Severe acute malnutrition

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:

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 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.

Other complications

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

• Hypoglycaemia, seizures, Chapter 1.
• Acute pneumonia, Chapter 2.
• Stomatitis, Chapter 3.
• Xerophthalmia (vitamin A deficiency), Chapter 5.

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.