guidelines for the integrated management of severe acute malnutrition

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.