What is the recommended management of severe acute malnutrition (SAM) in children (weight‑for‑height/length < ‑3 Z‑score, MUAC < 115 mm, or presence of nutritional edema) according to the Indian Academy of Pediatrics (IAP) guidelines?

Management of Severe Acute Malnutrition Based on IAP Guidelines

Initial Classification and Triage

The IAP recommends that not all children with SAM require hospital admission; many can be successfully managed on an outpatient basis in the community, with facility-based care reserved for complicated cases. 1

• Diagnose SAM using WHO Growth Standards with Z-scores rather than percentage weight deficit, as this is statistically more appropriate 1
• Children meet SAM criteria when: weight-for-height/length Z-score <-3 SD, MUAC <115 mm, or presence of bilateral pitting nutritional edema 2, 3
• Uncomplicated SAM (no medical complications or edema) should be managed as outpatients in community-based programs 2, 1
• Complicated SAM (presence of medical complications, edema, or inability to eat) requires inpatient facility-based care in Nutrition Rehabilitation Centers (NRCs) 2, 1, 4

Antibiotic Therapy

All children with SAM—even without obvious infection—should receive empirical antibiotics because they reduce mortality and improve nutritional recovery. 5, 2

For Uncomplicated SAM (Outpatient):

• First-line: Oral amoxicillin 50-100 mg/kg/day for 5-7 days 5, 2
• Antibiotics reduce mortality with OR 4.0 (95% CI 1.7-9.8) even in children without apparent infection 5, 2

For Complicated SAM (Inpatient):

• First-line: Parenteral benzylpenicillin PLUS gentamicin 5, 2
• Alternative: Ampicillin PLUS gentamicin 5
• Use the same doses as for adequately nourished children unless severe diarrhea, renal failure, or shock are present 5

Nutritional Rehabilitation Protocol

Stabilization Phase (Days 1-7):

Begin with F-75 therapeutic milk providing 75 kcal per 100 mL with low protein (0.9 g per 100 mL) for 2-7 days until the child stabilizes. 5, 3

• Target: 150 kcal/kg body weight/day and 3 g protein/kg body weight/day 5, 2, 3
• Divide into 4-6 small meals per day to maximize tolerance and absorption 5, 2, 3
• For severely ill children with poor appetite, 24-hour feeding centers are most effective 5, 3
• Nasogastric feeding may be used for short periods in children with very poor appetite, but requires trained personnel 5, 3

Rehabilitation Phase (After Stabilization):

Once stabilized, transition to Ready-to-Use Therapeutic Food (RUTF) or F-100 for continued rehabilitation. 5, 3

• RUTF is a semisolid product containing milk powder, sugar, peanut butter, vegetable oil, vitamins, and minerals 5
• Home-based treatment with RUTF is superior to clinic-based treatment, especially in rural areas 5
• Continue until discharge criteria are met 2, 3

Essential Micronutrient Supplementation

All children with SAM require routine micronutrient supplementation on admission regardless of clinical signs of deficiency. 5, 2, 3

Vitamin A:

• Children <12 months: 100,000 IU on admission, repeat every 3 months while in program 5, 2, 3
• Children 12 months to 5 years: 200,000 IU on admission, repeat every 3 months 5

Iron:

• Supplement only if iron deficiency anemia is highly prevalent in the population 2, 3
• Dose: 3 mg/kg/day elemental iron (ferrous sulfate) given between meals 2, 3

Other Micronutrients:

• Vitamin C: Weekly supplementation if not included in therapeutic ration 3
• Mebendazole: Two 100-mg tablets (chewed) with vitamin A if available 5, 3
• Do NOT give mebendazole to infants <12 months or pregnant women 5, 3

Immunization:

• Check measles vaccination status on admission and vaccinate if needed 5, 3

Monitoring Protocol

Daily weighing is mandatory initially, transitioning to twice-weekly once the child stabilizes. 5, 2, 3

• Target weight gain: 10 g/kg body weight/day 5, 2, 3
• Maintain detailed patient register with personal ration card and identification bracelet 5, 3
• Follow up all absentees at home and encourage return to program 5, 3
• Programs should aim for ≥80% enrollment and ≥80% daily attendance 5, 3

Discharge Criteria (All Must Be Met)

Discharge from therapeutic feeding when the child maintains ≥80% weight-for-height (Z-score ≥-2) for 2 consecutive weeks. 5, 2, 3

• Weight gain must have occurred without edema 5, 2, 3
• Child must be active and free from obvious illness 5, 2, 3
• Child must demonstrate a good appetite 5, 2, 3
• Transition to supplementary feeding program for continued monitoring until full recovery 2

Integration with IMNCI

The IAP emphasizes that SAM management should not be a stand-alone program but must integrate with Integrated Management of Neonatal and Childhood Illnesses (IMNCI). 1

• Establish linkages between community-based therapeutic programs, child treatment centers, district hospitals, and tertiary care facilities 1
• All healthcare providers need training in integrated SAM management 1
• Community-based programs should handle uncomplicated cases, reserving facility-based care for complicated SAM 1, 6

Critical Pitfalls to Avoid

Metabolic Complications:

• Monitor for refeeding syndrome during early stabilization as severely malnourished children have impaired metabolic capacity 3
• Avoid overfeeding, which increases risk of hyperglycemia and respiratory distress 3
• Watch for hypoglycemia if F-75 is abruptly discontinued; use gradual tapering 3

Program Implementation:

• Default rates remain high (32-38%) in Indian programs 4, 6, 7, 8
• Risk factors for default include: no community referral, more severe wasting, younger age, and long commute 8
• Recovery rates are moderate (46-65%) in Indian NRCs, indicating protocols need improvement 4, 6, 7
• Mean length of stay in Indian programs ranges 13-16 days for facility-based care 4, 6

Special Populations:

• For infants <6 months, prioritize reinitiating exclusive breastfeeding as the primary therapeutic goal 2
• HIV-infected children should receive the same therapeutic feeding approach, though they have higher failure rates 5