From the Guidelines
For a 2-year-old boy with severe acute malnutrition (SAM), immediate comprehensive evaluation and treatment is essential, following a two-phase approach of stabilization and rehabilitation, as recommended by the World Health Organization 1. Initial investigations should include:
- Complete blood count
- Serum electrolytes
- Blood glucose
- Renal and liver function tests
- Urinalysis
- Stool examination for parasites
- Tuberculosis screening
- HIV testing where appropriate Anthropometric measurements (weight, height, mid-upper arm circumference) should be documented. The child should be assessed for complications like:
- Hypoglycemia
- Hypothermia
- Dehydration
- Electrolyte imbalances
- Infections
- Micronutrient deficiencies During stabilization (typically 1-7 days), provide F-75 therapeutic milk (130 ml/kg/day divided into 8-12 feeds) to restore metabolic balance without overwhelming the compromised system 1. Treat infections with broad-spectrum antibiotics like amoxicillin (25 mg/kg twice daily for 5-7 days) or if severely ill, parenteral antibiotics. Correct hypoglycemia with 10% glucose solution (5 ml/kg). Address dehydration cautiously with ReSoMal solution rather than standard ORS. During rehabilitation, transition to F-100 formula or ready-to-use therapeutic food (RUTF) like Plumpy'Nut (200 kcal/kg/day) 1. Provide vitamin A (100,000 IU for 6-12 months, 200,000 IU for >12 months), folic acid (5 mg day 1, then 1 mg daily), and other micronutrients. Gradually reintroduce normal foods while continuing supplementation. This approach addresses the physiological adaptations in malnutrition, where aggressive refeeding can cause dangerous metabolic shifts, and treats the immunocompromised state that makes infections particularly dangerous in these children. Training courses for Emergency Triage Assessment and Treatment (ETAT) and in management of severe malnutrition can be beneficial for healthcare providers 1. Outpatient management of children with SAM can be effective, but it is essential to monitor for complications and adjust treatment accordingly 1.
From the Research
Investigations for Severe Acute Malnutrition
- Anthropometric measurements: weight, height, mid-upper arm circumference (MUAC) 2, 3, 4
- Clinical screening for complications such as infections, fluid and electrolyte imbalances, and metabolic abnormalities 2, 4
- Laboratory tests: complete blood count, blood culture, electrolyte panel, liver function tests, and renal function tests 5
Treatment and Management
- Outpatient treatment with ready-to-use therapeutic foods (RUTF) or appropriately formulated home diets, along with psychosocial care, for children with uncomplicated severe acute malnutrition 2, 3
- Inpatient treatment for children with severe acute malnutrition and life-threatening complications, with initial dietary management relying on low-lactose, milk-based, liquid formulas 2
- Antibiotic therapy: oral amoxicillin for children with uncomplicated malnutrition, and parenteral benzylpenicillin and gentamicin for those with complicated malnutrition 5
- Energy needs: average estimated total daily energy requirement of 92-110 kcal/kg/day, with therapeutic feeding protocols providing adequate energy intake 6
Community-Based Management
- National programs for community-based management of acute malnutrition (CMAM) provide periodic anthropometric and clinical screening of young children, and referral of those who meet established criteria 2
- Community-based treatment is preferred by caregivers and is less costly than inpatient care 2
- A reduced schedule of follow-up, with monthly distribution of RUTF, may be a feasible alternative to weekly follow-up 3