What is the SAM Protocol?
In the context of nutrition and diet, the SAM protocol refers to the standardized approach for the management of Severe Acute Malnutrition. Endorsed and updated by the World Health Organization (WHO), this set of guidelines provides a systematic method for diagnosing and treating children with SAM, especially those aged 6 to 59 months. The protocol distinguishes between complicated and uncomplicated cases, dictating whether care should be provided in an inpatient facility or a community-based outpatient program. Its primary goal is not just to feed the child, but to reverse the physiological complications of starvation, stabilize the patient, and promote rapid, safe weight gain.
The Phased Approach to SAM Treatment
Treatment under the SAM protocol is divided into two distinct phases, with a brief transitional period between them. This structured progression ensures that the child's weakened body can handle re-feeding without developing serious complications like re-feeding syndrome.
Phase 1: Stabilization (Inpatient Care)
This initial phase, lasting approximately 1 to 7 days, is for children with complications such as poor appetite, severe edema, or other medical issues like infection or hypoglycemia. It is carried out in a hospital or therapeutic feeding center. The focus here is on addressing life-threatening medical problems and restoring metabolic function, not rapid weight gain.
Key steps in the stabilization phase include:
- Treatment of Medical Complications: Addressing hypoglycemia, hypothermia, dehydration (using a low-sodium oral rehydration solution called ReSoMal), and infection with broad-spectrum antibiotics.
- Initial Feeding: Slow, frequent, and small feeds are given using a special milk-based formula known as F-75. F-75 is low in protein and sodium to prevent stress on the child's body.
- Micronutrient Supplementation: Providing essential vitamins and minerals, without iron, to correct deficiencies.
Transition Phase
Once a child is stabilized and their appetite returns, a transition phase of 1 to 3 days begins. The child is transitioned from F-75 to a higher-energy therapeutic milk, F-100, or a ready-to-use therapeutic food (RUTF) like Plumpy'Nut®.
Phase 2: Rehabilitation (Inpatient or Outpatient Care)
This phase aims to promote rapid weight gain and catch-up growth once the child's metabolic state is more stable. It lasts several weeks and is conducted either in the hospital or, for uncomplicated cases, at home under the Community-Based Management of Acute Malnutrition (CMAM) model.
Actions during rehabilitation include:
- Nutritional Rehabilitation: The child receives energy-dense, nutrient-rich food like F-100 or RUTF, designed for rapid weight gain. RUTF is particularly valuable for outpatient care as it is shelf-stable and requires no preparation.
- Iron Supplementation: Iron is introduced in this phase to treat potential anemia.
- Sensory Stimulation and Play: Crucial for a child's psychological development, which can be negatively affected by malnutrition.
Key Components of the SAM Protocol
The success of the SAM protocol depends on several key elements working in concert:
- Assessment Tools: Anthropometric measurements like mid-upper arm circumference (MUAC) and weight-for-height z-score, along with the presence of bilateral pitting edema and an appetite test, are used for screening and diagnosis.
- Therapeutic Foods: Specialized foods are the cornerstone of nutritional treatment:
- F-75: A low-lactose, low-protein milk for initial stabilization.
- F-100: A high-protein, high-energy milk for inpatient rehabilitation.
- RUTF: A ready-to-use, energy-dense peanut paste for outpatient rehabilitation.
- ReSoMal: A low-sodium oral rehydration solution for children with malnutrition and dehydration.
- Antibiotics: A broad-spectrum antibiotic is given to all complicated SAM children, as infection is often present without obvious signs.
SAM Protocol vs. Traditional Inpatient Treatment
The SAM protocol, particularly through the CMAM approach, revolutionized malnutrition treatment. Here is a comparison with the older, traditional, inpatient-only model.
| Feature | Traditional Inpatient Treatment | Modern SAM Protocol (CMAM Model) |
|---|---|---|
| Location of Care | Entirely in a hospital or therapeutic feeding center. | Divided between inpatient facilities (for complicated cases) and home-based outpatient care (for uncomplicated cases). |
| Accessibility | Limited, especially in rural or remote areas due to travel costs and time away from home. | High, as it decentralizes services and utilizes community health workers for screening and monitoring. |
| Treatment Product | Relied on inpatient-prepared therapeutic milk formulas, requiring clean water and careful preparation by health staff. | Utilizes RUTF, which is ready-to-use and shelf-stable, reducing preparation errors and contamination risk. |
| Cost | High costs associated with staffing, infrastructure, and hospital stay. | More cost-effective, with reduced hospitalization costs and increased treatment coverage. |
| Effectiveness | Often had high case fatality rates (20-30%) and lower coverage. | Achieved significantly lower case fatality rates and higher recovery rates by reaching more children. |
Implementation and Outcomes of the SAM Protocol
Since its widespread adoption in the early 2000s, the SAM protocol has led to major improvements in global malnutrition outcomes. The integration of the protocol into the broader CMAM model has been particularly impactful, allowing for early detection and rapid, effective treatment at the community level. In emergency settings and resource-constrained environments, simplified versions of the protocol have been successfully tested, using a single product (RUTF) and simplified admission criteria (MUAC) to improve coverage and cost-effectiveness. Despite challenges like high costs and ensuring consistent supply chains, the SAM protocol remains the global standard for addressing severe acute malnutrition. Research continues to refine the protocol, including exploring locally produced alternatives to standard RUTF to increase affordability and accessibility.
Conclusion
The SAM protocol is a systematic, evidence-based strategy that has dramatically improved the treatment and survival rates for children suffering from severe acute malnutrition. By transitioning from an inpatient-only approach to a model that incorporates community-based outpatient care, the protocol ensures a more accessible, effective, and sustainable response to this critical health crisis. Through its careful, phased feeding regimen and targeted medical interventions using specialized products like F-75, F-100, and RUTF, the SAM protocol continues to save millions of young lives worldwide. For further information on the WHO's guidelines, visit the World Health Organization's website(https://www.who.int/tools/elena/interventions/sam-infants).
