This document provides guidelines for the management of severe acute malnutrition (SAM) in children aged 6 months to 5 years. It outlines the stabilization phase (days 1-2), which focuses on preventing death while stabilizing the child by addressing hypoglycemia, hypothermia, dehydration, electrolyte imbalances, infections, and micronutrient deficiencies. It then describes the rehabilitation phase (days 3-7 and weeks 2-6), which focuses on catch-up growth through initiation of feeding, sensory stimulation, and preparation for follow-up care. The document provides detailed protocols for treatment during each stage.

1. By Dr. Sonali Paradhi Mhatre

2. WHO and UNICEF defines Severe Acute
Malnutrition (SAM) for children aged 6
months to 60 months as :
● Weight for height below -3
SD score of the median WHO growth
standards.

5. WHO and UNICEF defines Severe Acute
Malnutrition (SAM) for children aged 6
months to 60 months as :
● Weight for height below -3
SD score of the median WHO growth
standards.
● By visible severe wasting .
● Bipedal oedema ; and
● Mid upper arm circumference below
115mm.

7. History
1

11. History
1
Clinical
Examination

18. Laboratory Investigations2.

20.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

21.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

22.  If the child is lethargic, unconscious, or
convulsing IV 10% glucose
5ml/kg followed by 50ml of 10% glucose or
sucrose by NG tube.
 If conscious child formula feed
(75 cals/100ml), if it is quickly available and
then continue with 2 hourly feeds.

23.  If the child is lethargic, unconscious, or
convulsing IV 10% glucose
5ml/kg followed by 50ml of 10% glucose or
sucrose by NG tube.
 If conscious child formula feed
(75 cals/100ml), if it is quickly available and
then continue with 2 hourly feeds.

24.  If first feed not quickly available
50ml of 10% glucose orally orby nasogastric
tube, followed by the first feed as soon as
possible.
 Repeat blood sugar measurement after30
minutes. If glucose is again <54mg/dl, repeat
the 10% glucose orsugarsolution
Give 2-hourly feeds, day and night, at least forthe
first day

25.  If first feed not quickly available
50ml of 10% glucose orally orby nasogastric
tube, followed by the first feed as soon as
possible.
 Repeat blood sugar measurement after30
minutes. If glucose is again <54mg/dl, repeat
the 10% glucose orsugarsolution
Give 2-hourly feeds, day and night, at least forthe
first day

26.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

27.  If the axillary temperature is <35ºC (<95ºF) or
does not registeron a normal thermometer,
assume hypothermia.
 Coverthe child well. esp. head . Coverwith a
warmblanket.
 Placing in warmer, nearheater.
 KANGAROOMOTHERCARE.

28.  If the axillary temperature is <35ºC (<95ºF) or
does not registeron a normal thermometer,
assume hypothermia.
 Coverthe child well. esp. head . Coverwith a
warmblanket.
 Placing in warmer, nearheater.
 KANGAROOMOTHERCARE.

29.  Taking the child’s temperature 2-hrly until it
rises to more than 36.5°C.
 Take it half-hourly if a heateris being used.
 Feed the child immediately
(if necessary, rehydrate first).

30.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

31.  Child with SAMmay be dehydrated even in the
presence of Oedema.
 Dehydration tends to be overdiagnosed and its severity
is overestimated in severely malnourished children.
 Riskof Hypokalemia is present due to decreased
muscle mass . Therefore along with ORS ,Potassium
supplements need to be added to prevent Hypokalemia.

32. Oral Rehydration :-
ORS How Often ORS How much
Every 30 min for first 2 Hrs. 5ml/kg
Alternate Hrs. for upto 10 Hrs. * 5 – 10 ml/kg
* This should be on basis of child’s willingness to drink and the amount of
ongoing losses
Monitorevery 30 minutes forfirst 2 Hrs and 1 Hourly thereafter.

33.  Signs to check:
• Respiratory rate.
• Pulse rate.
• Urine output – Ask: Has the child passed urine since
last checked?
• Frequency of stools and vomiting – Ask: Has the child
had a stool orvomitted since last checked?

35. Insert an IV line and draw blood for emergency laboratory investigations
Give IV Glucose
Give IV fluid 15ml/kg over 1 hour of either half NS with 5% glucose or
Ringer Lactate
Measure HR and RR at the start and every 5 - 10min
Signs of Improvement
(HR and RR fall)
If the child fails to improve after
the first 15ml/kg IV
If the child deteriorates
during the IV
Rehydration (HR
increase by 15/min or
RR increase by 5/min,
stop IV and Reassess*Repeat same IV fluid
15ml/kg over 1 more
hour.
*Then switch to oral or
NG Rehydration with
ORS 10ml/kg/hr for 10
hrs.
*Initiate refeeding with
starter formula.
Assume the child has septic
shock.
*Give maintainance IV fluid
4ml/kg/hr.
*Start Antibiotic treatment.
*Start Dopamine
*Initiate Refeeding as soon
as possible.

36.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

37.  Supplemental potassium at 3-4
meq/kg/day for at least 2 weeks.
 On day 1, give 50% magnesium
sulphate IM once (0.3mL/kg up to a
maximum of 2ml), Thereafter, give
extra magnesium (0.4–0.6 meq/kg
daily) orally.


38.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

39.  Assume all children with severe malnutrition
admitted in a hospital have an infection and
give broad spectrumantibiotics.
 Hypoglycaemia and hypothermia are often
signs of severe infection.

40. STATUS ANTIBIOTICS
All admitted cases • Inj. Ampicillin 50mg/kg/dose 6 hrly and Inj.
Gentamicin 7.5mg/kg once day for7 days
• Add Inj. Cloxacillin 50mg/kg/dose 6 hrly if
staphylococcal infection is suspected.
• Revise therapy based on sensitivity report
For septic shock or
worsening/ no improvement
in initial hours
• IV Cefotaxime 50mg/kg/dose 6 hrly or
Inj. Ceftriaxone 50mg/kg/dose 12 hrly
+
Inj. Amikacin 15mg/kg/once a day
Meningitis • IV Cefotaxime 50mg/kg/dose 6 hrly or
Inj. Ceftriaxone 50mg/kg/dose 12 hrly
+
Inj. Amikacin 15mg/kg/once a day
Dysentery Inj. Ceftriaxone 100mg/kg once a day for5
days

41.  Duration of antibiotic therapy depends on the
diagnosis i.e.:
* Suspicion of clinical sepsis: at least 7
days
* Culture positive sepsis: 10-14 days
* Meningitis: at least 14-21 days
* Deep seated infections like arthritis and
osteomyelitis: at least 4 weeks

43.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

44.  Vitamin A orally in single dose stat as given below:
• < 6 months : 50,000 IU (if clinical signs of
deficiency
are present).
• 6-12 months : 1 lakh IU.
• Olderchildren: 2 lakh IU.
Children < 8kg irrespective of age should receive 1
lakh IU orally.
Give same dose on Day 0,1 and 14 if there is clinical
evidence of vitamin A deficiency.

45.  Othermicronutrients should be given daily forat
least 2 weeks:
• Multivitamin supplements
• Folic acid: 5mg on day 1, then 1mg/day.
• Zinc : 2mg/kg/day.
• When weight gain commences and there is no
diarrhoea 3mg of iron/kg/day can be added.

46.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

47.  Starting feeds ASAP Small and frequent feeds
recommended.
 Offer130ml/kg/day of liquids (100ml/kg/day if child has
severe oedema),
80-100 Kcal/kg/day and
1-1.5 g/kg/day of proteins.
If child breastfed, continue breastfeeding but give the feed
first.
Ensure night feeds.

48.  Starterformula is to be used during initial
management.
 Starterformula is specially made to meet the child’s
needs without overwhelming the body’s systems in the
initial stage of treatment which provides 75 calories /
100ml and 0.9 gmof protein/100ml.
 These feeds can be given orally orthrough NG Tube.
 Record intake and output on a 24-Hourfood intake
chart.

49.  Starterformula is to be used during initial
management.
 Starterformula is specially made to meet the child’s
needs without overwhelming the body’s systems in the
initial stage of treatment which provides 75 calories /
100ml and 0.9 gmof protein/100ml.
 These feeds can be given orally orthrough NG Tube.
 Record intake and output on a 24-Hourfood intake
chart.

51.  Criteria forincreasing volume/decreasing frequency of
feeds :
1. If there is vomiting, significant diarrhoea, orpoorappetite,
continue 2-hrly feeds.
2. If there is little orno vomiting, diarrhoea is less than before,
and most feeds are consumed 3-hrly feeds.
3. Aftera day on 3-hrly feeds: If there is no vomiting,
occasional diarrhoea, and most feeds are consumed
4-hrly.

52.  Criteria forincreasing volume/decreasing frequency of
feeds :
1. If there is vomiting, significant diarrhoea, orpoorappetite,
continue 2-hrly feeds.
2. If there is little orno vomiting, diarrhoea is less than before,
and most feeds are consumed 3-hrly feeds.
3. Aftera day on 3-hrly feeds: If there is no vomiting,
occasional diarrhoea, and most feeds are consumed
4-hrly.

53.  Recommended schedule with gradual increase in
feed volume is as follows :
DAYS FREQUENCY VOL/KG/FEED VOL/KG/DAY
1 – 2 2Hourly 11ML 130 ML
3 – 5 3Hourly 16ML 130 ML
6 onwards 4 Hourly 22 ML 130 ML

56.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

57.  Signs that a child has reached the phase
of transition:
STARTER FEEDS CATCH UP FEEDS
1. Return of appetite
(easily finishes 4 - hourly feeds of starter
formula)
2. Most /all of the edema has gone.

58.  Catch up formula is used to rebuild wasted tissues.
 the starterformula should be replaced with an equal
amount of catch-up formula for2 days.
 Then on the 3rd day: Increase each successive feed by
10ml as long as child is finishing feeds. Continue this
until some food remains uneaten. (approx.
200ml/kg/day)
 Aftera gradual transition , give frequent feeds –
unlimited amounts, 150 – 220kcal/day & 4 –

59.  Catch up formula is used to rebuild wasted tissues.
 the starterformula should be replaced with an equal
amount of catch-up formula for2 days.
 Then on the 3rd day: Increase each successive feed by
10ml as long as child is finishing feeds. Continue this
until some food remains uneaten. (approx.
200ml/kg/day)
 Aftera gradual transition , give frequent feeds –
unlimited amounts, 150 – 220kcal/day & 4 –

62.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

63.  Tenderloving care.
 A cheerful stimulating environment.
 Structured play therapy for15-30 min a day.
 Physical activity as soon as child is well.
 Maternal involvement as much as possible (eg.
comforting, feeding, play).

64. PRIMARY FAILURE
Failure to regain appetite Day 4
Failure to start to loose oedema Day 4
Oedema still persists Day 10
Failure to gain atleast 5gm/kg/day
body weight
Day 10
SECONDARY FAILURE
Failure to gain atleast 5 gm/kg/day body weight during rehabilitation
during 3 successive days.

65.  Day1-2 Day 3-7 Week 2-6
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolytes
 Infection
 Micronutrients no iron with iron
 Initiate feeding
 Catch up growth
 Sensory stimulation
 Prepare for follow up
Stabilization Rehabilitation
The focus of initial management is to prevent death while stabilizing the child.

67.  Follow-up regularly at 1, 2, 4 weeks, then monthly for6
months and subsequently every 6-months for2 years.
 Criteria forearly Discharge :
Has a good apetite, eating atleast 120-130 Kcal/kg/day and receiving
adequate micronutrients·
Has lost oedema
Consistent weight gain (at least 5 gm/kg/day for3 consecutive days)·
Completed antibiotic treatment
Completed immunization appropriate forage
Child
Trained on appropriate feeding
Has financial resources to feed the child·
Motivated to follow the advise given
Mother
or
Caretaker

68. THANK YOU!!