How should I manage a child aged 6 months to 59 months who meets WHO criteria for severe acute malnutrition (weight‑for‑height < ‑3 SD, MUAC < 115 mm, or nutritional edema) from stabilization through rehabilitation?

Management of Severe Acute Malnutrition in Children 6-59 Months

Children with severe acute malnutrition should be enrolled in therapeutic feeding programs and receive 150 kcal/kg/day with 3 grams protein/kg/day divided into 4-6 meals, combined with oral amoxicillin and vitamin A supplementation, with the goal of achieving 10 grams/kg/day weight gain until they maintain 80% weight-for-height for 2 consecutive weeks. 1, 2, 3

Step 1: Identification and Enrollment

Enroll children meeting ANY of these criteria:

• Weight-for-height Z-score < -3 (or <70% median) 1
• MUAC < 115 mm 1
• Bilateral pitting edema (nutritional) 1

Critical caveat: MUAC and WHZ identify different subgroups of malnourished children with distinct mortality risks. 4, 5 Children with WHZ < -3 but MUAC ≥115 mm have higher mortality rates than those identified by MUAC alone, and using MUAC < 115 mm as the sole criterion would miss up to 90% of children with WHZ < -3 and 33% of deaths. 4, 5, 6 Therefore, both criteria must be used independently - treat if either is met. 4, 5

Step 2: Stabilization Phase (Days 1-7)

Nutritional Rehabilitation

Provide therapeutic feeding with these exact targets:

• 150 kcal/kg body weight/day 1, 2, 3
• 3 grams protein/kg body weight/day 1, 2, 3
• Divide into 4-6 small meals per day 1, 2, 3
• Use F75 formula during initial stabilization for 2-7 days 2
• Transition to ready-to-use therapeutic food (RUTF) once stabilized and appetite returns 2

For children with poor appetite: Nasogastric feeding may be required for short intervals, but requires trained personnel. 1, 2

Antibiotic Therapy

Initiate oral amoxicillin immediately at 50-100 mg/kg/day for 5-7 days, even without obvious infection, as this reduces mortality (OR 4.0; 95% CI 1.7-9.8) and improves nutritional recovery. 2, 3

Micronutrient Supplementation - Upon Admission

Vitamin A (mandatory):

• 100,000 IU for children < 12 months 2, 7
• Repeat every 3 months while in program 1, 2

Vitamin C:

• Weekly supplementation if not included in ration 1, 2

Iron:

• Only if iron deficiency anemia is highly prevalent 1
• Dose: 3 mg/kg/day elemental iron between meals 2, 3

Mebendazole:

• Two 100 mg tablets (chewed) with vitamin A if available 1
• Do NOT give to infants < 12 months 1

Measles vaccination:

• Check status upon admission and vaccinate if needed 1, 2

Step 3: Monitoring Protocol

Weight Tracking

Weigh daily initially, then twice weekly once stabilized 1, 2, 7, 3

Target: 10 grams/kg body weight/day weight gain 1, 2, 7

Documentation Requirements

• Maintain detailed patient register 1, 2
• Provide personal ration card and identification bracelet 1, 2
• Follow up all absentees at home 1, 2

Step 4: Discharge Criteria - ALL Must Be Met

Discharge to supplementary feeding program when:

• Child maintains 80% weight-for-height (Z-score ≥ -2) for 2 consecutive weeks 1, 2, 7, 3
• Weight gain occurred without edema 1, 2, 7
• Child is active and free from obvious illness 1, 2, 7
• Child exhibits good appetite 1, 2

Critical Pitfalls to Avoid

Refeeding Syndrome Risk

Monitor closely for metabolic complications during early stabilization, as severely malnourished children have impaired metabolic capacity. 2 Avoid overfeeding, which increases risk of hyperglycemia and respiratory distress. 2 Never abruptly discontinue F75; use gradual tapering when transitioning. 2

Screening Errors

Do not rely on MUAC < 115 mm alone - this misses the majority of children with WHZ < -3 who have higher mortality rates. 4, 5, 6 A two-step approach is optimal: MUAC screening at community level, followed by both MUAC and WHZ measurement at health facilities, with treatment initiated if either criterion is met. 4

Special Populations

Infants < 6 months: Prioritize reinitiating exclusive breastfeeding as the primary therapeutic goal alongside therapeutic feeding. 2, 7

Children with edema: Those with both edema and low WHZ have dramatically increased mortality, whereas adding MUAC criterion to edema does not further increase mortality risk. 5

Program Performance Standards

Aim for ≥80% enrollment and ≥80% daily attendance in therapeutic feeding programs. 1, 2 Recent implementation data shows 92% recovery rates with mean length of stay of 40 days when using simplified combined protocols. 8