Severe acute malnutrition

Scope and clinical danger

Severe acute malnutrition is a severe deficiency of energy, fat, protein, vitamins, minerals, or a combination of nutrients. The source protocol focuses on children 6 to 59 months.

SAM is dangerous because metabolic adaptation and immune compromise can hide severe illness. Fever may be absent despite serious infection, and ordinary dehydration signs may be misleading.

Every child with SAM needs nutritional treatment plus routine medical management and active screening for complications.

Clinical assessment and diagnosis

• Marasmus: marked loss of muscle and subcutaneous fat with a skeletal appearance.
• Kwashiorkor: bilateral pitting oedema of the lower limbs, sometimes extending to arms, hands, and face; hair may be discoloured or brittle; skin may be shiny, cracked, weeping, or infected.
• Measure MUAC at the midpoint of the relaxed left upper arm without compressing the skin. MUAC under 115 mm indicates SAM and high mortality risk.
• Weight-for-height z-score below -3 using WHO child growth standards indicates SAM.
• Bilateral pitting oedema of the lower limbs indicates SAM after other causes of oedema have been excluded, regardless of MUAC or WHZ.
• Admission criteria vary by programme and country; follow national and local nutrition protocols.

Hospital admission and complication screening

• Admit for hospital-based medical management if oedema extends from the lower limbs to the face, appetite test shows anorexia, or severe complications are present.
• Severe complications include persistent vomiting, shock, altered mental status, seizures, severe anaemia, persistent hypoglycaemia, vitamin A deficiency eye lesions, frequent or abundant diarrhoea, dysentery, dehydration, severe malaria, pneumonia, meningitis, sepsis, severe skin infection, or fever without clear focus.
• If none of these are present and appetite is adequate, many children can be treated as outpatients with regular follow-up and reliable caregiver support.
• Screen actively for hypoglycaemia, hypothermia, infection, anaemia, diarrhoea, dehydration, pneumonia, malaria, stomatitis, eye lesions, tuberculosis, HIV, and vaccination gaps.

Nutritional treatment phases

• Continue breastfeeding in breastfed children.
• Give drinking water in addition to meals, especially in hot weather, fever, or when receiving RUTF.
• Therapeutic foods already contain zinc; extra zinc is not needed when recommended therapeutic food intake is achieved.

Routine medical management

Infection management

• Respiratory, skin, urinary, and systemic infections are common, and fever may be absent.
• Suspect severe infection or sepsis in a child with lethargy, apathy, hypothermia, hypoglycaemia, seizures, breathing difficulty, or shock.
• For severe infection or sepsis, give ampicillin IV 50 mg/kg every 8 hours plus gentamicin IV 7.5 mg/kg once daily, then adapt when the source is identified.
• If circulatory impairment or shock is present, give ceftriaxone IV 80 mg/kg once immediately, assess the source, and continue treatment according to the cause.
• For less severe infection, identify the source using the fever pathway and treat accordingly.
• For fever causing discomfort, undress the child. If this is insufficient, use low-dose paracetamol 10 mg/kg orally up to 3 times in 24 hours and encourage oral fluids including breast milk.
• For hypothermia, place the child skin-to-skin with the caregiver and cover with a warm blanket. Treat infection and check/treat hypoglycaemia.
• In kwashiorkor, infected skin lesions can progress to soft-tissue or systemic infection. If cutaneous infection is present, stop amoxicillin and use amoxicillin/clavulanic acid at 50 mg/kg twice daily expressed as amoxicillin for 7 days, using 8:1 or 7:1 formulations.

Severe anaemia in SAM

• Children with Hb under 4 g/dl, or Hb under 6 g/dl with decompensation such as respiratory distress or ongoing blood loss, need transfusion within the first 24 hours.
• Packed red blood cells are preferred when available.
• Monitor very closely for fluid overload during and after transfusion and follow the anaemia transfusion protocol for volume and monitoring.

Diarrhoea and dehydration assessment

Diarrhoea is common in SAM and often improves with therapeutic feeding and routine amoxicillin. When a specific cause is suspected, use the acute diarrhoea pathway.

Dehydration assessment is difficult because sunken eyes and delayed skin pinch may be present even without dehydration. Use adapted SAM criteria and weight change when possible.

Rehydration plans in SAM

• If previous weight is unknown, estimate target weight as current weight x 1.06 for some dehydration, or current weight x 1.1 for severe dehydration.
• Continue feeding and breastfeeding whenever the child is alert and able.
• Stop rehydration regardless of target weight if fluid overload signs appear.

Fluid overload monitoring

• Watch for respiratory rate rising by 10 breaths/minute or more from baseline, heart rate rising by 20 beats/minute or more, new or worsening hypoxia, new rales or fine crackles, new gallop rhythm, increasing liver size, or new peripheral/eyelid oedema.
• Mark the liver edge before rehydration when possible so enlargement can be detected.
• Monitor vital signs and dehydration signs every 15 to 30 minutes during severe dehydration treatment; monitor urine output.
• If fluid overload appears, stop or reduce fluids, reassess perfusion and respiratory status, and manage urgently.

Other complications

• Treat hypoglycaemia and seizures using the Chapter 1 pathways.
• Treat acute pneumonia using the respiratory pathway.
• Treat stomatitis using the gastrointestinal/mouth pathway.
• Treat xerophthalmia and vitamin A deficiency eye lesions using the eye disease pathway.
• Treat severe malaria, meningitis, sepsis, dysentery, and skin infection urgently using the relevant protocols.

Discharge criteria

• A child can generally leave hospital for outpatient SAM treatment when clinically well, complications are controlled, appetite test confirms ability to eat RUTF, oedema is reduced or absent, the caregiver can provide outpatient care, and vaccination status is up to date or referral is arranged.
• Discharge from nutritional treatment generally requires stable co-existing medical conditions with outpatient care organised, vaccinations up to date or arranged, absence of oedema, and WHZ above -2 or MUAC above 125 mm for at least 2 weeks.
• Local and national nutrition programme criteria may differ and should be followed.

Prevention, referral, and handover

• Prevention includes food security, breastfeeding support, vaccination, vitamin and mineral sufficiency, safe water and sanitation, malaria prevention, early infection treatment, maternal nutrition, growth monitoring, and timely referral for wasting or oedema.
• Refer urgently for anorexia, facial oedema, shock, persistent vomiting, altered consciousness, seizures, severe anaemia, persistent hypoglycaemia, severe dehydration, dysentery, pneumonia, meningitis, sepsis, severe malaria, severe skin infection, or eye signs of vitamin A deficiency.
• Handover should include age, weight, MUAC, WHZ if available, oedema grade, appetite test result, temperature, glucose, dehydration classification, stool/vomiting history, urine output, haemoglobin, malaria result, antibiotics, fluids, therapeutic feeds, vaccination status, HIV/TB screening, complications, and caregiver reliability.