Severe Acute Malnutrition

For children 6–59 months, diagnose severe acute malnutrition (SAM) when any one of the following is present: mid-upper arm circumference (MUAC) <115 mm, weight-for-height/length z score (WHZ/WLZ) <−3, or bilateral pitting edema. These criteria identify children with severe wasting or nutritional edema who require prompt clinical assessment. clinicaltrials+1clinicaltrialsStudy Details | NCT06642012 | Cash Plus Interventions for Prevention of Acute Malnutrition in Children Under 5 and Their Mothers in Somalia | ClinicalTrials.govnice org ukPneumonia: diagnosis and management (update)

Do not use a reassuring weight or MUAC to exclude SAM when bilateral pitting edema is present. Nutritional edema can falsely elevate both weight and arm circumference, masking depleted lean and fat mass. publications aappublications aap10: The Global Burden of Pediatric Undernutrition and ...

Document edema distribution and severity at presentation and serially. Bilateral lower-extremity pitting edema supports kwashiorkor; generalized edema may occur in more severe edematous malnutrition and should prompt inpatient assessment for coexisting complications. PubMed+1PubMedBackground - The Effectiveness of Interventions to Treat Severe Acute Malnutrition in Young Children: A Systematic Review - NCBI BookshelfPubMedKwashiorkor - StatPearls - NCBI Bookshelf

Treat a child with SAM as medically high risk until hypoglycemia, hypothermia, infection, dehydration or fluid imbalance, and feeding intolerance have been assessed. SAM predisposes to hypoglycemia, hypothermia, severe infection, and micronutrient deficiencies, and these threats can be clinically occult. PubMedPubMedSevere Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls - NCBI Bookshelf

Inpatient management is indicated for children with SAM who have medical complications or cannot tolerate usual nutritional loads. During this phase, protein, fat, and sodium tolerance is reduced; standard inpatient care therefore begins with stabilization rather than immediate high-energy catch-up feeding. WHOWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Assess for concurrent infection at presentation. WHO guidance has recommended routine broad-spectrum antibiotic treatment, including amoxicillin, because children with SAM often have subclinical bacterial infection; this practice remains controversial because of antimicrobial-resistance and adverse-effect concerns. Local protocols and the child’s clinical findings should determine agent selection and disposition. PubMedPubMedSevere Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls - NCBI Bookshelf

For inpatient children 6–59 months with SAM, use F-75 during stabilization, then transition only after stabilization, return of appetite, and reduction in edema. F-75 is a low-protein milk-based formula designed for the stabilization phase; rehabilitation diets provide higher protein and energy. WHOWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Where RUTF is used for rehabilitation, transition from F-75 to RUTF over 2–3 days as tolerated. RUTF is generally a lipid-based paste containing milk powder, electrolytes, and micronutrients and provides nutrient intake comparable to F-100 with added iron. WHOWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Do not equate persistent edema with nutritional recovery. Kwashiorkor is associated with edema and fatty liver, while evidence syntheses describe more severe depletion of antioxidants, vitamins, and minerals than in marasmus. Reduced edema and improved appetite are the clinical prerequisites for rehabilitation transition, not an isolated gain in body weight. ScienceDirect+2ScienceDirectDifference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment - ScienceDirectPubMedDifference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment - PubMedWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Obtain a focused nutritional history, past medical history, vaccination history, and family history in every child with suspected malnutrition. These elements are specifically identified as part of the clinical evaluation and can reveal restricted diets, recent weaning, chronic illness, recurrent infections, or household constraints that will determine relapse risk after nutritional recovery. PubMedPubMedKwashiorkor - StatPearls - NCBI Bookshelf

Differentiate phenotypes clinically, but do not assume that kwashiorkor is explained by protein intake alone. Comparative analyses associate kwashiorkor with fatty liver, edema, methionine and glutathione depletion, greater antioxidant and micronutrient depletion, and altered gut microbial patterns; these findings reinforce the need to assess infection and nutritional adequacy during management. ScienceDirect+1ScienceDirectDifference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment - ScienceDirectPubMedDifference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment - PubMed

Acute infection changes metabolic behavior in SAM. In one isotope-tracer study of children with acute infection, whole-body protein breakdown and synthesis were higher in marasmus than in kwashiorkor, despite similar C-reactive protein concentrations; phenotype should therefore inform risk assessment but not replace direct clinical evaluation of infection or organ dysfunction. ScienceDirectScienceDirectWhole-body protein kinetics in marasmus and kwashiorkor during acute infection - ScienceDirect

During inpatient treatment, monitor appetite, edema, tolerance of prescribed feeds, and signs of refeeding-related electrolyte, fluid, glucose, cardiac, respiratory, renal, and hepatic complications. This monitoring is most important during early reintroduction and transition because refeeding syndrome can impair organ function and precipitate arrhythmias. Wolters Kluwer+1Wolters KluwerRefeeding syndrome in critically ill children : Journal of The Arab Society for Medical ResearchWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Use the change in edema as a treatment marker rather than interpreting early weight gain as unequivocal nutritional recovery. The WHO transition criterion specifically requires reduced edema along with stabilization and appetite before moving from F-75 to RUTF. WHOWHOTransition feeding of children 6–59 months of age with severe acute malnutrition

Before discharge or transfer to outpatient nutritional rehabilitation, ensure that the child has completed stabilization, can tolerate the rehabilitation plan, and has a follow-up structure that can detect recurrent edema, faltering intake, infection, or failure to regain nutritional status. SAM historically carried wide treatment-center mortality variation, with lower mortality associated with adherence to staged management principles. PubMed+1PubMedBackground - The Effectiveness of Interventions to Treat Severe Acute Malnutrition in Young Children: A Systematic Review - NCBI BookshelfWHOMANAGEMENT OF SEVERE MALNUTRITION: A MANUAL ...