Admission and Discharge Criteria in SAM

The management of Severe Acute Malnutrition (SAM) is categorized into facility-based (inpatient) care and community-based (outpatient) care. The decision to admit or discharge depends on the presence of "medical complications," the child's appetite, and age.

1. Diagnostic Criteria for SAM (Entry Criteria)

A child is identified as having SAM if they meet any one of the following criteria:

• Weight-for-Height/Length: Z-score < -3 SD of the WHO Child Growth Standards,,.
• Mid-Upper Arm Circumference (MUAC): < 115 mm (< 11.5 cm) in children aged 6–59 months,,.
• Nutritional Oedema: Bilateral pitting oedema of the feet (after excluding other medical causes),,.
• Visible Severe Wasting: Severe loss of muscle and fat (e.g., gluteal wasting/baggy pants), particularly useful for infants < 6 months or where anthropometry is not possible.

2. Admission Criteria (Indications for Inpatient Care)

Children diagnosed with SAM are triaged into "Complicated" or "Uncomplicated" cases. Admission is mandatory for Complicated SAM and for all infants under 6 months with SAM.

A. Failure of Appetite Test

• The child is unable to drink or eat the therapeutic food (Catch-up diet/RUTF) provided during the test,.
• Poor appetite indicates a serious underlying metabolic or infectious problem requiring stabilization.

B. Medical Complications

Admission is required if the child presents with any of the following IMNCI danger signs or medical conditions,:

• General Danger Signs: Lethargy, unconsciousness, convulsions, or vomiting everything,.
• Shock: Cold hands with capillary refill time > 3 seconds and weak/fast pulse,.
• Severe Dehydration: Sunken eyes, very slow skin pinch, lethargy/unconsciousness.
• Hypoglycemia: Blood glucose < 54 mg/dL (< 3 mmol/L) or symptomatic (jitters, lethargy),.
• Hypothermia: Axillary temperature < 35°C (95°F) or rectal temperature < 35.5°C,.
• Fever: High fever > 38.5°C (or > 37.5°C depending on protocol guidelines).
• Severe Anaemia: Severe palmar pallor; Hb < 4 g/dL or Hb 4-6 g/dL with respiratory distress,.
• Respiratory Infection: Fast breathing, chest indrawing, or pneumonia.
• Severe Dermatosis: Extensive skin lesions, ulceration, or "raw skin" often associated with Kwashiorkor.
• Eye Signs: Corneal clouding, ulceration, or Bitot's spots (Vitamin A deficiency).
• Severe Oedema: Grade +++ (generalized oedema including face and upper limbs),.

C. Special Vulnerable Groups

• Infants < 6 Months: All infants < 6 months with SAM (W/L < -3SD or visible severe wasting or oedema) should be admitted,.
  • Specific admission signs include recent weight loss, ineffective feeding (attachment/suckling issues), or depression of the caregiver.
• Caregiver Issues: If the mother/caregiver is unable to provide adequate home care or if the home environment is not conducive to recovery.

3. Discharge Criteria

Discharge planning involves two stages: transferring from the stabilization phase (inpatient) to the rehabilitation phase (often community-based), and finally declaring the child "cured."

A. Discharge from Inpatient Care (Transfer to Outpatient/Community Care)

Children can be discharged from the hospital to complete their recovery at home or in a community program when they are metabolically stable and eating well. This is often termed "Early Discharge."

Criteria for the Child:

• Resolution of Complications: No fever, hypothermia, vomiting, or diarrhea; treated for infections/medical problems,.
• Resolution of Oedema: Oedema has resolved or is minimal (some guidelines suggest discharge when oedema is reducing),.
• Return of Appetite: The child has a good appetite and eats at least 120–130 kcal/kg/day of nutritious food.
• Weight Gain: Consistent weight gain of at least 5 g/kg/day for 3 consecutive days,,.
• Alertness: The child is clinically well and alert.
• Interventions Completed: Completed antibiotic treatment and received appropriate immunization,.

Criteria for the Mother/Caregiver:

• Training: Knows how to prepare appropriate nutritious food and feed the child,.
• Home Care: Knows how to give oral drugs (e.g., iron, folic acid) and recognize danger signs requiring immediate return,.
• Resources: Has the financial resources and motivation to feed the child.

B. Criteria for Discharge for Infants < 6 Months

• Clinical Status: All clinical conditions and medical complications, including oedema, are resolved.
• Feeding: The infant is breastfeeding effectively or feeding well on replacement feeds.
• Weight Gain: Satisfactory weight gain on exclusive breastfeeding (or replacement) for at least 5 days (e.g., gaining > 5 g/kg/day or above the median of WHO velocity standards),.
• Maternal Health: Physical and mental health status of the mother/caregiver has been assessed and supported.

C. Final Discharge Criteria (Cured)

A child is considered fully recovered (cured) when they meet the anthropometric criteria for a healthy child. This usually occurs after follow-up in the community/outpatient program.

• Anthropometry:
  • Weight-for-Height/Length reaches ≥ -2 SD (Z-score) according to WHO standards,.
  • Note: Some hospital guidelines define recovery as reaching -1 SD,, or 90% weight-for-length.
  • Mid-Upper Arm Circumference (MUAC) ≥ 12.5 cm,.
• Oedema: Absence of nutritional oedema for at least 2 weeks.
• Clinical State: The child is active, eating well, and free of illness.

4. Procedures Before Discharge

To ensure sustainable recovery and prevent relapse, the following steps are mandatory before the child leaves the facility:

• Micronutrient Supplementation: Ensure the child is prescribed Iron and Folic acid to continue at home (Iron for 2-3 months).
• Deworming: Administer a single dose of Albendazole (200 mg for 12-23 months; 400 mg for > 24 months) if not given on admission.
• Immunization: Update all due vaccines.
• Dietary Counseling: Teach the mother about energy-dense home foods (katori-spoon feeding), hygiene, and frequency of feeding.
• Sensory Stimulation: Train the mother in play therapy and structured play activities (15-30 min/day) to support mental development,.
• Follow-up Plan: Schedule a follow-up visit (usually 1 week after discharge, then every 2 weeks/monthly).