10.1 Severe Acute Malnutrition (SAM) Management

Severe Acute Malnutrition (SAM) Management

Severe Acute Malnutrition (SAM) remains a major contributor to pediatric mortality in sub-Saharan Africa, accounting directly or indirectly for nearly one-third of under-five deaths in endemic counties across Kenya. In arid and semi-arid lands (ASAL) such as Turkana, Wajir, Mandera, Garissa, and Marsabit, recurring droughts and food insecurity lead to high caseloads of acute wasting. The Clinical Officers Council (COC) examination frequently tests the clinician's ability to accurately diagnose SAM, triage between outpatient and inpatient pathways, avoid fatal rehydration and refeeding errors, and execute the World Health Organization (WHO) 10-Step Protocol.

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1. SAM Diagnostic Criteria (6–59 Months)

Under the Kenya National Guidelines for Integrated Management of Acute Malnutrition (IMAM), Severe Acute Malnutrition in children aged 6 to 59 months is diagnosed by the presence of ANY ONE of the following three independent criteria:

SAM DIAGNOSTIC TRIAD (Ages 6–59 Months):

1. Mid-Upper Arm Circumference (MUAC) < 11.5 cm (115 mm) [Red Band on Color-Coded Tape]
                            OR
2. Weight-for-Height / Length Z-score (WHZ) < -3 Standard Deviations (SD)
   (Based on WHO Child Growth Standards)
                            OR
3. Bilateral Pitting Nutritional Edema (+, ++, or +++)
   (Independent of anthropometric measurements)

Clinical Examination Protocol for Bilateral Nutritional Edema

Nutritional edema must be bilateral (present on both feet or limbs simultaneously) and pitting. Non-nutritional causes (nephrotic syndrome, congestive cardiac failure, acute glomerulonephritis, severe hepatic failure, or severe uncorrected anemia) must be excluded.

• Technique: Firmly press both thumbs against the dorsum of both feet for a minimum of three full seconds (counting: one-thousand-and-one, one-thousand-and-two, one-thousand-and-three). Release and inspect for a persistent indentation (pit).
• Grading Scale:
  • Grade + (Mild): Pitting edema restricted to the dorsum of both feet and/or ankles.
  • Grade ++ (Moderate): Bilateral pitting edema involving the feet, lower legs, hands, and/or lower forearms.
  • Grade +++ (Severe / Anasarca): Generalized bilateral pitting edema involving the feet, legs, hands, arms, sacrum, and facial periorbital tissues.

Exam Rule: Any child with Grade +++ generalized edema is automatically classified as Complicated SAM, regardless of appetite or alertness, and mandates immediate inpatient hospital admission.

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2. Marasmus vs. Kwashiorkor vs. Marasmic Kwashiorkor

Severe acute malnutrition presents along a pathophysiological spectrum determined by the balance of protein intake, total caloric deficit, adaptive hormonal regulation, and systemic oxidative stress.

                      MALNUTRITION CLINICAL SPECTRUM

         [ MARASMUS ]             [ MARASMIC KWASHIORKOR ]             [ KWASHIORKOR ]
   Severe somatic wasting                Concurrent severe               Bilateral pitting edema
   Caloric & protein deficit           wasting + bilateral edema         Dysfunctional liver (steatosis)
   Alert, ravenous appetite               Highest mortality risk         Apathy, marked anorexia

Detailed Clinical Differentiation

Pathophysiological Mechanism of Hepatomegaly in Kwashiorkor

A hallmark board question on the COC Pre-Internship Examination concerns why the liver enlarges in kwashiorkor. Due to extreme dietary amino acid deprivation, the liver cannot synthesize Apolipoprotein B-100, the structural protein required to package triglycerides and cholesterol into very-low-density lipoproteins (VLDL). While free fatty acids are mobilized from peripheral adipose tissue and taken up by hepatocytes, they cannot be exported as VLDL. Triglycerides accumulate massively within hepatocytes, resulting in gross hepatic steatosis (fatty liver), palpable hepatomegaly, and impaired gluconeogenesis and albumin synthesis.

Marasmic Kwashiorkor

Marasmic kwashiorkor represents the combination of severe somatic wasting (evidenced by prominent ribs, sunken eyes, wasted gluteal muscles) alongside bilateral nutritional pitting edema. Children with marasmic kwashiorkor possess the lowest physiological reserves, suffer severe metabolic derangement, and carry the highest case-fatality rate among all forms of acute malnutrition.

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3. Triage Framework: OTP vs. Inpatient Stabilization

Under Kenya IMAM protocols, every child presenting with SAM must be immediately triaged into one of two management streams:

                                  TRIAGE ALGORITHM

                           Child Confirmed SAM (6–59 Months)
                         (MUAC < 11.5 cm, WHZ < -3, or Edema)
                                          │
                                          ▼
                           Conduct Standard APPETITE TEST
                             & Screen for Danger Signs
                                          │
             ┌────────────────────────────┴────────────────────────────┐
             ▼                                                         ▼
      [ PASSED APPETITE TEST ]                                  [ FAILED APPETITE TEST ]
      AND Alert & clinically stable                             OR Any IMCI General Danger Sign
      AND Edema Grade + or ++                                   OR Edema Grade +++ (Anasarca)
      AND No severe medical complications                       OR Acute Medical Complication
      AND Age ≥ 6 months                                        OR Age < 6 months / Weight < 4.0 kg
             │                                                         │
             ▼                                                         ▼
     OUTPATIENT THERAPEUTIC                                     INPATIENT STABILIZATION
         PROGRAM (OTP)                                               CENTRE (SC)

The Standard Appetite Test Protocol

The appetite test is the most critical functional assessment determining whether a child can safely be managed at home:

1. Ensure the child is in a calm, quiet environment with the caregiver.
2. Have the caregiver wash their hands and the child's hands with soap and water.
3. Open a sachet of Ready-to-Use Therapeutic Food (RUTF, e.g., Plumpy'Nut).
4. Offer small amounts from the sachet gently using a clean spoon or clean finger.
5. Observe for 30 to 60 minutes. Do not force-feed.

• Passing the Test: The child willingly consumes the minimum required amount based on body weight (typically at least one-third to one-half sachet for a child weighing 4 to 10 kg). The child shows interest, swallows easily, and retains the feed.
• Failing the Test: The child refuses to take RUTF, consumes less than the minimum required volume after 60 minutes, gags, vomits repeatedly, or is too weak or dyspneic to swallow.

Management in the Outpatient Therapeutic Program (OTP)

Uncomplicated SAM managed at an OTP site receives:

1. RUTF Ration: High-density, peanut-based lipid paste fortified with milk powder, vegetable oils, vitamins, and minerals. Prescribed at 175 to 200 kcal/kg/day (approximately 2 to 3 sachets per day depending on weight).
2. Routine Empirical Antibiotic: Oral Amoxicillin (50 to 100 mg/kg/day in two divided doses) for 7 days starting on Day 1, even in the absence of fever or respiratory symptoms. (SAM blunts the immune response, leading to occult small-bowel bacterial overgrowth and subclinical bacteremia).
3. Measles Vaccination: Administered at OTP admission if the child is ≥ 9 months old and lacks documented vaccination.
4. Deworming: Single dose of oral Albendazole (200 mg for 12–23 months; 400 mg for ≥ 24 months) administered at Week 2 of OTP enrollment.
5. Weekly Monitoring: Clinical review, weight check, MUAC measurement, edema assessment, and appetite reassessment every 7 days until discharge criteria are met.

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4. The WHO 10-Step Inpatient Protocol for Complicated SAM

Complicated SAM is managed in a specialized Inpatient Stabilization Centre (SC) across three chronological phases:

• Phase 1: Stabilization (Days 1 to 2 / up to Day 7): Treat life-threatening complications, re-establish metabolic equilibrium, correct fluid and electrolyte imbalances, initiate cautious low-protein feeding with F-75 formula. Catch-up weight gain is NOT the objective during this phase.
• Transition Phase (Days 3 to 7): Gradual escalation of caloric density; introduce F-100 formula or RUTF while monitoring for fluid overload or heart failure.
• Phase 2: Rehabilitation / Catch-Up Growth (Weeks 2 to 6): Rapid feeding with F-100 or RUTF (150–220 kcal/kg/day); stimulate motor and emotional development; prepare for OTP step-down or community discharge.

                  WHO 10-STEP CHRONOLOGICAL MATRIX

  STEP                                  STABILIZATION      TRANSITION      REHABILITATION
                                         (Days 1–2)        (Days 3–7)       (Weeks 2–6)
  ───────────────────────────────────────────────────────────────────────────────────────
  1. Treat / Prevent Hypoglycemia        ███████████
  2. Treat / Prevent Hypothermia         ███████████
  3. Treat / Prevent Dehydration         ███████████
  4. Correct Electrolyte Imbalances      ████████████████████████████████████████████
  5. Treat / Prevent Infections          ████████████████████
  6. Correct Micronutrient Deficiencies  ████████████████████████████████████████████
     (STRICTLY NO IRON in Phase 1)                                        (Iron started)
  7. Start Cautious Feeding (F-75)       ████████████████████
  8. Achieve Catch-Up Growth (F-100)                       ██████████████████████████
  9. Sensory Stimulation & Play                                           ███████████
  10. Plan Discharge & Follow-up                                          ███████████

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Step-by-Step Clinical Practice Rubric

Step 1: Hypoglycemia

• Diagnostic Cut-Off: Blood glucose < 3.0 mmol/L (< 54 mg/dL). (Note: The threshold in SAM is higher than the standard pediatric threshold of 2.2 mmol/L because malnourished children possess zero hepatic glycogen stores and compromised gluconeogenesis).
• Management:
  • Conscious child: Administer 50 mL of 10% Dextrose (or 10% sucrose solution: 1 rounded teaspoon of sugar in 3.5 tablespoons of water) orally or via nasogastric tube (NGT), immediately followed by the first feed of F-75.
  • Lethargic / Unconscious / Convulsing child: Immediately administer 5 mL/kg of 10% Dextrose IV as a slow push over 3 to 5 minutes, followed immediately by 50 mL of 10% Dextrose/sucrose via NGT and early F-75 feeds.
• Prevention: Feed every 2 hours day and night without skipping nocturnal feeds. Hypoglycemia and hypothermia frequently occur together between 02:00 and 06:00.

Step 2: Hypothermia

• Diagnostic Cut-Off: Axillary temperature < 35.0°C or rectal temperature < 35.5°C.
• Management: Immediate warming using Kangaroo Mother Care (KMC) (skin-to-skin contact against mother's chest, covered with warm blankets and a cap). Ensure room ambient temperature is 28°C to 32°C. Avoid hot water bottles directly touching skin (high risk of contact thermal burns). Monitor axillary temperature every 2 hours until stable above 36.5°C.

Step 3: Dehydration

• Clinical Diagnostic Challenge: Signs of dehydration (sunken eyes, slow skin pinch) are frequently false positives in marasmus due to severe loss of subcutaneous facial and abdominal fat. Conversely, in kwashiorkor, edema masks intravascular hypovolemia.
• Oral Fluid of Choice: ReSoMal (Rehydration Solution for Malnutrition).
  • Composition Rationale: Standard WHO low-osmolarity ORS contains 75 mmol/L sodium, which is dangerous in SAM. ReSoMal contains lower sodium (45 mmol/L), higher potassium (40 mmol/L), and added magnesium (3 mmol/L), zinc, and copper.
  • Dosing Protocol: 5 mL/kg every 30 minutes for the first 2 hours (orally or via NGT), then 5 to 10 mL/kg/hour in alternate hours with F-75 formula for up to 10 hours.
  • Danger of Standard ORS: High sodium content causes severe sodium retention, acute hypernatremic fluid shift into the intravascular space, and fatal congestive heart failure.
• Strict Indications for Intravenous Fluids: IV fluids are strictly contraindicated in SAM unless the child exhibits unequivocal lethargy or unconsciousness combined with absent peripheral pulses, cold extremities, and capillary refill time > 3 seconds (decompensated septic or hypovolemic shock).
  • IV Shock Protocol: Administer 15 mL/kg of IV Ringers Lactate with 5% Dextrose (or Half-Strength Darrow's with 5% Dextrose) over 1 hour.
  • Reassess at 10, 30, and 60 minutes. If respiratory rate increases by > 5 breaths/min, heart rate rises by > 15 bpm, or jugular venous distension/basilar lung crackles develop, STOP THE IV INFUSION IMMEDIATELY (cardiac overload).

Step 4: Correct Electrolyte Imbalance

• Children with SAM suffer from defective cellular membrane sodium-potassium pumps (Na+/K+ ATPase), resulting in leaky cell membranes. Intracellular potassium and magnesium leak out and are excreted in urine, while sodium leaks into cells. Consequently, body sodium is excessive while potassium and magnesium are critically depleted, even if serum electrolyte levels appear falsely normal.
• Management: Provide extra potassium (3 to 4 mmol/kg/day) and magnesium (0.4 to 0.6 mmol/kg/day), which are pre-incorporated into F-75, F-100, and ReSoMal formulations or added as Combined Mineral Vitamin Mix (CMV).
• Absolute Contraindications: NEVER administer extra sodium. NEVER administer diuretics (e.g., Furosemide) to treat nutritional edema; diuretics precipitate fatal hypokalemia, hypovolemia, and circulatory collapse.

Step 5: Treat Infections

• Children with SAM exhibit 'nutritional acquired immune deficiency' (NAIDS). They cannot mount a standard systemic inflammatory response: fever, tachycardia, and peripheral leukocytosis are typically absent, even in the presence of severe bacteremia, bronchopneumonia, or extensive peritonitis.
• Standard Inpatient Antimicrobial Regimen (Kenya Basic Paediatric Protocols):
  • IV / IM Ampicillin (50 mg/kg every 6 hours) for 2 days, followed by oral Amoxicillin (50 mg/kg every 12 hours) for 5 days, PLUS
  • IV / IM Gentamicin (7.5 mg/kg once daily) for 7 full days.
  • If the child fails to improve after 48 hours or presents with septic shock or meningitis: Switch to IV Ceftriaxone (80–100 mg/kg once daily).

Step 6: Correct Micronutrient Deficiencies

• Vitamin A: Administer orally on Day 1:
  • Age < 6 months: 50,000 IU
  • Age 6–11 months: 100,000 IU
  • Age 12–59 months: 200,000 IU (Repeat on Day 2 and Day 14 if clinical signs of xerophthalmia or measles are present).
• Folic Acid: 5 mg on Day 1, then 1 mg daily thereafter.
• Zinc: 10–20 mg daily (promotes intestinal mucosal repair and cellular immune recovery).
• THE IRON RULE (Strict Board Exam Favorite):

[!CAUTION] IRON IS STRICTLY WITHHELD DURING PHASE 1 STABILIZATION. In SAM, transferrin synthesis is severely depressed by the damaged liver. Administering supplemental iron leaves unbound iron circulating in plasma. This free iron acts as an essential growth substrate for pathogenic bacteria (Klebsiella, E. coli, Salmonella), transforming subclinical infection into fulminant, fatal septicemia. Furthermore, unbound iron catalyzes Fenton reactions, producing hydroxyl free radicals that cause lethal cell membrane peroxidation in tissues already depleted of glutathione and vitamin E. Iron is introduced ONLY in Phase 2 (Catch-up Growth Phase) after edema has completely resolved, appetite is vigorous, and active tissue synthesis is underway (typically after 7 to 14 days).

Step 7: Initial Cautious Feeding (Phase 1: F-75 Formula)

During Phase 1, the objective of feeding is to sustain basic physiological processes and prevent death from hypoglycemia and hypothermia, NOT to achieve weight gain. Aggressive feeding with high protein or high calorie loads overwhelms the child's stunted liver, exhausted myocardium, and reduced renal solute excretion capacity, precipitating fatal Refeeding Syndrome and acute heart failure.

• F-75 Nutritional Composition:
  • Energy: 75 kcal per 100 mL
  • Protein: 0.9 grams per 100 mL (low protein to prevent renal solute overload and hepatic encephalopathy)
  • Low sodium, high potassium and magnesium.
• Target Prescribed Volume: 130 mL/kg/day (provides 100 kcal/kg/day and 1 to 1.5 g protein/kg/day).
• Feeding Schedule:
  • Days 1 and 2: Feed every 2 hours (11 mL/kg/feed; 12 feeds in 24 hours, day and night).
  • Days 3 to 5: If tolerated, advance to every 3 hours (16 mL/kg/feed; 8 feeds in 24 hours).
  • If the child cannot ingest feeds by cup or spoon, pass a nasogastric tube (NGT) and administer the calculated volume slowly by gravity. Do not push feeds rapidly via syringe.

Step 8: Catch-up Growth (Phase 2: F-100 or RUTF)

Transition from Phase 1 to Phase 2 occurs when the child has survived the acute stabilization phase, exhibits a marked return of appetite (eating all F-75 eagerly), and nutritional edema is resolving (reduced from Grade +++ to Grade ++ or +).

• Transition Protocol: Replace F-75 with equal volumes of F-100 (100 kcal and 2.9 g protein per 100 mL) for 48 hours. Gradually increase feeds by 10 mL per feed until some feed is left uneaten (ad libitum intake, reaching 150 to 220 kcal/kg/day and 4 to 6 g protein/kg/day). If transitioning directly to RUTF, offer RUTF sachets alongside clean boiled drinking water.
• Monitoring Daily Weight Gain:

$\text{Weight Gain (g/kg/day)} = \frac{\text{Weight Today (g)} - \text{Weight Yesterday (g)}}{\text{Body Weight (kg)}}$

Step 9: Sensory Stimulation & Emotional Support

Children with severe acute malnutrition suffer delayed cognitive, emotional, and motor development due to prolonged cerebral undernutrition and environmental neglect. Staff and caregivers must provide a warm, stimulating environment, gentle touch, maternal-child vocal interaction, structured play sessions, and brightly colored toys. Sensory stimulation significantly accelerates neurocognitive recovery and improves long-term developmental outcomes.

Step 10: Discharge & Follow-Up Planning

• Step-Down from Inpatient SC to OTP Criteria:
  • Medical complications resolved (fever, hypoglycemia, hypothermia, sepsis controlled).
  • Consistent return of good appetite (successfully consuming at least 75% of daily RUTF ration).
  • Nutritional edema reduced to Grade + or completely resolved.
  • Child alert, smiling, and interactive.
• Final Discharge Criteria from OTP:
  • WHZ ≥ -2 SD (measured on two consecutive weekly visits), OR
  • MUAC ≥ 12.5 cm (green band, confirmed on two consecutive visits), AND
  • Absence of bilateral pitting edema for at least 14 days.
  • Fully completed immunization updates and vitamin A/deworming series.