What community‑based interventions are recommended for treating severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) in children under five in low‑ and middle‑income (third‑world) settings?

Community-Based Management of Acute Malnutrition in Low- and Middle-Income Settings

Severe Acute Malnutrition (SAM) Treatment Protocol

Community-based treatment with ready-to-use therapeutic food (RUTF) is the recommended approach for uncomplicated SAM in children under five, as it is more effective than facility-based care and achieves 51% higher recovery rates compared to standard care. 1

Enrollment Criteria for SAM Programs

• Enroll children with weight-for-height Z-score < -3 (or <70% of reference median), mid-upper arm circumference (MUAC) <115 mm, or bilateral pitting edema 2
• Children referred by medical personnel should also be enrolled 2

Nutritional Rehabilitation for SAM

Stabilization Phase (Days 1-7):

• Provide F-75 therapeutic milk delivering 150 kcal/kg/day and 3 g protein/kg/day, divided into 4-6 small meals 3, 4
• Continue F-75 for 2-7 days until clinical stability is achieved 3
• For severely ill children with poor appetite, 24-hour feeding centers are most effective 2, 3
• Short-term nasogastric feeding may be used when trained personnel are available 2, 3

Rehabilitation Phase (After Stabilization):

• Transition to RUTF or F-100 formula once the child is stabilized and appetite returns 3
• RUTF contains milk powder, sugar, peanut butter, vegetable oil, and complete vitamins/minerals 3
• Home-based treatment with RUTF is more effective than clinic-based care, particularly in rural settings 3

Essential Antibiotic Therapy

All children with SAM should receive empirical antibiotics even without obvious infection, as this reduces mortality (OR 4.0; 95% CI 1.7-9.8) 3, 4

• For uncomplicated SAM managed as outpatients: oral amoxicillin 50-100 mg/kg/day for 5-7 days 3, 4
• For complicated SAM requiring inpatient care: parenteral benzylpenicillin plus gentamicin 3, 4

Micronutrient Supplementation for SAM

Vitamin A (mandatory on admission):

• Children <12 months: 100,000 IU on admission, repeated every 3 months 2, 3, 4
• Children 12 months-5 years: 200,000 IU on admission, repeated every 3 months 3, 5

Other Essential Supplements:

• Mebendazole: two 100-mg tablets with vitamin A (contraindicated in infants <12 months and pregnant women) 2, 3, 5
• Measles vaccination: verify status on admission and vaccinate if needed 2, 3, 4
• Iron supplementation: only if iron deficiency anemia is highly prevalent, at 3 mg/kg/day elemental iron between meals 2, 3, 4
• Vitamin C: weekly supplementation if not included in rations 2, 3

Monitoring Requirements for SAM

• Weigh children daily initially, then twice weekly once stabilized 2, 3, 4
• Target weight gain of 10 g/kg body weight/day 2, 3, 4
• Maintain detailed patient register with personal ration card and identification bracelet 2, 3
• Follow up all absentees at home and encourage program return 2, 3

Discharge Criteria from SAM Programs

All four criteria must be met:

• Child maintains ≥80% weight-for-height (Z-score ≥-2) for 2 consecutive weeks 2, 3, 4
• Weight gain occurred without edema 2, 3, 4
• Child is active and free from obvious illness 2, 3, 4
• Child exhibits good appetite 2, 3, 4

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Moderate Acute Malnutrition (MAM) Treatment Protocol

Lipid-based nutrient supplements (LNS) are superior to fortified blended flours (FBF) for MAM treatment, increasing recovery probability by 5% (RR 1.05; 95% CI 1.01-1.09). 6

Supplementary Feeding Program (SFP) Implementation

Implement SFPs when any of the following conditions exist:

• General ration provides <1,500 kcal/person/day 2
• >20% of children <5 years are acutely malnourished (Z-score <-2) 2
• Acute malnutrition prevalence 10-20% AND general ration 1,500-1,900 kcal/day 2, 5
• High incidence of measles or diarrheal disease 2

Enrollment Criteria for MAM/SFP

Target the following groups:

• Children <5 years with weight-for-height Z-score <-2 (or <80% of reference median) 2, 5
• Pregnant and lactating women 2, 5
• Elderly, chronically ill (e.g., tuberculosis patients), or disadvantaged groups 2, 5

Nutritional Requirements for SFP

When general ration is adequate (≥1,900 kcal/day):

• Provide minimum 500 kcal and 15 g protein/day in one or two feedings 2, 5

When general ration is inadequate (<1,900 kcal/day):

• Provide 700-1,000 kcal/day in two to three feedings 2, 5

High Energy Milk (HEM) formula for SFP (makes 5 liters):

• 420 g dried skimmed milk, 250 g sugar, 320 g oil, 4.4 L water (provides 1 kcal/mL) 2

Discharge Criteria from SFP

• Child maintains >85% median weight-for-height (Z-score >-1.5) for 1 month 2, 5

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Program Delivery Models and Performance Standards

On-Site vs. Take-Home Rations

On-site "wet" feeding advantages:

• Reduces likelihood of ration sharing among family members 2
• Staff maintain control over preparation and consumption 2
• Additional services can be incorporated (health screening, education) 2

On-site feeding disadvantages:

• Young children must be accompanied, creating hardship for mothers with other family responsibilities 2
• Requires feeding centers near recipients' homes 2
• Requires regular supply of clean water and cooking fuel 2

Performance Targets

All feeding programs should achieve:

• ≥80% enrollment of eligible children 2, 3, 5
• ≥80% daily attendance 2, 3, 5
• Active case-finding by health workers in communities to identify malnutrition early 2, 5

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General Ration Requirements for Food-Insecure Populations

For populations totally dependent on food aid:

• Minimum 1,900 kcal/person/day 2
• At least 10% of calories from fats 2
• At least 12% of calories from proteins 2

Essential ration components:

• Fortified blended foods (corn-soya milk, corn-soya blend) when fresh fruits/vegetables unavailable 2
• All rations should be fortified with vitamin A 2
• Provide seeds, gardening implements, and land for kitchen gardens to prevent pellagra and scurvy 2

Distribution guidelines:

• Distribute every 10-14 days maximum 2
• Provide grains in ground form or make grinders available 2
• Permit access to local markets; allow trading of ration commodities 2
• Include culturally significant items (tea, sugar, spices) to prevent ration selling 2

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Critical Pitfalls and Special Considerations

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

Special Populations

Infants <6 months:

• Prioritize reinitiating exclusive breastfeeding as the primary therapeutic goal alongside F-75 3

HIV-infected children:

• Receive the same therapeutic feeding protocol as HIV-negative children, though they experience higher treatment failure rates during transition 3

Pregnant and lactating women:

• Provide extra calories and protein 2
• Lactating mothers: 200,000 IU vitamin A within 2 months postpartum 5
• Routine iron + folic acid supplementation through antenatal and postnatal clinics 5

Breastfeeding and Infant Formula

• Encourage and support breastfeeding 2
• Discourage bottle feeding; do not distribute infant bottles and formula 2
• Dry skim milk should not be included in general rations except where milk consumption is traditional; if included, must be fortified with vitamin A 2

Micronutrient Fortification Evidence

Multiple micronutrient interventions reduce anemia across multiple delivery platforms:

• Iron alone, iron-folic acid, multiple micronutrient supplementation, micronutrient powders (MNPs), targeted fortification, and large-scale fortification all reduce anemia risk 7
• Vitamin A supplementation likely reduces all-cause mortality 7
• Zinc supplementation decreases diarrhea incidence 7
• LNS and MNPs effects persist in effectiveness studies (real-world settings) 7

Anemia Screening Thresholds

Use portable hemoglobin photometer (e.g., HemoCue) with the following thresholds:

• Children <15 years: Hb <11.0 g/dL 5
• Pregnant women: Hb <11.0 g/dL 5
• Non-pregnant women: Hb <12.0 g/dL 5