Hospital-Based Management of Severe Acute Malnutrition (SAM) in Children

Definition (Quick Recap)

• Weight-for-height Z-score < -3SD (WHO standards)
• Mid-upper arm circumference (MUAC) < 115 mm
• Presence of bilateral pitting nutritional oedema

Part A: Principles of Hospital-Based Management (7 marks)

Phase 1: Stabilization Phase (Days 1-2)

Step 1 - Treat/Prevent Hypoglycaemia

• Blood glucose < 54 mg/dL (3 mmol/L) is an emergency
• Give 50 mL of 10% glucose (or sucrose solution) orally/by nasogastric tube immediately
• Then start feeding every 2-3 hours, including at night
• If unconscious: IV 10% glucose (5 mL/kg), then start feeding
• Avoid 50% dextrose (causes rebound hypoglycaemia)

Step 2 - Treat/Prevent Hypothermia

• Temperature < 35.5°C axillary is hypothermia
• Warm the child: skin-to-skin (Kangaroo care), warm room (25-30°C), cover the head
• Feed immediately to generate internal heat
• Check for hypoglycaemia simultaneously (they commonly coexist)

Step 3 - Treat/Prevent Dehydration

• Rehydrate more slowly than usual - cardiac failure from fluid overload is a real risk
• Do NOT use IV fluids in dehydrated SAM children unless in shock
• Use ReSoMal (Rehydration Solution for Malnutrition) - low sodium, high potassium
  • 5 mL/kg every 30 minutes for 2 hours orally/NG, then 5-10 mL/kg/hour
• Signs of improvement: eyes less sunken, skin pinch returning, moist mucosa
• Watch for overhydration: increasing respiratory rate, pulse rate - stop if these rise

Step 4 - Correct Electrolyte Imbalance

• SAM children have excess total body sodium but serum sodium may be low (do NOT give sodium)
• Give extra potassium (3-4 mmol/kg/day) and magnesium (0.4-0.6 mmol/kg/day) for at least 2 weeks
• Use combined mineral-electrolyte mix added to feeds (not given separately)
• Restrict sodium in all feeds and medications

Step 5 - Treat/Prevent Infections

• All SAM children have presumed infection even without fever (fever response is blunted)
• Routine antibiotics: Amoxicillin (oral) or Ampicillin + Gentamicin (parenteral) for 5-7 days
• If child appears systemically ill or septic: third-generation cephalosporins
• Also treat: malaria (if endemic), TB (if suspected), intestinal parasites (albendazole or mebendazole)
• Measles immunization if not up to date, but delay vitamin A until day 2

Phase 2: Transition Phase (Days 3-7)

Step 6 - Micronutrient Supplementation (Started Day 2 onward)

• Vitamin A: High-dose on Day 1 (if not given in past month):
  • < 6 months: 50,000 IU; 6-12 months: 100,000 IU; > 1 year: 200,000 IU
• Folic acid: 5 mg on Day 1, then 1 mg/day
• Zinc: 2 mg/kg/day
• Copper: 0.3 mg/kg/day
• Iron: Withheld in the stabilization phase (free iron worsens oxidative stress and infection); introduced only in rehabilitation phase once infection controlled

Step 7 - Initiate Cautious Feeding

• Begin with F-75 formula (75 kcal/100 mL, 0.9 g protein/100 mL)
• Provides 100 kcal/kg/day and 1-1.5 g protein/kg/day initially
• Feed every 2-3 hours (8 feeds/day), small volumes, by cup or NG if needed
• F-75 avoids metabolic stress while restoring physiological homeostasis
• Never give F-100 or high-protein diet at this stage - risks "refeeding syndrome"

Phase 3: Rehabilitation Phase (Weeks 2-6)

Step 8 - Catch-Up Growth (Aggressive Feeding)

• Switch to F-100 formula (100 kcal/100 mL, 2.9 g protein/100 mL)
• Provide 150-220 kcal/kg/day and 4-6 g protein/kg/day
• Encourage the child to eat as much as possible; increase feed volume as appetite returns
• Alternatively use RUTF (Ready-to-Use Therapeutic Food, e.g. Plumpy'Nut) at 200 kcal/kg/day
• In Indian NRCs: use locally prepared catch-up diet meeting these caloric densities
• Iron supplementation begins in this phase: 3 mg/kg/day elemental iron for 3 months
• Target weight gain: > 10 g/kg/day

Step 9 - Sensory Stimulation, Play, and Emotional Support

• Prolonged SAM causes developmental regression, emotional withdrawal, cognitive delay
• Structured play therapy for at least 15-30 minutes/day
• Tender loving care (TLC) - gentle handling, encouraging interaction
• Caregiver involvement: teach the mother structured play techniques, positive parenting
• Age-appropriate toys and stimulating environment in the ward

Step 10 - Prepare for Discharge and Follow-Up

• Educate the mother on feeding practices (timing, amounts, energy-dense foods)
• Demonstrate preparation of age-appropriate meals using locally available foods
• Counsel on hand-washing, hygiene, safe water, continuation of breastfeeding
• Ensure the child can eat family foods before discharge
• Gradually phase out therapeutic formula, replace with home diet while in ward

Discharge Criteria from NRC/Hospital

1. No oedema for at least 3 days
2. Good appetite (able to consume ≥ 90% of feed)
3. Weight-for-height Z-score > -3SD (or > -2SD per some criteria)
4. No acute infections requiring inpatient treatment
5. Mother/caregiver adequately counselled and confident in home feeding
6. Average inpatient stay: 10-15 days

Part B: Follow-Up After Discharge from NRC (3 marks)

Schedule of Follow-Up Visits

What is Assessed at Each Follow-Up Visit

1. Anthropometry: Weight, MUAC, check for oedema
2. Weight gain: Adequate = > 5 g/kg/day; weight loss or failure to gain over 2 weeks = re-admit
3. Dietary assessment: Is the child receiving adequate quantity and frequency of home food?
4. Feeding counselling reinforcement: Correct any deficient feeding practices
5. Morbidity check: Infections (diarrhoea, ARI, fever) - treat promptly
6. Immunization status: Ensure complete EPI schedule, catch up on missed vaccines
7. Developmental monitoring: Gross motor, language, social development
8. Supplementation continuation: Iron, zinc, vitamin A at scheduled intervals

Community-Level Linkages

• The NRC shares a list of discharged children with ANM (Auxiliary Nurse Midwife) and ICDS Supervisor in the child's home area
• ASHA and Anganwadi Worker (AWW) perform home visits to monitor feeding and care
• Child is enrolled in the Anganwadi Centre (AWC) for supplementary nutrition and growth monitoring
• If the child lives far from NRC, the ANM/ASHA escalates concerns to the MO at PHC

Indications to Re-Admit

• Loss of weight between two measurements
• Failure to gain weight over 2-week period
• Return of oedema
• Loss of appetite
• Acute illness (pneumonia, severe diarrhoea, altered sensorium)

Goals of Follow-Up Program

1. Prevent relapse (recurrence of SAM)
2. Prevent infection-related mortality
3. Ensure completion of catch-up growth to reach -1 SD W/H
4. Support neurodevelopmental recovery
5. Address social determinants - food security, household hygiene, maternal education

Summary Table: WHO 10 Steps and Phases

• India MoHFW, Operational Guidelines on Facility Based Management of SAM (2011, NHM)
• WHO Pocket Book of Hospital Care for Children - Chapter 7: Severe Acute Malnutrition
• Park's Textbook of Preventive and Social Medicine, SAM section