Severe acute malnutrition (SAM) with complications is a critical condition that affects children, posing a significant threat to their health and well-being. It is crucial to recognize the signs and symptoms of SAM with complications early on to provide timely and appropriate treatment. In this article, we will delve into the details of severe acute malnutrition, including when to suspect it, the triage process, necessary investigations, and the essential treatment strategies for stabilization and rehabilitation.

When evaluating a child for severe acute malnutrition with complications, several factors should be examined. These include vital signs such as pulse rate (PR), respiratory rate (RR), and capillary refill time (CRT). Additionally, the child's overall condition, including lethargy or irritability, loss of subcutaneous fat, muscle wasting, pallor, signs of vitamin deficiencies (B, K, and A), respiratory distress, and dehydration, should be carefully assessed.

The triage process plays a crucial role in determining the appropriate level of care for children with severe acute malnutrition. If a child has SAM with good appetite and no medical complications, home-based treatment can be initiated, including oral amoxicillin administration twice a day for 7-10 days. However, if the child has complications, poor appetite, or failed home treatment, hospitalization is necessary for further management.

To accurately diagnose and monitor severe acute malnutrition with complications, certain investigations are essential. These include a hemogram, random blood sugar (RBS), liver function tests (LFT), kidney function tests (KFT), chest X-ray, rapid diagnostic test for HIV (RDT-HIV), and gastric aspirate for CBNAAT/AFB. Additionally, other desirable investigations such as ECG, stool pH, stool microscopic examination, urine culture, serum electrolytes (Na, K, Cal), serum B12, and serum folate levels can provide valuable information. Optional investigations like blood culture, blood gases, and ultrasound can be considered based on the specific needs of the child.

The management of severe acute malnutrition with complications involves two phases: stabilization and rehabilitation.

A. Stabilization Phase:

During the stabilization phase, close monitoring of vital signs, urine frequency, stool/vomitus volumes, and intake is crucial. Intravenous fluids (IVF) at a rate of 4 ml/kg/hr for 2-3 days should be administered along with early or concomitant initiation of oral feeds (130 ml/kg/day). The treatment of infections typically involves empiric antibiotic therapy, such as intravenous ampicillin and gentamicin. In cases of no response within 48 hours or critically ill patients, intravenous ceftriaxone may be required. If the child can accept oral medications, the switch to oral amoxicillin is recommended. Prolonged diarrhea (>7 days) may require metronidazole treatment. Other complications, including hypoglycemia, hypothermia, severe dehydration, electrolyte imbalances, and anemia, require appropriate interventions based on the child's condition.

B. Rehabilitation Phase:

Once the child meets the criteria for discharge and accepts home-available foods, they can be transferred to a Nutritional Rehabilitation Center (NRC) for the rehabilitation phase. Feeding strategies vary depending on the age of the child. For children aged 6 months and above, gradual increases in caloric intake using F75 and F100 therapeutic formulas are recommended. For children below 6 months, the same approach is followed with the addition of a return to exclusive breastfeeding wherever possible. Electrolyte supplementation with zinc, copper, and iron is also important during this phase. Additionally, the child should receive vitamin supplementation, including vitamin A, vitamin D, and B-complex, as per recommended daily allowances.

A child can be discharged from the hospital to outpatient care if they are clinically well, alert, have no or resolving medical complications, and show no or resolving edema. Satisfactory oral intake with a good appetite and appropriate weight gain are also criteria for discharge. However, if the child experiences primary failure of treatment, such as a failure to regain appetite, failure to lose edema, or inadequate weight gain, further investigations should be conducted to identify underlying causes or conditions.

Severe acute malnutrition with complications is a serious health condition that requires early recognition and effective management. Through proper triage, timely investigations, and appropriate treatment strategies in the stabilization and rehabilitation phases, we can improve the outcomes for children affected by this condition. It is essential to adhere to established guidelines and work closely with healthcare professionals to ensure the best possible care for children with severe acute malnutrition.

References:

World Health Organization. The WHO growth standards. Available at http://www.who.int/childgrowth/standards/en/

World Health Organization. Management of severe acute malnutrition in children 6–59 months of age with edema. Available at http://www.who.int/elena/titles/oedema_sam/en/

Ministry of Health and Family Welfare, Government of India. Operational guidelines on Facility Based Management of Children with Severe Acute Malnutrition. Available at http://nhm.gov.in/nrhm-components/rmnch-a/child-health-immunization/child-health/guidelines.html

Kumar R, Kumar P, Aneja S, Kumar V, Rehan HS. Safety and Efficacy of Low-osmolarity ORS vs. Modified Rehydration Solution for Malnourished Children for Treatment of Children with Severe Acute Malnutrition and Diarrhea: A Randomized Controlled Trial. J Trop Pediatr. 2015 Dec;61(6):435-41.

By following these guidelines and providing comprehensive care, we can effectively manage severe acute malnutrition with complications in children, leading to better health outcomes and improved quality of life for these vulnerable individuals.