring lipid-based nutrient supplements (LNS) over fortified blended foods.
- Modified RUTF Dosages: Modified dosages of RUTF are endorsed for children recovering from SAM, optimizing the use of these critical resources.
- Infant (<6 months) Management: New recommendations for infants under six months provide tailored care, focusing on breastfeeding support.
Comparison of Inpatient vs. Outpatient SAM Treatment
| Aspect | Inpatient (Complicated SAM) | Outpatient (Uncomplicated SAM) |
|---|---|---|
| Patient Condition | Bilateral oedema (+++), poor appetite (failed test), medical complications (e.g., hypoglycemia, infection) | Good appetite (passed test), no medical complications, no severe oedema |
| Primary Treatment Site | Health facility (hospital), therapeutic feeding unit | Community-based care, home-based therapy, local health center |
| Initial Feeding | Cautious refeeding with F-75 formula; frequent, small feeds | Immediate, home-based treatment using RUTF |
| Therapeutic Food | F-75 (stabilization), then F-100 or RUTF (rehabilitation) | RUTF, home-based feeding by caregiver |
| Antibiotic Protocol | Broad-spectrum antibiotics administered upon admission | Oral antibiotics (e.g., amoxicillin) for uncomplicated cases |
| Micronutrients | Controlled supplementation with specific vitamins and minerals, iron delayed | RUTF contains all necessary micronutrients; separate supplements may not be needed |
| Caregiver Burden | Significant opportunity costs due to time away from home | Reduced burden, allowing caregivers to continue daily activities |
| Case Fatality Rate | Historically high (20–30% in traditional models), now lower with WHO protocol | Generally lower (<5%) due to early intervention |
Challenges and Importance of Implementation
Despite the clear benefits of the WHO's evolving guidelines, their effective implementation faces numerous challenges in many low-resource settings. These include inconsistent supply chains for therapeutic foods, inadequate training and supervision of health workers, and contextual factors like high rates of co-existing illnesses such as HIV. The success of CMAM hinges on robust community engagement and reliable resources. Continual research is needed to refine treatment protocols, especially concerning antibiotic resistance and optimal therapeutic food composition. Efforts to improve prevention strategies and integrate malnutrition treatment with broader health services are ongoing.
Conclusion
The WHO guidelines on SAM have transformed the approach to treating severe acute malnutrition, moving from a hospital-centric model to a more effective, integrated system that includes community-based care. By providing clear protocols for inpatient and outpatient treatment, and with continued updates to address specific populations like infants under 6 months, the WHO has significantly improved survival rates for millions of children. Effective implementation of these guidelines remains a challenge, but adherence is crucial for a positive public health impact. For further details on the latest 2023 updates, you can refer to relevant publications from organizations like Action Against Hunger that collaborated with WHO.
