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24.4 Severe Acute Malnutrition (SAM)

Table of Contents

Diagnostic criteria for SAM in children aged 6-59 months (any one of the following):

Indicator Measure Cut off
Severe wasting Weight for height Z-Score (WHZ) <-3
Mid upper arm circumference MUAC <11.5cm
Bilateral pitting oedema Clinicasign

Severe underweight

  • WHZ < -3 (usually clinically reflective of marasmus) where no other explanation is present, and/or clinically severe wasting (usually clinically reflective of marasmus – thin arms, thin legs, “old man” appearance, baggy pants folds around buttocks, wasted buttocks)

Nutritional oedema:

  • Supported by findings of skin changes, fine pale sparse hair, enlarged smooth soft liver, moon face.

24.4.1 Complicated SAM

Any child with SAM who has any ONE of the following features:

  • < 6 months of age or weighs < 4 kg
  • Bilateral pitting oedema
  • Refusing feeds or is not eating well (poor appetite)
  • Any of the danger signs listed below

Danger Signs

  • dehydration
  • hypoglycaemia
  • vomiting
  • hypothermia
  • respiratory distress (including fast breathing)
  • convulsions
  • not able to feed
  • shock
  • lethargy (not alert)
  • jaundice
  • weeping skin lesions
All children with complicated SAM are at risk of complications or death.

• Refer urgently!

• Stabilise before referral.

• Initiate treatment while waiting for transport to hospital

General Measures

  • Keep the child warm.
  • Test for and prevent hypoglycaemia in all children.

If the child is able to swallow:

  • If breastfed: ask the mother to breastfeed the child, or give expressed breastmilk.
  • If not breastfedgive a breastmilk substitute (F-75). Give 30–50 mL before the child is referred.
  • If no breastmilk substitute is available, give 30–50 mL of sugar water
To make sugar water:

  • Dissolve 4 level teaspoons of sugar (20 g) in a 200 mL cup of clean water.
    Repeat 2 hourly until the child reaches hospital.

If the child is not able to swallow:

  • Insert a nasogastric tube and check the position of the tube.
  • Give 50 mL of milk or sugar water by nasogastric tube (as above).

If blood sugar < 3 mmol/L treat with 10% Glucose  Nasogastric tube: 10 mL/kg.

  • Intravenous line: 2 mL/kg.

NOTE:

  • The only indication for intravenous infusion in a child with severe acute malnutrition is circulatory collapse caused by severe dehydration or septic shock when the child is lethargic or unconscious (excluding cardiogenic shock);
  • All children with severe acute malnutrition with signs of shock with lethargy or unconsciousness should be treated for septic shock. This includes especially children with signs of dehydration but no history of watery diarrhoea, children with hypothermia hypoglycaemia, and children with both oedema and signs of dehydration;
  • In case of shock with lethargy or unconsciousness, intravenous rehydration should begin immediately, using 15 mL/kg/h of one of the recommended fluids;
  • It is important that the child is carefully monitored every 5–10 min for signs of overhydration and signs of congestive heart failure.
  • If signs of overhydration and congestive heart failure develop, intravenous therapy should be stopped immediately;
  • If a child with severe acute malnutrition presenting with shock does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg slowly over at least 3 h) should be given;
  • Children with severe acute malnutrition should be given blood if they present with severe anaemia, i.e. Hb <4 g/dL or <6 g/dL if with signs of respiratory distress;
  • Blood transfusions should only be given to children with severe acute malnutrition within the first 24 h of admission.

CAUTION!!:

Children with SAM and signs of shock or severe dehydration, and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either:

A: Ringer’s lactate solution + Dextrose 5%

If neither is available, A: 0.45% saline + Dextrose 5% should be used

Give an additional dose of Vitamin A:Vitamin A (retinol) (PO)

Age range Dose unit Capsule
Infants 6–11 months 100,000U 1
Children 12 months–5 years 200,000U 2

Pharmacological Treatment

Treat other medical conditions as per IMCI guide

24.4.2 Uncomplicated SAM

Children with SAM who meet the following criteria:

  • The child is > 6 months of age and weight > 4 kg, and
  • There is no pitting oedema, and
  • The child is alert (not lethargic), and
  • The child has a good appetite and is feeding well, and
  • The child does not have any danger signs or severe classification.

All cases require careful assessment for possible TB or HIV.

General Measures

  • Provide RUTF (ready to use therapeutic food regular nutritional supplements) and/or other nutritional supplements according to supplementation guidelines.
  • Counsel according to IMCI guidelines.
  • Regular follow-up to ensure that the child gains weight and remains well.
  • Discharge with supplementation, once the following criteria are met:
    • WHZ (weight-for-height z-score): > –2
    • WHZ for two consecutive visits at least one month apart and/or
    • MUAC: > 11.5 cm (preferable at 12 cm, if MUAC used alone).
  • Follow-up patients for at least 6 months to ensure sustained growth.

Pharmacological Treatment

Do not repeat if child has received these during inpatient stay:

  • Give an additional dose of Vitamin A:
    • High dose of vitamin A (50,000 IU, 100,000 IU or 200,000 IU, depending on age) should be given to all children with SAM and eye signs of vitamin A deficiency on day 1,
    • Second and a third dose on day 2 and day 15 (or at discharge from the programme), irrespective of the type of therapeutic food they are receiving;
  • To all children with SAM with recent measles on day 1, with a second and a third dose on day 2 and day 15 (or at discharge from the programme), irrespective of the type of therapeutic food they are receiving Empiric treatment for worms:
    A: Mebendazole, oral.
    Dose: Children 1–2 years: 100 mg (PO) 12 hourly for 3 days. Children > 2–5 years: 500 mg (PO) as a single dose.

Referral:

  • When RUTF cannot be provided and follow-up on an ambulatory (outpatient) basis is not possible.
  • The child develops pitting oedema or any of the danger signs (see above).
  • Failure to gain weight despite provision of nutritional supplements.

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