guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Triage 36
outcomes like gain of weight and length of stay, are poorer than HIV negative malnourished children.
Drugs that are used for TB and HIV are quite toxic to the liver, intestine and pancreas. These organs
are also the ones particularly affected by SAM. If treatment with anti-TB drugs or ARVs is started in
the severely malnourished patient, very severe side effects from the drugs are expected. The
treatment already difficult to follow for a non-malnourished patient because of side effects is worse for
a SAM patient and leads to withdrawal of many of them from the HIV /TB treatment programmes. This
is why it is acceptable to delay the start of TB /HIV drugs and first stabilize the nutritional condition of
the patient.
The treatment of malnutrition should start at first, before the introduction of anti-retroviral
drugs (minimum of one week and it is better to wait the child is stabilized for malnutrition). It will
diminish the risk of serious side effects from the anti-retroviral drugs, until organs have recovered
sufficiently to metabolise the drugs safely.
4. To summarise
First the patient is identified in the community or health structure and referred to the programme where
anthropometric measurements and bilateral oedema are checked. The severely ill are “fast tracked” to
treatment by the person doing the triage. The appetite test is performed while waiting to see the
doctor or nurse who looks for the presence of medical complications. S/he discusses with the
caretaker and decides upon the appropriate treatment options. Those that need in-patient treatment
are referred for admission to the appropriate structure; those that can be treated as out-patients are
referred the OTP site nearest to their home.
� See table below
Table 2: Summary of Criteria for admission to in-patient or out-patient care
Factor In-patient care Out-patient care
Choice of caretaker
(at any stage of
management – the
caretaker is often
the best judge of
severity)
Caretaker chooses to start, continue or
transfer to in-patient treatment. The
caretaker’s wishes must be respected.
Caretaker chooses to start,
continue or transfer to outpatient
treatment. The
caretaker’s wishes must be
respected.
Appetite Failed or equivocal Appetite test Passes Appetite test
Oedema • Bilateral pitting oedema Grade 3
(+++)
• Both marasmus and Kwashiorkor
(W/H