Severe Acute Malnutrition

Severe acute malnutrition in children 6 to 59 months is defined by MUAC below 11.5 cm, weight for height or length Z score below minus 3, or bilateral pitting nutritional oedema.

Physiological adaptation in SAM affects cardiac, renal, gastrointestinal and immune function. Standard approaches to fluids, sodium, iron and feeding can therefore cause harm if applied without modification.

Marasmus causes profound wasting, loss of subcutaneous fat and muscle, prominent ribs and an aged appearance.

Nutritional oedema causes symmetrical pitting oedema beginning in the feet and potentially progressing to generalized oedema.

Complications may be subtle:

• Poor appetite
• Hypoglycaemia
• Hypothermia
• Sepsis without fever
• Severe anaemia
• Dehydration
• Electrolyte disturbance
• Heart failure

Measure:

• MUAC
• Weight and length or height
• Weight for height Z score
• Bilateral pitting oedema

Assess appetite and search actively for medical complications.

Check glucose immediately in an unwell child. Additional investigations should be clinically directed and may include FBC, malaria testing, HIV testing, electrolytes and cultures.

• Uncomplicated SAM with preserved appetite and no danger signs can generally be treated through structured outpatient therapeutic care using ready to use therapeutic food and close follow up.

• Complicated SAM requires inpatient stabilization.

• Treat hypoglycaemia, hypothermia, dehydration and infection cautiously.

• Avoid unnecessary rapid IV fluids. Cardiovascular reserve is limited and fluid overload can be rapidly fatal.

• Do not start iron during the initial unstable phase. Introduce iron once appetite returns and the child is gaining weight.

• Provide therapeutic feeding according to stabilization and rehabilitation phase, progressing from F75 to higher energy rehabilitation feeding or ready to use therapeutic food.

Current WHO guidance emphasizes rapid triage and inpatient care for severe wasting or nutritional oedema when danger signs or major complications are present.