Severe acute malnutrition


Severe acute malnutrition (SAM) is caused by a significant imbalance between nutritional intake and individual needs. It is most often caused by both quantitative (number of kilocalories/day) and qualitative (vitamins and minerals, etc.) deficiencies.

Children over 6 months of age

The two principal forms of SAM are:
– Marasmus: significant loss of muscle mass and subcutaneous fat, resulting in a skeletal appearance.
– Kwashiorkor: bilateral oedema of the lower limbs/oedema of the face, often associated with cutaneous signs (shiny or cracked skin, burn-like appearance; discoloured and brittle hair).

The two forms may be associated (marasmic-kwashiorkor).

In addition to these characteristic signs, SAM is accompanied by significant physiopathological disorders (metabolic disturbances, anaemia, compromised immunity, leading to susceptibility to infections often difficult to diagnose, etc.).
Complications are frequent and potentially life-threatening.
Mortality rates may be elevated in the absence of specific medical management.

Admission and discharge criteria for treatment programmes for SAM are both anthropometric and clinical:
– Mid-upper arm circumference (MUAC) is the circumference, measured in mid-position, of the relaxed left upper arm, taken in children of 6 to 59 months (65 to 110 cm in height). MUAC measures the degree of muscle wasting. A MUAC of < 115 mm indicates SAM and significant mortality risk.
– Weight for height (W/H) index assesses the degree of weight loss by comparing the weight of the SAM child with non-malnourished children of the same height. Severe malnutrition is defined as a W/H index of < – 3Z with reference to the new WHO child growth standards1 .
– The presence of bilateral oedema of the lower limbs (when other causes of oedema have been ruled out) indicates SAM, regardless of the MUAC and W/H.

Usual admission criteria are: MUAC < 115 mm (MUAC is not used as an admission criterion in children older than 59 months or taller than 110 cm) or W/H < – 3Z1  or presence of bilateral oedema of the lower limbs.

Usual discharge (cure) criteria are: W/H > – 2Z1  and absence of bilateral oedema (2 consecutive assessments, one week apart) and absence of acute medical problems.

Medical management (hospitalisation or ambulatory care) is based on the presence or absence of associated serious complications:
– Children exhibiting anorexia, or significant medical complications, such as severe anaemia, severe dehydration or severe infection (complicated acute malnutrition) should be hospitalised2 .
– Children without significant medical complications (uncomplicated acute malnutrition) may undergo treatment on an ambulatory basis, with weekly medical follow-up.

Treatment

1) Nutritional treatment

Nutritional treatment is based on the use of therapeutic foods enriched with vitamins and minerals:

– Therapeutic milks (for use exclusively in hospitalised patients):
• F-75 therapeutic milk, low in protein, sodium and calories (0.9 g of protein and 75 kcal per 100 ml) is used in the initial phase of treatment for patients suffering from complicated SAM. It is used to cover basic needs while complications are being treated. It is given in 8 daily meals.
• F-100 therapeutic milk, in which the concentration of protein and calories is higher (2.9 g of protein and 100 kcal per 100 ml), replaces F-75 after several days, once the patient is stabilised (return of appetite, clinical improvement; disappearance or reduction of oedema). The objective is to facilitate rapid weight gain. It can be given with, or be replaced by, RUTF.

– RUTF (ready-to-use therapeutic food), i.e. foods which are ready for consumption (for example, peanut paste enriched with milk solids, such as Plumpy’nut®), are used in children treated in both hospital or ambulatory settings. The nutritional composition of RUTF is similar to F-100, but the iron content is higher. It is designed to promote rapid weight gain (approximately 500 kcal per 100 g). RUTF are the only therapeutic foods which can be used in ambulatory treatment.

Furthermore, it is important to give drinking water, in addition to meals, especially if the ambient temperature is high or the child has a fever.

Breastfeeding should continue in children of the appropriate age.

2) Routine medical treatment

In the absence of specific medical complications, the following routine treatments should be implemented in both ambulatory and hospital settings:

Infections

– Measles vaccination on admission.
– Broad spectrum antibiotherapy starting on D1 (amoxicillin PO: 50 mg/kg 2 times daily for 5 days)3 .
– In endemic malaria areas: rapid test on D1, with treatment in accordance with results. If testing is not available, give malaria treatment (Malaria, Chapter 6).
– Treatment for intestinal worms on D8:
albendazole PO
Children > 6 months: 400 mg single dose (200 mg in children > 6 months but < 10 kg)

Micronutrient deficiencies

Therapeutic foods correct most of these deficiencies.

3) Management of common complications

Diarrhoea and dehydration

Diarrhoea is common in malnourished children. Therapeutic foods facilitate the recovery of gastrointestinal mucosa and restore the production of gastric acid, digestive enzymes and bile. Amoxicillin, administered as part of routine treatment, is effective in reducing bacterial load. Diarrhoea generally resolves without any additional treatment.

Watery diarrhoea is sometimes related to another pathology (otitis, pneumonia, malaria, etc.), which should be considered.

If an aetiological treatment is necessary, see Acute diarrhoea, Chapter 3.

If a child has a significant diarrhoea (very frequent or abundant stools) but is not dehydrated, administer specific oral rehydration solution (ReSoMal, see below), after each watery stool, to avoid dehydration, according to the Treatment Plan A (Appendix 2b).

However, if the child has no profuse diarrhoea, give plain water (not ReSoMal) after each loose stool.

Dehydration is more difficult to assess in malnourished than healthy children (e.g., delay in return of skin pinch and sunken eyes are present even without dehydration in children with marasmus.).

The diagnosis is made on the basis of a history of watery diarrhoea of recent onset accompanied by weight loss, corresponding to fluid losses since the onset of diarrhoea. Chronic and persistent diarrhoea does not require rapid rehydration.


In the event of dehydration:

– In there is no hypovolaemic shock, rehydration is made by the oral route (if necessary using a nasogastric tube), with specific oral rehydration solution (ReSoMal)4 , containing less sodium and more potassium than standard solutions.
ReSoMal is administered under medical supervision (clinical evaluation and weight every hour). The dose is 20 ml/kg/hour for the first 2 hours, then 10 ml/kg/hour until the weight loss (known or estimated) has been corrected. Give ReSoMal after each watery stool according to the Treatment Plan A (Appendix 2b).
In practice, it is useful to determine the target weight before starting rehydration. The target weight is the weight before the onset of diarrhoea. If the child is improving and showing no signs of fluid overload, rehydration is continued until the previous weight is attained.
If the weight loss cannot be measured (e.g. in newly admitted child), it can be estimated at 2 to 5% of the child’s current weight. The target weight should not exceed 5% of the current weight (e.g., if the child weighs 5 kg before starting rehydration, the target weight should not exceed 5.250 kg). Regardless of the target weight, rehydration should be stopped if signs of fluid overload appear.

– In case of hypovolaemic shock (weak and rapid or absent radial pulse, cold extremities, CRT ≥ 3 seconds, whether or not consciousness is altered) in a child with diarrhoea or dehydration:

  • Place an IV line and administer 10 ml/kg of 0.9% sodium chloride over 30 minutes, under close medical supervision.
    Simultaneously:
  • Start broad spectrum antibiotic therapy: ceftriaxone IV 100 mg/kg once daily + cloxacillin IV 50 mg/kg every 6 hours
  • Administer oxygen (2 litres minimum).
  • Check blood glucose level or administer 5 ml/kg of 10% glucose by IV injection.
    Every 5 minutes, evaluate clinical response (recovery of consciousness, strong pulse, CTR < 3 seconds) and check for signs of over-hydration.
    - If the clinical condition has improved after 30 minutes, switch to the oral route with ReSoMal: 5 ml/kg every 30 minutes for 2 hours.
    - If the clinical condition has not improved, administer again 10 ml/kg of 0.9% sodium chloride over 30 minutes then, when the clinical condition has improved, switch to the oral route as above.
    When switching to the oral route, stop the infusion but leave the catheter (capped) in place to keep a venous access, for IV antibiotherapy.

Bacterial infections

Lower respiratory infections, otitis, skin and urinary infections are common, but sometimes difficult to identify (absence of fever and specific symptoms).
Infection should be suspected in a drowsy or apathetic child.
Severe infection should be suspected in the event of shock, hypothermia or hypoglycaemia. Since the infectious focus may be difficult to determine, a broad spectrum antibiotic therapy (cloxacilline + ceftriaxone) is recommended.

Fever

Avoid antipyretics. If absolutely necessary, paracetamol PO: 10 mg/kg 3 times daily maximum
Do not wrap children in wet towels or cloths: not effective, increases disconfort, risk of hypothermia.

Hypothermia and hypoglycaemia

Hypothermia (rectal temperature < 35.5 °C or axillary < 35 °C) is a frequent cause of death in the first days of hospitalisation.
Prevention measures include keeping the child close to the mother ’s body (kangaroo method) and provision of blankets.
In case of hypothermia, warm the child as above, monitor the temperature, treat hypoglycaemia. Severe infection should be suspected in the event of hypothermia (see above).

In hypoglycaemia, suspected or confirmed (test strip < 3.3 mmol/litre or 60 mg/dl), administer glucose PO if the child is able to drink (50 ml of sugar water [50 ml water + a teaspoon of sugar] or 50 ml of milk); if the child is unconscious, 5 ml/kg of 10% glucose slow IV, to be repeated once if necessary. Treat possible underlying infection.

Oral candidiasis

Look routinely for oral candidiadis as it interferes with feeding; see Chapter 3, Stomatitis.


If the child fails to recover despite appropriate nutritional and medical treatment, consider another pathology: tuberculosis, HIV infection, etc.

Adolescents and adults

Clinical examination of the patient (sudden weight loss, loss of mobility from muscle wasting, cachexia, bilateral lower limb oedema in the absence of other causes of oedema) is indispensable for the diagnosis and adapted medical, nutritional and even social care of the patient.

Admission and discharge criteria, as a rough guide, are:

– Admission criteria:
Adolescents: W/H according to NCHS-CDC-WHO 1982 reference table or bilateral lower limb oedema (Grade 3 or more, having excluded other causes of oedema).
Adults: MUAC < 160 mm or bilateral lower limb oedema or MUAC < 185 mm in poor general condition (for example, inability to stand, evident dehydration).
As in children, any malnourished patient presenting with significant complications should initially be hospitalised, regardless of the anthropometric criteria above.

– Discharge criteria:
Adolescents: as in children.
Adults: weight gain of 10-15% over admission weight and oedema below Grade 2 and good general condition.

Nutritional treatment follows the same principles as in children, but the calorie intake in relation to body weight is lower.

Routine treatment is similar to that in children, with the following exceptions:
– Measles vaccine is only administered to adolescents (up to age 15).
– Antibiotics are not routinely given, but infections should be considered, and treated or excluded, in the assessment of the patient.



Footnotes
Ref Notes
1

Some national programmes define anthropometric admission and discharge criteria with reference to NCHS growth standards, with thresholds expressed in percentage of the median.

[ a b c ]
2

As a rule, any malnourished child presenting with medical complications should initially be hospitalised, even if s/he suffers from moderate, rather than severe, malnutrition (W/H > – 3Z).

3

If specific signs of infection are present, the choice of treatment should be directed by the suspected focus.

4

Except for cholera, in which case standard oral rehydration solutions are used.