What is the treatment approach for a patient with severe acute malnutrition?

Treatment of Severe Acute Malnutrition

For uncomplicated severe acute malnutrition in children, initiate oral amoxicillin immediately along with ready-to-use therapeutic food (RUTF), while complicated cases require parenteral benzylpenicillin plus gentamicin with nutritional rehabilitation. 1, 2

Initial Assessment and Classification

• Every child with severe acute malnutrition must be classified as either uncomplicated or complicated based on the presence of medical complications such as shock, severe dehydration, infection, or inability to tolerate oral intake 1
• Diagnosis requires assessment of weight-for-height Z-score, mid-upper arm circumference (MUAC <11.5 cm indicates SAM), and presence of bilateral pitting edema (kwashiorkor) 3, 4
• Assess for danger signs immediately: altered consciousness, severe dehydration, hypothermia, hypoglycemia, or signs of septic shock, as these indicate complicated SAM requiring inpatient care 5

Antibiotic Therapy

Uncomplicated SAM (Outpatient Management)

• Amoxicillin is the first-choice antibiotic for uncomplicated severe acute malnutrition, given for 7 days at doses ranging from 50-100 mg/kg/day 1, 2
• The addition of routine antibiotics to RUTF significantly improves recovery rates (88.7% vs 85.1% with placebo) and reduces mortality (4.8% vs 7.4% with placebo) 2
• Do not withhold antibiotics even in the absence of obvious infection, as children with SAM have impaired immune function and subclinical infections are common 2, 3

Complicated SAM (Inpatient Management)

• Parenteral benzylpenicillin plus gentamicin is the first-choice combination for complicated severe acute malnutrition 1
• Alternative first-line options include amoxicillin (parenteral or oral depending on ability to take oral medications) 1
• Second-choice antibiotics include ampicillin and gentamicin as alternatives 1
• Continue antibiotics until clinical improvement is evident and the child has stabilized, typically 5-7 days minimum 1, 5

Nutritional Rehabilitation

Outpatient Nutritional Management

• Ready-to-use therapeutic food (RUTF) is the cornerstone of outpatient treatment, providing 150-220 kcal/kg/day until nutritional recovery is achieved 2, 4
• Nutritional recovery is defined as weight-for-height Z-score >-2, MUAC >12.5 cm, and absence of edema for at least one visit 6
• Community-based therapeutic care using RUTF has dramatically reduced case fatality rates from 20-30% to <5% and increased treatment coverage 4

Inpatient Nutritional Management

• Initial stabilization phase (days 1-7): Provide F-75 therapeutic milk at 80-100 kcal/kg/day and 1-1.5 g protein/kg/day, with frequent small feeds every 2-3 hours 5
• Transition phase (days 7-14): Switch to F-100 therapeutic milk or RUTF when appetite returns and edema resolves, gradually increasing to 150-220 kcal/kg/day 5
• Rehabilitation phase: Continue high-energy feeding until weight-for-height reaches >-2 Z-score, then transition to outpatient care with RUTF 6, 4

Fluid Management in Complicated SAM

Treating Dehydration

• Use hypo-osmolar oral rehydration solution (H-ORS) rather than standard WHO-ORS for children with acute diarrhea and SAM, as it reduces stool output and duration of diarrhea 5
• ReSoMal (rehydration solution for malnutrition) is not significantly different from WHO-ORS, but safety concerns exist regarding its use 5
• Provide zinc supplementation (10-20 mg/day) along with ORS for children with diarrhea, as this reduces diarrhea duration and ORS requirements 5

Treating Shock

• Avoid aggressive intravenous fluid resuscitation in children with SAM and shock, as they are at high risk of fluid overload and heart failure 5
• Limited evidence exists for optimal fluid resuscitation protocols; use cautious boluses of 10 mL/kg over 1 hour and reassess frequently 5

Micronutrient Supplementation

• Provide routine vitamin A supplementation on day 1 (50,000 IU for infants 6-11 months; 100,000 IU for children 12-59 months) unless already given in previous month 3, 5
• Daily folic acid (5 mg on day 1, then 1 mg daily) and multivitamin supplementation should be provided throughout treatment 3
• Zinc supplementation evidence is mixed, but consider 10-20 mg/day, particularly in children with diarrhea 5
• Potassium and magnesium supplementation are critical, as deficiencies are universal in SAM and contribute to cardiac complications 3

Monitoring and Follow-Up

• Weekly monitoring of weight, MUAC, and edema is essential during outpatient treatment until nutritional recovery 6, 4
• Children should be assessed at 2,4,6,8,12, and 24 weeks post-discharge to monitor for relapse, as mortality risk remains elevated for months after apparent recovery 6
• Failure to gain weight after 2 weeks of treatment indicates treatment failure and requires reassessment for complications, inadequate intake, or underlying conditions 4, 5

Common Pitfalls and How to Avoid Them

• Do not delay antibiotic treatment while waiting for signs of infection – subclinical infections are nearly universal in SAM and contribute to treatment failure and mortality 2, 3
• Avoid using standard pediatric fluid resuscitation protocols (20 mL/kg boluses) in children with SAM and shock, as this causes fluid overload and heart failure 5
• Do not rely solely on weight gain as a marker of recovery – children may gain weight from edema or fat deposition while remaining protein-depleted and at high risk of relapse 3, 6
• Never discharge children from inpatient care before they have transitioned to RUTF and demonstrated good appetite – premature discharge is associated with high mortality 4, 5
• Do not assume children are fully recovered when they reach discharge criteria – they remain at elevated risk of death and readmission for 6-12 months and require continued monitoring 6

Special Considerations for Infants <6 Months

• Evidence for treating SAM in infants <6 months is extremely limited, and standard RUTF is not appropriate for this age group 5
• These infants require specialized inpatient management with focus on re-establishing breastfeeding or providing appropriate breast milk substitutes 5
• Mortality rates are particularly high in this age group, requiring intensive monitoring and supportive care 5