- Severe acute malnutrition is defined as a weight-for-height below -3 z-scores, visible severe wasting, or nutritional edema. It can be diagnosed based on weight-for-length/height, mid-upper arm circumference, or edema. - Management of severe acute malnutrition involves three phases - an initial inpatient stabilization phase using formula F75, a transition phase using formulas F100 or RUTF, and an outpatient or continued inpatient treatment phase using RUTF. Children are assessed for medical complications and appetite to determine inpatient vs outpatient management.

1. Management of Sever
Acute Malnutrition
Lecturer: Nimo Abdi Nur (BSN, MPH-Nutrition)

2. Recap:
Definition
• According WHO Malnutrition refers to deficiencies, excesses or imbalances in a
person’s intake of energy and/or nutrients.
• What are the consequences of malnutrition?
• Malnutrition affects people in every country. Around 1.9 billion adults worldwide are
overweight, while 462 million are underweight. An estimated 41 million children
under the age of 5 years are overweight or obese, while some 159 million are stunted
and 50 million are wasted. Adding to this burden are the 528 million or 29% of
women of reproductive age around the world affected by anaemia, for which
approximately half would be amenable to iron supplementation.

3. Types of Malnutrition

4. UNICEF Conceptual Framework on the causes of
Malnutrition

5. • WHO defined severe acute malnutrition?
• Severe acute malnutrition is defined by a very low weight for height (below -
3z scores of the median WHO growth standards), by visible severe wasting,
or by the presence of nutritional oedema.

6. • Diagnosis
• The main diagnostic features are:
• weight-for-length/height < -3SD (wasted) or
• mid-upper arm circumference < 115 mm or
• oedema of both feet (kwashiorkor with or without severe wasting).

7. • Children with severe acute malnutrition should first be assessed with a full
clinical examination to confirm whether they have any general danger sign,
medical complications and an appetite.
• Children with severe acute malnutrition with loss of appetite or any medical
complication have complicated severe acute malnutrition and should be
admitted for inpatient care. Children who have a good appetite and no
medical complications can be managed as outpatients.

8. • Children who have an appetite (pass the appetite test) and are clinically well
and alert should be treated as outpatients for uncomplicated severe acute
malnutrition. Children who have severe oedema +++ or a poor appetite (fail
the appetite test) or present with one or more general danger signs or
medical conditions requiring admission should be treated as inpatients.

9. Initial assessment
• Assess for general danger signs or emergency signs and take a history concerning:
• recent intake of food and fluids
• usual diet before the current illness
• breastfeeding
• duration and frequency of diarrhoea and vomiting
• type of diarrhoea (watery/bloody)
• loss of appetite
• family circumstances
• cough > 2 weeks
• contact with TB
• recent contact with measles
• known or suspected HIV infection/exposure.

10. Child with severe acute malnutrition oedema

11. Child with marasmus

12. On examination, look for:
• shock: lethargic or unconscious; with cold hands, slow capillary refill (> 3 s),
or weak (low volume), rapid pulse and low blood pressure
• signs of dehydration
• severe palmar pallor
• bilateral pitting oedema
• eye signs of vitamin A deficiency:
• dry conjunctiva or cornea, Bitot spots
• corneal ulceration

13. Medical Complications
• If there is a serious medical complication then the patient should be referred for in-
patient treatment – these complications include the following:
• Bilateral pitting oedema Grade 3 (+++)
• Marasmus-Kwashiorkor (W/H<70% with oedema or MUAC<11cm with oedema)
MUAC Resources - Sources for MUAC Straps
• Severe vomiting/ intractable vomiting
• Hypothermia: axillary's temperature < 35°C or rectal < 35.5°C
• Fever > 39°C

14. • Number of breaths per minute:
• 60 resps/ min for under 2 months
• 50 resps/ minute from 2 to 12 months
>40 resps/minute from 1 to 5 years
• 30 resps/minute for over 5 year-olds or
• Any chest in-drawing

15. • Extensive skin lesions/ infection
• Very weak, lethargic, unconscious
Fitting/convulsions
• Severe dehydration based on history & clinical signs
• Any condition that requires an infusion or NG tube feeding.
• Very pale (severe anaemia)
• Jaundice
• Bleeding tendencies
• Other general signs the clinician thinks warrants transfer to the in-patent facility for assessment.

16. Admission criteria
Children with sever acute malnutrition with ;
• Medical complication
• Sever oedema +++
• Poor appetite
• Danger sign

18. The principles of management of Severe Acute Malnutrition, whatever the program
setting, are based on three phases:
Phase 1:
• Patients that have not passed the appetite test and/or have a major medical complication
should be admitted to an in-patient facility for phase 1 treatment. The F75 formula is used
during this phase to promote recovery of normal metabolic function and nutrition-
electrolytic balance. The duration in this Phase is 2-7 days until the child is stabilized.
• A short training video on the RUTF appetite test (following the WHO guidelines) is also
available here.
• Rapid weight gain at this stage is dangerous, which is why F75 is formulated so that patients
do not gain weight during this stage.
• F-75 contains 75 kcal of energy and 0.9 g protein per 100ml.

19. Transition Phase:
• In-patients transferred from Phase 1 are introduced to F100
formula or RUTF and start to gain weight. The Transition Phase is crucial to
monitor an in-patient's adjustment capacity to a sudden change of diet as this
may lead to electrolyte disequilibrium. The expected weight gain should be
around 6g per kg per day. The duration in this phase is 1-3 days.
• F-100 contains 100 kcal of energy and 2.9g proteins per 100ml.

20. Phase 2:
• In-patients transferred from Transition Phase may continue to use F100
formula or RUTF in the facility-setting until discharged or they may be
transferred to out-patient treatment where they are given RUTF only.
• Patients that have passed the appetite test and/or do not have a
major medical complication can be admitted directly to an out-patient facility
for Phase 2 treatment using RUTF. The expected weight gain should be 8g
per kg per day.

21. • Program settings may depend on national guidelines and facilities available.
The following are the most common types of services for treatment:
• In-patient treatment: Management of severe malnutrition in facilities should
ideally be only for Phase 1 and the Transition Phase.
• Patients that are admitted can be treated on a 24 hour basis with full medical
surveillance and treatment of complications. They would receive 6-12 meals
of F75 per day during Phase 1 followed by 6 meals of F100 per day during
the Transition Phase.

23. • F-75 has is specially mixed to meet the child's needs without overwhelming
the body's systems in the initial stage of treatment. Use of F-75 prevents
deaths. F-75 contains 75 kcal and 0.9 g protein per 100 ml.
• As soon as the child is stabilized on F-75, F-100 is used as a "catch-up"
formula to rebuild wasted tissues. F-100 contains more calories and protein:
100 kcal and 2.9g protein per 100 ml.

25. • What is RUTF?
• RUTF is peanut butter “amplified” – it is loosely defined as a fortified
peanut butter paste rich in vitamins and energy contained in a
package that looks like an oversized ketchup packet.
• RUTF has been revolutionary in treating severe acute malnutrition because it
allows SAM (Severe Acute Malnourishment) to be treated in the community,
does not require water, and does not spoil.
• Each packet contains 500 calories of therapeutic food, it’s basically a
mix of powdered milk, peanut butter, and micro-nutrients. Some have said it
tastes like peanut butter frosting.

26. How to do the appetite test?
• The appetite test should be conducted in a separate quiet area.
• Explain to the mother/caregiver the purpose of the appetite test and how it will be
carried out.
• The mother/caregiver, where possible, should wash her/his hands.
• The mother/caregiver should sit comfortably with the child on her/his lap and
either offer the RUTF from the packet or put a small amount on her/his finger and
give it to the child.
• The mother/caregiver should offer the child the RUTF gently, encouraging the child
all the time. If the child refuses then the mother/caregiver should continue to
quietly encourage the child and take time over the test. The test usually takes a short
time but may take up to one hour. The child must not be forced to take the RUTF.
• The child needs to be offered plenty of water to drink from a cup as he/she is
taking the RUTF.

27. The result of the appetite test
Pass:
• A child that takes at least the amount shown in the table below passes the appetite
test.
Fail:
• A child that does not take at least the amount of RUTF shown in the table below
should be referred for in-patient care.
• Even if the caregiver/health worker thinks the child is not taking the RUTF because
s/he doesn't like the taste or is frightened, the child still needs to be referred to in-
patient care for least a short time. If it is later found that the child actually takes
sufficient RUTF to pass the test then they can be immediately transferred to the
out-patient treatment.

28. The following table gives the MINIMUM
amount of RUTF that should be take

29. Discharge and Follow-up
• The discharge criteria for severely malnourished children is applicable for both in-
patient and out-patient treatment programs.
• Note: Any transfer from in-patient to out-patient treatment and vice-versa should
always be recorded as "transfer from" and never as "discharge" or "new admission"
• Discharge criteria for children aged 6 months to 18 years:
• Weight-for-Height (W/H) and Weight-for-Length (W/L) > = 85% (WHO/NCHS
table) on at least two weighing sessions
or
• No oedema for 14 days

30. Follow-up after discharge:
• Patient should be enrolled in a nutritional support program for another four-six
months. For the first two months, they should attend every two weeks and than
once per month if progress is satisfactory.
• Patient and family should be prioritized in accessing food rations from public
distribution systems.
• If there is no nutritional support program near the patients' home, they should be
referred to the nearest health centers or linked up with mobile clinics for continuous
growth monitoring and support.

31. • NB: a person admitted with a weight-for-height of 70% (NCHS median)
will be discharged when they reach 85% weight-for-height (NCHS Median).
• Those admitted at 65% weight-for-height will reach 79% weight-for-height
at the target weight.
• Most patients below 65% will be treated as in-patients and will have their
height measured and an individual target weight calculated.

32. THANK YOU