Severe Acute Malnutrition (SAM) in Children
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define severe acute malnutrition (SAM) according to WHO criteria.
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Identify children at risk using anthropometric measurements and clinical signs.
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Differentiate between inpatient and outpatient management.
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Perform appropriate investigations for SAM.
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Implement the WHO 10-step management protocol for complicated SAM.
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Recognize time frames for treatment and monitoring in SAM care.
Description
Severe acute malnutrition is defined in children 6–59 months by very low weight-for-height/length (<–3 SD), mid-upper arm circumference (MUAC < 11.5 cm), and/or bilateral pitting oedema. SAM is a life-threatening condition that requires rapid identification and appropriate management.
Identification and Assessment
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Children 6–59 months with MUAC <115 mm, weight-for-height/length <–3 SD, or bilateral oedema should immediately enter a SAM management program.
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Clinical assessment should determine whether the child has medical complications and appetite.
Management setting:
| Criteria | Recommended Setting |
|---|---|
| Clinically well, alert, passes appetite test | Outpatient therapeutic care |
| Medical complications, severe oedema (+++), poor appetite (fail appetite test), or IMCI danger signs | Inpatient care |
Investigations
Initial investigations on admission may include:
| Investigation | Purpose |
|---|---|
| Blood sugar and haemoglobin | Detect hypoglycaemia and anemia |
| Full blood count, ESR | Assess infection and inflammation |
| Malaria thick and thin smear | Identify malaria |
| Blood culture | Identify sepsis |
| Urinalysis and urine m/c/s | Identify urinary infection |
| Gastric lavage for AFB | Rule out tuberculosis |
| Lumbar puncture (if indicated) | Rule out meningitis |
| Chest X-ray | Detect pneumonia or other lung pathology |
| Routine counselling and testing | HIV testing (RVT) |
| Reducing substances test (if watery stool) | Assess carbohydrate malabsorption |
Treatment Approach
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Assess for emergency and danger signs and manage promptly.
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Follow the WHO 10-step management protocol for complicated SAM.
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Monitor and re-assess frequently, paying attention to hydration, hypoglycaemia, hypothermia, infection, and electrolyte disturbances.
Time Frame for Management of Complicated SAM
| Step | Time Frame / Action |
|---|---|
| 1. Treat/prevent hypoglycaemia | Immediate on admission |
| 2. Treat/prevent hypothermia | Continuous |
| 3. Treat/prevent dehydration | Within first hours |
| 4. Correct electrolyte imbalance | Within first 24 hours |
| 5. Treat infections | Start empirically within first hour; adjust per results |
| 6. Correct micronutrient deficiencies | Early, as per WHO supplements |
| 7. Initiate cautious feeding (F-75) | First 24–48 hours for stabilization |
| 8. Achieve catch-up growth (F-100 / RUTF) | After stabilization phase |
| 9. Provide sensory stimulation and emotional support | Throughout admission |
| 10. Prepare for follow-up and discharge | Ensure safe transition to outpatient care |
⚠️ Children with SAM are extremely vulnerable. Frequent monitoring of vital signs, fluid balance, and nutritional intake is critical.
Key Summary
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SAM is defined by MUAC <11.5 cm, weight-for-height/length <–3 SD, or bilateral oedema in children 6–59 months.
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Children with complications or poor appetite require inpatient care; others can be managed as outpatients.
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Investigations help identify infection, hypoglycaemia, electrolyte disturbances, and comorbidities.
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Management follows the WHO 10-step protocol, with careful attention to stabilization, feeding, and micronutrient supplementation.
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Time-sensitive interventions are essential for survival and recovery.