guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 109
inadequate stimulation by the feeble infant.
The objective of treatment of these patients is to return them to full exclusive breast feeding. Thus, the
admission criterion is failure of effective breast feeding and the discharge criterion is gaining weight on
breast milk alone (anthropometry is not used as primary admission criterion).
1. Organisation
It is inappropriate to admit young infants to most general paediatric or nutrition wards. There should be
a completely separate ward/section for these infants. This is best integrated with a special
service/programme to assist mothers who have difficulty breast feeding. The aim of such a service
would be to re-establish exclusive breast feeding and achieve confidence in their ability to produce
sufficient milk for their baby to thrive for any mother. It’s out-patient arm would counsel and provide
one-to-one support for mothers who have difficulty with breast-feeding; the in-patient arm would be for
mothers whose children are not “thriving” and become malnourished. If such a service does not exist
then the programme should be part of the neonatal service.
The staff should be female and have professional advanced training in breast-feeding support and
counselling as well as skills in care of the neonate.
In most cultures, the ward/room where these infants are managed should be adequately screened and
private; unannounced arrival of males in the section should be forbidden. The mothers must be
confident that they will not be disturbed or surprised by men arriving in the ward. Rounds by male
doctors should be announced in advance. There should be a separate visiting room where mothers
can meet with their husbands without them being admitted to the service.
2. Admission criteria
The only admission criterion is failure of satisfactory breast feeding so that the child is not gaining
weight and developing normally.
This is normally assessed by longitudinal measures of weight (growth monitoring programmes). A
single weight-for-height measurement is not a satisfactory admission criterion. This is particularly
difficult to measure in small infants, is unreliable at this age without accurate equipment and skill, and,
if normal, is an inappropriate measure of “thriving” in the less than 6 months old child. MUAC is not
used in the small infant as it changes rapidly in the first 6 months of life (children under 65 cm of
length).
From birth to 6 months of age weight-for-age is the most appropriate measure to assess nutritional
status. At this age, failure to gain weight can be defined as acute malnutrition. However, there are
premature or small-for-gestational-age babies born who are being exclusively breast fed and gain
weight at a satisfactory rate 168 ; they follow their “channels” of growth and even catch-up, crossing
centile lines despite the fact that their current weight-for-age may still be much below “normal”. Such
children are thriving and do not need admission to the programme. The best way to differentiate those
infants who are thriving from those that are becoming malnourished is to take repeated weight
measures longitudinally; this is the value of the growth-monitoring programme.
Where there is a growth-monitoring programme:
• all infants who are not following the weight-for-age growth channels should be considered for
admission;
168 In the first 6 months of life birth weight is the dominant determinant of current weight. Birth weight is statistically
related to current weight up to 18 months of age, but beyond 6 months other factors become statistically more important.