Community management of SAM

Community-based management of SAM is the strategy to treat children with uncomplicated severe acute malnutrition at home. This approach recognizes that the majority of children with SAM do not have medical complications and can be successfully rehabilitated in their communities without exposing them to hospital-acquired infections or incurring the social/economic costs of hospitalization.

1. Triage and Selection Criteria

The decision to manage a child in the community versus a facility depends on the classification of SAM into "Uncomplicated" or "Complicated."

• Diagnostic Criteria for SAM (6–59 months):

  • Weight-for-height/length < -3 SD (WHO Standards).
  • Mid-Upper Arm Circumference (MUAC) < 11.5 cm.
  • Bilateral pitting oedema.

• Criteria for Community/Home-Based Care (Uncomplicated SAM): A child qualifies for home management if they meet all of the following conditions:

  • Good Appetite: Passed the appetite test (able to eat a specified amount of therapeutic food).
  • Clinically Well: Alert and distinct absence of medical complications (e.g., pneumonia, severe dehydration, hypothermia, hypoglycemia).
  • No Severe Oedema: Oedema is absent or mild (+ or ++). Severe oedema (+++) requires hospitalization.

2. Components of Home Management

The management essentially covers Steps 8, 9, and 10 of the standard WHO 10-step protocol (Rehabilitation Phase), along with broad-spectrum antibiotic cover.

A. Nutritional Rehabilitation

• Energy Requirement: The goal is to provide 175 kcal/kg/day.
• Dietary Sources:
  • Home-Based High Energy Food: Prepared from locally available cereals, pulses, sugar, oil, milk, and eggs.
  • Energy Density: Foods must be nutrient-dense. Catch-up diets providing 100 kcal/100 mL are used initially, followed by home foods.
  • Frequency: Feeds should be given 6–8 times a day.
• Breastfeeding: Continued breastfeeding is essential if the child is breastfed.
• RUTF: Ready-to-Use Therapeutic Food (RUTF) is often used where available; it is a high-energy paste (milk, peanuts, oil, sugar) resistant to bacterial growth.

B. Medical Interventions

Every child under home-based management must receive the following systematic medical treatments:

• Antibiotics: Oral Amoxicillin for 5 days is mandatory to treat hidden infections.
• Vitamin A: Single mega dose (50,000 to 200,000 IU based on age) if there are clinical signs of deficiency or if not received in the last month.
• Deworming: Single dose of Albendazole (200 mg for 12–23 months; 400 mg for >24 months) or Mebendazole.
• Immunization: Update age-appropriate vaccines, especially measles.
• Micronutrients: Supplementation of minerals (potassium, magnesium) and vitamins. Iron supplementation is started in this phase (rehabilitation) once the child starts gaining weight.

C. Sensory Stimulation

• Tender Loving Care (TLC): Active feeding, talking to the child, and physical interaction are vital for brain recovery.
• Structured Play: Encourage play therapy for 15–30 minutes daily using simple local toys to reverse developmental delay.

3. Monitoring and Supervision

Home management is impossible without strong community support and monitoring by frontline workers (ASHA, AWW, ANM).

• Home Visits: Ideally daily initially, then twice a week.
• Parameters to Monitor:
  • Intake: Assess if the child is finishing feeds.
  • Medical Status: Check for danger signs (fever, vomiting, lethargy).
  • Growth: Assess weight, MUAC, and oedema weekly.
• Referral: Immediate referral to a facility if the child deteriorates, loses appetite, or develops complications.

4. Discharge Criteria

A child is considered to have completed treatment when:

• Anthropometry: Weight-for-height reaches > -2 SD OR MUAC > 12.5 cm.
• Oedema: No oedema for at least 2 weeks.
• Weight Gain: Achieved weight gain of ≥15% and satisfactory gain (>5 g/kg/day) for 3 consecutive days.
• Clinical Status: Child is eating adequate nutritious food and is clinically well.

Summary Flowchart for Management Location

1. Assess Child: Check WFH < -3SD / MUAC < 11.5 cm / Oedema.
2. Check for Complications:
   • Complications present / Failed Appetite Test / Severe Oedema $\to$ Inpatient Care (Facility).
   • No Complications + Good Appetite + Alert $\to$ Outpatient/Home Care (Community).