Severe acute malnutrition

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    Last updated: February 2024

     

    Severe acute malnutrition (SAM) results from insufficient energy (kilocalories), fat, protein and/or other nutrients (vitamins and minerals, etc.) to cover individual needs.

     

    SAM is frequently associated with medical complications due to metabolic disturbances and compromised immunity. It is a major cause of morbidity and mortality in children globally.

     

    The protocols below are focused on the diagnosis and management of SAM in children 6 to 59 months only. For further details regarding this age group, and guidance for other age groups, refer to national recommendations and/or specialised protocols. 

    Clinical assessment

    Characteristic physical signs

    • In marasmus: skeletal appearance resulting from significant loss of muscle mass and subcutaneous fat.
    • In kwashiorkor:
      • Bilateral oedema of the lower limbs sometimes extending to other parts of the body (e.g. arms and hands, face).
      • Discoloured, brittle hair; shiny skin which may crack, weep, and become infected.

    Diagnostic and admission criteria

    Diagnostic criteria for SAM are both anthropometric and clinical:

    • Mid-upper arm circumference (MUAC) a Citation a. MUAC is measured at the mid-point of the left upper arm. The arm should be relaxed. The measuring tape should be in contact with the skin all around the arm, without exerting pressure. measures the degree of muscle wasting. MUAC < 115 mm indicates SAM and significant mortality risk.
    • Weight-for-height z-score (WHZ) indicates the degree of weight loss by comparing the weight of the child with the median weight of non-malnourished children of the same height and sex. SAM is defined as WHZ < –3 with reference to the WHO Child Growth Standards b Citation b. For WHZ, see WHO simplified field tables in z-scores for girls and for boys:
      https://www.who.int/tools/child-growth-standards/standards/weight-for-length-height
      .
    • The presence of bilateral pitting oedema of the lower limbs (when other causes of oedema have been ruled out) indicates SAM, regardless of MUAC and WHZ.

     

    Admission criteria for SAM treatment programmes vary with context. Refer to national recommendations.

    Medical complications

    • Children with any of the following severe medical conditions should receive hospital-based medical management:
      • Pitting oedema extending from the lower limbs up to the face;
      • Anorexia (observed during appetite test);
      • Other severe complications: persistent vomiting, shock, altered mental status, seizures, severe anaemia (clinically suspected or confirmed), persistent hypoglycaemia, eye lesions due to vitamin A deficiency, frequent or abundant diarrhoea, dysentery, dehydration, severe malaria, pneumonia, meningitis, sepsis, severe cutaneous infection, fever of unknown origin, etc.
    • In the absence of these conditions, children should be treated as outpatients with regular follow-up.

    Nutritional treatment

    • All children with SAM should receive nutritional treatment.
    • Nutritional treatment is based on the use of specialised nutritious foods enriched with vitamins and minerals: F-75 and F-100 therapeutic milks, and ready-to-use therapeutic food (RUTF).
    • Nutritional treatment is organised into phases:
      • Phase 1 (inpatient) intends to restore metabolic functions and treat or stabilize medical complications. Children receive F-75 therapeutic milk. This phase may last 1 to 7 days, after which children usually enter transition phase. Children with medical complications generally begin with phase 1.
      • Transition phase (inpatient) intends to ensure tolerance of increased food intake and continued improvement of clinical condition. Children receive F-100 therapeutic milk and/or RUTF. This phase usually lasts 1 to 3 days, after which children enter phase 2.
      • Phase 2 (outpatient or inpatient) intends to promote rapid weight gain and catch-up growth. Children receive RUTF. This phase usually lasts 1 to 3 days when inpatient, after which children are discharged for outpatient care. Children without medical complications enter directly into this phase as outpatients. The outpatient component usually lasts several weeks.
    • Breastfeeding should be continued in breastfed children.
    • Drinking water should be given in addition to meals, especially if the ambient temperature is high, or the child has a fever or is receiving RUTF.

    Routine medical management 

    The following should be provided to all inpatients and outpatients with SAM:

     

    Antibiotic treatment

    From D1, unless specific signs of infection are present:

    amoxicillin PO: 50 mg/kg (max. 1 g) 2 times daily for 5 to 7 days

    Malaria

    On D1, rapid diagnostic test in endemic areas and treatment for malaria according to results or if testing is not available (see Malaria, Chapter 6).

    Intestinal parasites

    In transition phase or upon outpatient admission, albendazole PO:

    Children 12 to 23 months: 200 mg single dose
    Children 24 months and over: 400 mg single dose

    Vaccination
    • In transition phase or upon outpatient admission, measles vaccine for children 6 months to 5 years, unless a document shows that the child received 2 doses of vaccine administered as follows: one dose at or after 9 months and one dose at least 4 weeks after the first dose. 

    Children vaccinated between 6 and 8 months should be re-vaccinated as above (i.e. with 2 doses) once they reach 9 months of age, provided that an interval of 4 weeks from the first dose is respected.

    • Other vaccines included in the EPI: check vaccination status and refer the child to vaccination services at discharge.
    Tuberculosis (TB)
     

    At D1 then regularly during treatment, screen for TB. For a child screening positive, perform complete diagnostic evaluation.

    For more information, refer to the guide Tuberculosis, MSF.

    HIV infection
     

    Perform HIV counselling and testing (unless the mother explicitly declines testing).

    • Children under 18 months: test the mother with rapid diagnostic tests. For a mother testing positive, request PCR test for the child.
    • Children 18 months and over: test the child with rapid diagnostic tests.

     

    Management of complications

    Infections

    • Respiratory, cutaneous and urinary infections are common. However, classic signs of infection, such as fever, may be absent [1] Citation 1. Jones KDJ, Berkley JA. Severe acute malnutrition and infection. Paediatrics and International Child Health 2014; 34(sup1): S1-S29.
      https://www.tandfonline.com/doi/full/10.1179/2046904714Z.000000000218 [Accessed 24 August 2022]
      .
    • Severe infection or sepsis should be suspected in children that are lethargic or apathetic or suffering from an acute complication such as hypothermia, hypoglycaemia, seizures, difficulty breathing, or shock. Immediately administer ampicillin IV 50 mg/kg every 8 hours + gentamicin IV 7.5 mg/kg once daily. Continue this treatment unless the source of infection is identified and different antibiotic treatment is required.
    • If circulatory impairment or shock, immediately administer ceftriaxone IV, one dose of 80 mg/kg, then assess the source of infection to determine further antibiotic treatment. See also Shock, Chapter 1. Transfuse urgently as for severe anaemia (see below) if haemoglobin (Hb)  is < 6 g/dl. 
    • In less severe infections, assess the source of infection (see Fever, Chapter 1) and treat accordingly.
    • If fever is present and causes discomfort, undress the child. If insufficient, administer paracetamol PO in low dose: 10 mg/kg, up to 3 times maximum per 24 hours. Encourage oral fluids (including breast milk).
    • If hypothermia is present, place the child skin-to-skin against the mother's body and cover with a warm blanket. Treat for infection as above. Check blood glucose level and treat for hypoglycaemia if necessary (see Hypoglycaemia, Chapter 1).
    • In children with kwashiorkor, infection of cutaneous lesions is common and may progress to soft tissue or systemic infection. If cutaneous infection is present, stop amoxicillin and start amoxicillin/clavulanic acid PO. Use formulations in a ratio of 8:1 or 7:1. The dose is expressed in amoxicillin: 50 mg/kg 2 times daily for 7 days.

    Severe anaemia

    • Children with Hb < 4 or < 6 with signs of decompensation (such as respiratory distress) or ongoing blood loss require transfusion within the first 24 hours. See Anaemia (Chapter 1) for volume to be transfused and patient monitoring during and after transfusion.
    • Preferably use packed red blood cells (PRBC), if available. Monitor closely for signs of fluid overload (see box below). 

    Diarrhoea and dehydration

    • Diarrhoea is common. Therapeutic foods facilitate the recovery of physiological function of the gastrointestinal tract. Amoxicillin administered as part of routine treatment reduces intestinal bacterial overgrowth. Diarrhoea generally resolves without additional treatment. If an aetiological treatment is necessary, see Acute diarrhoea, Chapter 3.
    • Zinc supplementation is not needed if children consume recommended amounts of therapeutic foods.

     

    • The diagnosis of dehydration is based on history and clinical features.
    • Clinical assessment is difficult in children with SAM as delayed skin pinch test and sunken eyes are often present even in the absence of dehydration.
    • For classification of degree of dehydration adapted for children with SAM, see table below:

      Clinical features

      (2 or more of the following signs)

      No

      dehydration

      Some

      dehydration

      Severe

      dehydration

      Mental status

      Normal

      Restless, irritability

      Lethargic or unconscious

      Thirst

      No thirst, drinks normally

      Thirsty, drinks eagerly

      Unable to drink or drinks poorly

      Urine output

      Normal

      Reduced

      Absent for

      several hours

      Recent frequent watery diarrhoea and/or vomiting

      Yes

      Yes

      Yes

      Recent obvious rapid weight loss

      No

      Yes

      Yes

     

    Acute diarrhoea with no dehydration (Plan A SAM)
    • Stools are neither frequent nor abundant (outpatient): oral rehydration solution (ORS) PO: 5 ml/kg after each loose stool to prevent dehydration.
    • Stools are frequent and/or abundant (inpatient): ReSoMal c Citation c. ReSoMal is a specific oral rehydration solution for malnourished children, containing less sodium and more potassium than standard ORS. It should be administered under medical supervision to avoid overdosing and hyponatremia. PO or by nasogastric tube (NGT): 5 ml/kg after each loose stool to prevent dehydration.
    • In all cases, continue feeding and breastfeeding, encourage oral fluids.
    Acute diarrhoea with some dehydration (Plan B SAM)
    • Determine the target weight (weight before the onset of diarrhoea) before starting rehydration. If not feasible (e.g. new admission), estimate target weight as current weight x 1.06.

    • ReSoMal c Citation c. ReSoMal is a specific oral rehydration solution for malnourished children, containing less sodium and more potassium than standard ORS. It should be administered under medical supervision to avoid overdosing and hyponatremia. PO or by NGT: 20 ml/kg/hour for 2 hours. In addition, administer 5 ml/kg of ReSoMal after each loose stool if tolerated.
    • Assess after 2 hours (clinical evaluation and weight):
      • If improvement (diarrhoea and signs of dehydration regress):
        • Reduce ReSoMal to 10 ml/kg/hour until the signs of dehydration and/or weight loss (known or estimated) have been corrected.
        • Assess every 2 hours.
        • Once there are no signs of dehydration and/or the target weight is reached, change to Plan A SAM to prevent dehydration.
      • If no improvement after 2 to 4 hours or if oral rehydration cannot compensate for losses: change to Plan C SAM "with circulatory impairment".
    • Continue feeding including breastfeeding.
    • Monitor for signs of fluid overload (see box below). Regardless of the target weight, stop rehydration if signs of fluid overload appear.
    Acute diarrhoea with severe dehydration (Plan C SAM)
    • In all patients:
      • Assess for circulatory impairment (see Shock, Chapter 1).
      • Estimate target weight as current weight x 1.1.
      • Measure blood glucose level and treat hypoglycaemia (Chapter 1) if necessary.
      • Monitor vital signs and signs of dehydration every 15 to 30 minutes.
      • Monitor urine output.
      • Monitor for signs of fluid overload (see box below).
    • If there is no circulatory impairment:
      • ReSoMal PO or by NGT: 20 ml/kg over 1 hour
      • If the child is alert, continue feeding including breastfeeding.
      • Assess after 1 hour:
        • If improvement: change to Plan B SAM, but keep the same target weight.
        • If rehydration PO/NGT not tolerated (e. g. vomiting):
          • Stop ReSoMal. Administer glucose 5%-Ringer lactate (G5%-RL) d Citation d. Remove 50 ml of Ringer lactate (RL) from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 ml of RL to obtain 500 ml of 5% glucose-RL solution. IV infusion: 10 ml/kg/hour for 2 hours.
          • Assess after 2 hours of IV fluids:
            • If improvement and/or not vomiting, stop G5%-RL IV infusion and change to Plan B SAM.
            • If no improvement or still vomiting, continue G5%-RL IV infusion: 10 ml/kg/hour for 2 hours.
        • If deterioration with circulatory impairment: see below.
    • If there is circulatory impairment:
      • Stabilize (see Shock, Chapter 1).
      • Administer ceftriaxone IV, one dose of 80 mg/kg. Subsequent antibiotic treatment depends on assessment of underlying cause.
      • Administer G5%-RL IV infusion: 10 ml/kg/hour for 2 hours. Stop ReSoMal if the child was taking it.
      • Assess after 1 hour of IV fluids:
        • If improvement and no vomiting: stop IV fluid and change to Plan B SAM, but keep the same target weight.
        • If no improvement:
          • Continue G5%-RL IV infusion: 10 ml/kg/hour.
          • Prepare for blood transfusion.
      • Assess after 2 hours of IV fluids:
        • If improvement: change to Plan B SAM, but keep the same target weight.
        • If no improvement or deterioration:
          • Check Hb as baseline and administer blood transfusion using a separate IV line. See Anaemia (Chapter 1) for volume to be transfused and patient monitoring during and after transfusion.
          • While transfusing, continue G5%-RL IV infusion 10 ml/kg/hour for another 2 hours.

     

    Signs of fluid overload include:

    • RR ≥ 10 breaths/minute compared to initial RR, or
    • HR ≥ 20 beats/minute compared to initial HR

    Plus any one of the following:

    • New or worsening hypoxia (decrease in SpO2 by > 5%)
    • New onset of rales and/or fine crackles in lung fields
    • New galloping heart rhythm
    • Increased liver size (must have marked liver border with pen before rehydration)
    • New peripheral or eyelid oedema

     

    Other complications

    For other complications (to be treated as inpatient), see:

    Discharge criteria

    In general:

    • Children can be discharged from hospital and be treated as outpatients if the following criteria are met:
      • clinically well;
      • medical complications controlled; 
      • able to eat RUTF (observed during appetite test);
      • reduction or absence of oedema;
      • caregiver feels able to provide care as outpatient;
      • vaccinations up to date or referral to vaccination service organised.
    • Children can be discharged from nutritional treatment if the following criteria are met:
      • co-existing medical conditions stable and outpatient treatment organised if necessary (e.g. dressing changes, follow-up for chronic diseases);

      • vaccinations up to date or referral to vaccination service organised;
      • absence of oedema and WHZ > –2 or MUAC > 125 mm for at least 2 weeks.

     

    Discharge criteria vary with context. Refer to national recommendations.

     

    Footnotes
    • (a)MUAC is measured at the mid-point of the left upper arm. The arm should be relaxed. The measuring tape should be in contact with the skin all around the arm, without exerting pressure.
    • (b)For WHZ, see WHO simplified field tables in z-scores for girls and for boys:
      https://www.who.int/tools/child-growth-standards/standards/weight-for-length-height
    • (c) ReSoMal is a specific oral rehydration solution for malnourished children, containing less sodium and more potassium than standard ORS. It should be administered under medical supervision to avoid overdosing and hyponatremia.
    • (d)Remove 50 ml of Ringer lactate (RL) from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 ml of RL to obtain 500 ml of 5% glucose-RL solution.
    References