guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Introduction 14 Stunting is due to long-standing moderate or mild malnutrition 4 . Although there is gain in height when children are treated according to these guidelines, the numbers of stunted children in many communities and the length of time treatment needs to be continued make it inappropriate to treat stunting according to these guidelines in children over 6 months of age. Other approaches that ensure the long-term improvement in the quality of the family diet are used (e.g. breast-feeding support, positive deviance programmes, family economic support such as micro-credit to enable diet diversification or supplementation with specially formulated diets [4]) as well as managing the convalescent phase of acute illnesses [5]. The community mobilisation part of these guidelines can usefully provide a starting point for such programmes. In many health facilities the mortality rate from complicated cases of severe malnutrition is over 20% [6,7]; this is unacceptable. If these guidelines are carefully followed the mortality rate should be less than 5%, even in areas with a high prevalence of HIV/AIDS although there is a higher mortality in patients with a low CD4 count. 2. Treatment of disease in the malnourished is different from the normally nourished “In the past 30 years the way of treating malnourished children has considerably improved. • The first revolution in the management of severe acute malnutrition occurred in the mid-1990s with the introduction of specialised milks (initially F100 and later F75) and improved protocols introduced by the World Health Organisation (WHO). The combination of the specialised milks, the use of antibiotics and better management of fluids reduced mortality substantially, reaching around 5%. These methods were scaled up during the 1990s and were predominantly centre-based and within in-patient facilities. • The second revolution in the management of severe acute malnutrition occurred at the beginning of 2000 with introduction of a decentralised community-based model involving RUTF. The approach involved management of severe acute malnutrition with the community following an initial period of community sensitisation and mobilization and then as a continue process. A primary aim of decentralisation of treatment (not only available in hospital wards) was to improve the coverage of programmes beyond those levels achieved with centre-based programmes. This move becomes possible through the use of RUTF. However, the approach was still mainly dependent upon humanitarian agencies operating in emergency settings. • A third revolution is currently happening, with the aim of managing severe acute malnutrition in the community in non-emergency settings. There is more involvement from governments with management of acute malnutrition that become a public health issue.” With the management in these guidelines the products (F75, F100, and RUTF) and other treatment usually lead to very rapid reversal of the clinical features of SAM. However, in the acute stages the physiological processes of the body and the way that diseases present clinically are completely changed by the malnutrition. This means that commonly there is failure to recognise infection and misdiagnosis of complications. Importantly, the treatments and drugs that are used appropriately in normally nourished patients can be toxic when given to the severely malnourished patient. In particular, the early treatment of SAM 5 entails large movements of electrolytes and water between the various compartments of the body (sodium moves out of the cells and potassium into the cells). This temporary electrolyte disequilibrium makes the patients very vulnerable to misdiagnosis and treatment of dehydration; the management of dehydration and severe anaemia as one would in a normally nourished child often leads to death from fluid overload and heart failure in the severely malnourished 4 ACF: ‘Mild malnutrition’ means ‘at risk of malnutrition’. 5 This particularly applies to complicated cases of SAM, but may occur in all cases of physiological malnutrition or where there has been adaptation to a greatly reduced intake for more than several weeks (including, for example, patients undergoing prolonged fasting for treatment of obesity) – see section on re-feeding syndrome.
ACF-In Guidelines for the integrated management of SAM Introduction 15 child. Furthermore liver and kidney function is abnormal so that drugs are not eliminated normally and the blood-brain barrier may be compromised. Drugs that are often given and thought to be very safe, such as paracetamol, metronidazole, ivermectin, anti-emetics (and other drugs that affect the nervous system), must be used with extreme caution in these children or not at all! Drugs that decrease the appetite (many drugs) may delay or prevent recovery. Thus, it is very important that the whole guideline is understood and implemented along with the introduction of the therapeutic products, particularly the diagnosis and management of the complications during in-patient care. It is only appropriate to refer SAM patients to facilities where the proper training in the care of the severely malnourished has been institutionalised. In particular, the staff in emergency wards need to understand that the standard treatment of complications given to non-malnourished children can lead to the death if the patient is severely malnourished 6 . It is common practice for patients seen in casualty departments to be treated conventionally overnight by junior staff and transferred to the ward or nutrition facility in the morning – the conventional therapy given overnight can lead to over-treatment from which the child does not recover. 3. Prevention of complicated malnutrition The majority of children who fulfil the anthropometric criteria for SAM can be managed entirely as outpatients provided that they have sufficient appetite and do not have any other medical complication. The concept is to identify these wasted children in the community before they develop complications, and then to treat them with RUTF in the community. This involves active screening within the community and full involvement of the community itself in support of the programme. Between 80% and 90% of children identified in the community do not require in-patient management at all. With proper triage procedures and easy referral to an in-patient facility there should be almost no deaths in those treated as out-patients. Children who first come to hospital generally complain of some other acute illness and most require initial treatment as in-patients because of these complications. Much of the literature on the management of severe malnutrition comes from studies of such children; these patients are at high risk of mortality and particular attention needs to be paid to their management if the overall mortality from SAM is to be reduced. Once the acute phase is over and the patient regains their appetite, the “clinical” part of treatment is complete and the in-patients are transferred to out-patient management in the community for the catch-up, “nutritional” phase of treatment. 6 Even giving oral rehydration fluid in and emergency ward can complicate subsequent treatment or even lead to death several days later in the malnutrition ward. This is because the additional sodium retained during the emergency-room treatment makes the occurrence of fluid overload more likely when treatment is started with F75 when more sodium starts to efflux from the cells to expand the extracellular and intravascular space or oedema fluid starts to be mobilised.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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