What is the treatment for severe acute malnutrition?

Treatment of Severe Acute Malnutrition

The treatment of severe acute malnutrition should follow a structured approach with different protocols for uncomplicated versus complicated cases, prioritizing appropriate nutritional therapy, antibiotics, and careful monitoring to reduce mortality and improve recovery rates. 1

Classification and Initial Assessment

• Uncomplicated severe acute malnutrition: Patients who can eat and have no medical complications
• Complicated severe acute malnutrition: Patients with medical complications, poor appetite, or edema

Key Assessment Parameters:

• Anthropometric measurements (weight, height, MUAC)
• Presence of edema
• Appetite test
• Medical complications (infections, metabolic abnormalities)
• Hydration status

Treatment Protocol

1. Uncomplicated Severe Acute Malnutrition

• First-line treatment: Oral amoxicillin 1
• Nutritional therapy: Ready-to-Use Therapeutic Food (RUTF) for home-based treatment
  • RUTF has been shown to result in higher recovery rates compared to corn-soya blend (CSB) formulations 2, 3
  • Standard dosing: Approximately 175-200 kcal/kg/day of RUTF 4
  • Gradually increase caloric intake from 5-10 kcal/kg/day to 25-30 kcal/kg/day over 5-7 days to prevent refeeding syndrome 4

2. Complicated Severe Acute Malnutrition

• First-line antibiotics: Amoxicillin or benzylpenicillin 1
• Second-line antibiotics: Ampicillin and gentamicin 1
• Nutritional therapy:
  • Initial phase: Start with low-dose nutrition (5-10 kcal/kg/day) 4
  • Transition phase: Gradually increase to 25 non-protein kcal/kg/day 4
  • Rehabilitation phase: Maximum caloric load not exceeding 30 kcal/kg/day 4
  • Protein intake: 1.2-1.5 g/kg/day initially, increasing to 1.5-2.0 g/kg/day during rehabilitation 4

Micronutrient Supplementation

• Vitamin A supplementation:
  • Children 12 months to 5 years: 200,000 IU every 3 months 1
  • Infants less than 12 months: 100,000 IU every 3 months 1
• Thiamine: Administer before initiating nutritional therapy to prevent refeeding syndrome 4
• Electrolyte monitoring: Check phosphorus, potassium, and magnesium levels every 6-12 hours initially 4

Monitoring and Follow-up

• Daily weight measurements
• Regular assessment of hydration status
• Blood glucose monitoring every 4-6 hours (target 140-180 mg/dL)
• Monitor for signs of refeeding syndrome:
  • Electrolyte abnormalities (particularly hypophosphatemia)
  • Fluid shifts
  • Cardiac abnormalities

Special Considerations

For Patients with Intra-Abdominal Hypertension (IAH)

• If IAP > 15 mmHg: Initiate enteral nutrition via nasojejunal route starting at 20 mL/h, increasing according to tolerance 1
• If IAP > 20 mmHg or abdominal compartment syndrome: Temporarily stop enteral nutrition and initiate parenteral nutrition 1

For Patients with Open Abdomen

• Administer enteral nutrition in small amounts
• Supplement with parenteral nutrition if required to meet nutritional requirements 1

Discharge Criteria

• Maintained at least 80% weight-for-height for 2 weeks
• Weight gain has occurred without edema
• Child is active and free from obvious illness
• Child exhibits good appetite

Pitfalls and Caveats

1. Avoid rapid refeeding: Starting with full caloric requirements can lead to refeeding syndrome, especially in severely malnourished patients

2. Don't underestimate infection risk: Malnourished patients often have occult infections requiring empiric antibiotics even without obvious signs

3. Monitor closely during initial phase: The first few days of treatment carry the highest mortality risk due to electrolyte imbalances and fluid shifts

4. Consider reduced RUTF dosing with caution: While some studies show similar weight gain with reduced RUTF doses after initial treatment, this approach may negatively impact linear growth, especially in children under 12 months 5

5. Don't rely solely on weight gain: Body composition studies show that approximately 45% of weight gain during treatment is fat-free mass, with the remainder being fat mass 6

By following this structured approach to treating severe acute malnutrition, clinicians can significantly reduce mortality and improve recovery rates in this vulnerable population.