Understanding the WHO 10 Steps to Treat Malnutrition
The World Health Organization's (WHO) 10-step protocol for managing severe malnutrition is a globally recognized standard, primarily for pediatric care. It is a phased approach that addresses the physiological fragility of severely malnourished individuals, moving from immediate life-saving interventions to long-term nutritional rehabilitation and recovery. This comprehensive strategy is divided into two distinct phases: the initial stabilization phase and the longer rehabilitation phase. Following this protocol is crucial for significantly reducing high case-fatality rates associated with severe malnutrition.
The Stabilization Phase: Steps 1-5
The initial phase focuses on addressing the most urgent, life-threatening complications that occur in the first 1-7 days of treatment. A malnourished person's immune system is severely compromised, and their body's compensatory mechanisms are often failing, making this period extremely delicate.
Step 1: Treat or Prevent Hypoglycemia
Low blood sugar is a common and dangerous symptom of severe malnutrition. Treatment involves immediate administration of 10% glucose or sucrose solution, followed by frequent feeding every two hours, day and night. Monitoring blood glucose levels is essential to prevent relapse.
Step 2: Treat or Prevent Hypothermia
Patients with severe malnutrition struggle to maintain body temperature. Rewarming must be done gradually, often through methods like skin-to-skin contact with a caregiver or covering the patient with a warm blanket. Feeding is also a critical component in preventing further hypothermia.
Step 3: Treat or Prevent Dehydration
Unlike in healthy individuals, standard oral rehydration solutions (ORS) are not suitable for severely malnourished patients due to electrolyte imbalances. A modified solution, such as ReSoMal (Rehydration Solution for Malnutrition), is used and administered slowly to prevent fluid overload and heart failure.
Step 4: Correct Electrolyte Imbalance
Severely malnourished individuals have excess total body sodium, despite possibly having low plasma sodium, and deficiencies in potassium and magnesium. Extra potassium and magnesium supplements are administered, and all food is prepared without added salt to correct these imbalances over the first two weeks.
Step 5: Treat or Prevent Infection
Infections in severely malnourished patients often do not present with typical symptoms like fever. For this reason, broad-spectrum antibiotics are administered to all patients on admission. Treatment for specific infections like pneumonia or dysentery is also initiated as needed.
The Rehabilitation Phase: Steps 6-10
After a patient is stabilized, the focus shifts to restoring nutritional health and preparing for discharge. This phase can last several weeks.
Step 6: Correct Micronutrient Deficiencies
All severely malnourished patients have vitamin and mineral deficiencies. While initial treatment corrects some, a daily multivitamin supplement is crucial. Importantly, iron is withheld until the patient starts gaining weight, as early iron supplementation can exacerbate infections.
Step 7: Start Cautious Feeding
Feeding is reinitiated cautiously with small, frequent feeds of therapeutic milk (like F-75). The goal is to provide sufficient energy for basic physiological processes without overwhelming the system. The feed volume is gradually increased as the patient's condition improves.
Step 8: Achieve Catch-up Growth
As the patient's appetite and medical state improve, they are transitioned to a higher-energy therapeutic food, such as F-100 therapeutic milk or Ready-to-Use Therapeutic Food (RUTF). This stage is aimed at rapidly replenishing lost weight and muscle mass.
Step 9: Provide Sensory Stimulation and Emotional Support
Malnutrition can cause developmental delays. Providing a stimulating, cheerful environment with structured play and emotional support from caregivers is vital for a child's mental and behavioral recovery.
Step 10: Prepare for Follow-up
Before discharge, caregivers are educated on how to provide energy-dense, nutrient-rich foods at home. A follow-up plan is established to monitor recovery, ensure immunization boosters are given, and provide continued support.
Comparison of Inpatient and Outpatient Management
The WHO guidelines have evolved to recommend outpatient treatment for uncomplicated cases of severe acute malnutrition (SAM). The following table highlights the key differences between inpatient and outpatient management strategies.
| Feature | Inpatient Management | Outpatient Management |
|---|---|---|
| Patient Profile | Complicated SAM: poor appetite, medical complications, or edema. | Uncomplicated SAM: good appetite and no medical complications. |
| Care Setting | Hospital-based, supervised medical care for stabilization. | Home-based, managed by caregivers with regular clinic visits. |
| Initial Treatment | Addressing life-threatening issues like hypoglycemia and dehydration. | Focusing on therapeutic feeding and routine medication. |
| Monitoring Frequency | Continuous, with regular checks on vital signs and intake. | Regular follow-up appointments, often weekly. |
| Therapeutic Food | Initial milk formulas (F-75, F-100) and later transition to RUTF. | Primarily Ready-to-Use Therapeutic Food (RUTF) from the start. |
| Antibiotics | Routine broad-spectrum antibiotics for all patients. | Oral antibiotics for uncomplicated cases. |
| Micronutrients | Supplements given during both stabilization and rehabilitation. | Supplements incorporated into RUTF packets. |
Conclusion
The WHO's 10-step protocol provides a structured, evidence-based roadmap for combating severe malnutrition. By separating treatment into a critical stabilization phase and a comprehensive rehabilitation phase, the guidelines ensure that the most immediate threats to life are addressed before focusing on long-term recovery. The protocol's evolution to include outpatient options for less severe cases has also made treatment more accessible and child-centric, reducing the risks and stresses associated with prolonged hospitalization. Adherence to these guidelines remains a cornerstone of effective global public health efforts to reduce childhood mortality and promote healthy development in vulnerable populations. The success of this approach is a testament to the power of standardized, evidence-based medicine in tackling complex health challenges.
