What is Severe Acute Malnutrition (SAM)?
Severe Acute Malnutrition, or SAM, is a major cause of child mortality worldwide, defined by a very low weight-for-height, a mid-upper arm circumference (MUAC) below 115mm, or the presence of bilateral pitting edema. The management of SAM for children with medical complications is an inpatient process guided by the World Health Organization (WHO) and Médecins Sans Frontières (MSF) protocols. These protocols divide the nutritional intervention into three distinct phases, ensuring the child's body can safely and effectively process therapeutic food and recover.
The Three Phases of SAM Nutritional Management
The nutritional treatment for SAM is carefully structured to avoid complications like refeeding syndrome, a potentially fatal metabolic disturbance that can occur when food is reintroduced too quickly. The phased approach ensures a gradual and safe return to health.
Phase 1: Stabilization (Days 1–7)
This initial phase, often lasting up to a week, focuses on treating the most critical, life-threatening symptoms associated with SAM. The primary goal is to restore the child's metabolic functions without overwhelming their weakened system.
Key nutritional and medical actions during this phase include:
- Initial Feeding: Children receive small, frequent feeds of a special low-protein, low-energy milk-based formula called F-75. This formula provides approximately 75 kcal and 0.9g protein per 100ml.
- Electrolyte Correction: All children with SAM have imbalances of potassium and magnesium. These are corrected without the use of diuretics for edema.
- Infection Control: Broad-spectrum antibiotics are administered, as infection signs like fever are often absent in severely malnourished children.
- Hypoglycemia and Hypothermia Management: Blood sugar and body temperature are closely monitored and corrected.
- Careful Rehydration: Slow rehydration is performed using a special oral rehydration solution (ReSoMal) to avoid circulatory overload.
- Micronutrient Supplementation: Vitamins and minerals are provided, except for iron, which is withheld because it can exacerbate an infection during this vulnerable stage.
Phase 2: Transition (Days 7–10, approximately)
Once the child is metabolically stable and their appetite has returned, they move into the transition phase. This is a short, but critical period lasting 1–3 days, designed to prepare the child's digestive system for higher-energy food.
The transition involves a gradual shift from the F-75 formula to a higher-energy diet, such as F-100 or a Ready-to-Use Therapeutic Food (RUTF). The amount of therapeutic food is carefully increased to ensure tolerance before the rehabilitation phase begins. This phase is a crucial bridge between acute medical management and long-term nutritional recovery.
Phase 3: Rehabilitation (Weeks 2–6)
This is the longest phase, during which the child achieves significant catch-up growth. The nutritional strategy is focused on providing sufficient energy and protein for rapid weight gain.
Key elements of the rehabilitation phase include:
- Catch-up Feeding: The diet consists of high-energy, high-protein foods like F-100 or RUTF. These therapeutic foods provide around 100 kcal and 2.9g protein per 100ml. RUTF is a paste that does not require water, reducing the risk of bacterial contamination in the field.
- Iron Supplementation: Once the child is gaining weight and has a good appetite, iron is introduced to address anemia.
- Sensory Stimulation: Providing a cheerful, stimulating environment with play activities helps promote emotional and physical recovery.
- Discharge: The child can be discharged to outpatient care once they are clinically well, have a good appetite, and all medical complications have resolved. Follow-up continues until full recovery.
Comparing Therapeutic Foods: F-75 vs. F-100
| Feature | F-75 (Stabilization) | F-100 (Rehabilitation) |
|---|---|---|
| Energy Density | 75 kcal per 100ml | 100 kcal per 100ml |
| Protein Content | Low (0.9g per 100ml) | High (2.9g per 100ml) |
| Carbohydrate | High, primarily from glucose | Moderate, from sugar |
| Purpose | To correct metabolic and electrolyte imbalances without causing refeeding syndrome. | To provide high energy for rapid weight gain and catch-up growth. |
| Nutrient Balance | Higher potassium, lower sodium to restore balance. | Balanced for nutritional repletion and growth. |
| Iron | Not included. | Included for treating anemia. |
Conclusion: The Path to Nutritional Recovery
The rigorous, phased approach to treating Severe Acute Malnutrition is a testament to the critical role of specialized nutrition in public health. By moving systematically through stabilization, transition, and rehabilitation, medical professionals can safely and effectively guide a severely malnourished child back to health. This methodology prevents potentially fatal complications and ensures the body's systems can handle the demands of recovery, making it a cornerstone of effective SAM management programs worldwide. For additional resources on malnutrition treatment protocols, the World Health Organization is a leading authority in this field.
