Facility based managed of SAM

The management of Severe Acute Malnutrition (SAM) is divided into two phases: the Stabilization Phase (Days 1–7) and the Rehabilitation Phase (Weeks 2–6). The primary goal of the stabilization phase is to restore cellular function, correct fluid and electrolyte imbalances, and treat infections to prevent death. The rehabilitation phase focuses on rebuilding wasted tissues and achieving catch-up growth.

The World Health Organization (WHO) and Indian Academy of Pediatrics (IAP) recommend a standardized 10-step protocol to reduce case fatality rates, which can otherwise be as high as 20–30% with inappropriate care (e.g., using diuretics for edema or high protein diets too early).

Phase I: Stabilization (Days 1–7)

Step 1: Treat/Prevent Hypoglycemia

Hypoglycemia and hypothermia often coexist with infection (the "Lethal Triad"). In SAM, glycogen stores are depleted, making the child dependent on continuous exogenous glucose.

• Definition: Blood glucose < 54 mg/dL (< 3 mmol/L).
• Management:
  • If blood glucose is low: Immediately give 50 ml of 10% glucose or sucrose solution (1 rounded teaspoon sugar in 3.5 tablespoons water) orally or by nasogastric (NG) tube.
  • If unconscious/lethargic: Give 5 ml/kg of 10% glucose IV followed by 50 ml of 10% glucose by NG tube.
  • Prevention: Start feeding Starter Diet (F-75) immediately upon admission. Feed every 2 hours (day and night) to provide a continuous supply of energy. Never keep the child fasting.

Step 2: Treat/Prevent Hypothermia

Children with SAM have impaired thermoregulation due to loss of insulating fat and reduced metabolic rate.

• Definition: Axillary temperature < 35°C (95°F) or Rectal temperature < 35.5°C (95.5°F).
• Management:
  • Rewarm: Place the child in skin-to-skin contact (Kangaroo Mother Care) or under a radiant warmer/heater.
  • Cover: Ensure the head is covered (cap) as significant heat is lost from the head. Clothe the child properly.
  • Monitor: Check temperature every 30 minutes during rewarming, then every 2 hours.
  • Avoid: Rapid rewarming (hot water bottles) which can cause vasodilation and shock.
• Prevention: Keep the room warm (25–30°C), avoid drafts, and feed frequently to fuel heat production.

Step 3: Treat/Prevent Dehydration

Diagnosis of dehydration is difficult in SAM because classic signs like skin pinch (tenting) and sunken eyes are unreliable due to the loss of subcutaneous fat.

• Assumption: Assume all children with watery diarrhea have some dehydration.
• Contraindication: Do NOT use IV fluids for routine rehydration. IV fluids can easily cause fluid overload and heart failure due to the weakened myocardium.
• Management (Oral Rehydration):
  • Use ReSoMal (Rehydration Solution for Malnutrition) or low-osmolarity ORS with added potassium (20 ml electrolyte solution per liter) and sugar. ReSoMal has less sodium (45 mmol/L) and more potassium (40 mmol/L) than standard ORS to prevent sodium overload.
  • Rate: Give 5 ml/kg every 30 minutes for the first 2 hours, then 5–10 ml/kg/hour for the next 4–10 hours on alternate hours with F-75.
• Management of Shock in SAM:
  • IV fluids are used only if there is definite shock (lethargic/unconscious + cold hands + slow capillary refill >3s + weak fast pulse).
  • Protocol: Give 15 ml/kg of Half-Normal Saline with 5% Dextrose or Ringer's Lactate over 1 hour. Monitor pulse and respiration every 10 minutes. If signs of failure (increased RR/HR) appear, stop immediately.

Step 4: Correct Electrolyte Imbalance

Children with SAM have a total body deficit of potassium and magnesium, but an excess of total body sodium, even though serum sodium may be low (dilutional hyponatremia). The sodium-potassium pump is impaired.

• Sodium: Do not give extra sodium/salt. Sodium overload can precipitate heart failure.
• Potassium: Give 3–4 mEq/kg/day (or ~300 mg/kg/day KCl syrup) for at least 2 weeks. This corrects the intracellular deficit and helps restore pump function.
• Magnesium: Give 0.4–0.6 mEq/kg/day (or 50% Magnesium Sulphate 0.3 ml/kg IM once on Day 1, then oral supplements).
• Note: Prepared F-75 and F-100 diets usually contain these electrolytes if commercial packets or Combined Mineral Vitamin (CMV) mix is used.

Step 5: Treat/Prevent Infection

In SAM, the immune system is suppressed ("Nutritionally Acquired Immunodeficiency"). Typical signs of infection like fever may be absent ("silent infection").

• Protocol: Treat all children with SAM with broad-spectrum antibiotics on admission.
• No Complications: Oral Amoxicillin (15 mg/kg 8-hourly) for 5 days.
• Complications (Shock/Hypoglycemia/Hypothermia/Drowsy): IV Ampicillin (50 mg/kg 6-hourly) + IV Gentamicin (7.5 mg/kg once daily) for 7 days.
• Specific Infections: Treat conditions like candidiasis, skin infections, or worms (Albendazole 400mg single dose if >2 years, after stabilization).

Step 6: Correct Micronutrient Deficiencies

Micronutrient depletion is universal. Supplementation is vital for tissue repair.

• Vitamin A: Give a single large dose on Day 1 (50,000 IU for <6 mo; 100,000 IU for 6–12 mo; 200,000 IU for >12 mo) unless given in the last month.
• Folic Acid: 5 mg on Day 1, then 1 mg/day.
• Zinc: 2 mg/kg/day. Zinc is critical for mucosal repair, immunity, and appetite recovery.
• Copper: 0.3 mg/kg/day.
• Iron: DO NOT GIVE IRON in the stabilization phase. Free iron promotes bacterial growth and oxidative stress (via free radicals). Start iron only in the rehabilitation phase (usually week 2) when the child is gaining weight.

Step 7: Start Cautious Feeding

The metabolic system is fragile. Feeding must be started slowly to avoid Refeeding Syndrome.

• Diet: Use F-75 (Starter Diet).
  • Energy: 75 kcal/100 ml.
  • Protein: Low protein (0.9 g/100 ml) to prevent liver overload (ammonia production).
  • Osmolarity: Low osmolarity to prevent osmotic diarrhea.
• Volume: 130 ml/kg/day initially (100 kcal/kg/day). Reduced to 100 ml/kg/day if severe edema is present.
• Frequency: Small, frequent feeds every 2 hours (12 feeds/day) initially to prevent hypoglycemia and overloading the gut. Use a cup and spoon (katori-spoon), never a bottle.

Phase II: Rehabilitation (Weeks 2–6)

Step 8: Achieve Catch-up Growth

Transition to this phase occurs when the child has returned appetite, edema is reduced/lost, and sepsis is controlled.

• Transition: Replace F-75 with F-100 (Catch-up Diet) over 2–3 days.
  • F-100: 100 kcal/100 ml and significantly higher protein (2.9 g/100 ml) to support muscle synthesis.
• Feeding: Increase volume until the child consumes 150–220 kcal/kg/day. The child should be fed ad libitum (as much as they want).
• Iron: Start Iron supplementation (3 mg/kg/day) in this phase.
• Weight Gain: Monitor for rapid weight gain (>10 g/kg/day is considered good).

Step 9: Provide Sensory Stimulation and Emotional Support

SAM results in "functional isolation," apathy, and delayed development.

• Intervention: Provide a cheerful, stimulating environment.
• Play Therapy: Structured play sessions (15–30 min/day) using simple, colorful, locally available toys.
• Interaction: Encourage the mother to talk, smile, and interact physically (Tender Loving Care - TLC) with the child. This is crucial for brain recovery.

Step 10: Prepare for Follow-up

Management involves preparing the family for discharge to prevent relapse.

• Discharge Criteria:
  • Weight-for-height > -2 SD.
  • No edema for 2 weeks.
  • Good appetite and eating home food.
  • Medical complications resolved.
• Home Diet: Transition from F-100 to nutritious home-based food (High energy/protein).
• Education: Teach the mother about hygiene, energy-dense food preparation, and danger signs.
• Schedule: Follow-up at 1 week, 2 weeks, 1 month, 3 months, and 6 months.

Summary of Dietary Formulas