Severe Acute Malnutrition (SAM) is the most severe and life-threatening form of undernutrition in children. It is characterized by severe wasting and/or nutritional oedema resulting from prolonged deficiency of macronutrients and micronutrients combined with metabolic and immune dysfunction.

Complicated SAM refers to children with SAM who present with medical complications, metabolic instability, or failure of appetite test and therefore require urgent inpatient hospital management.

These children have extremely high mortality risk due to:

• Infection without fever

• Hypoglycaemia

• Hypothermia

• Electrolyte imbalance

• Cardiac failure

• Septic shock

2. Pathophysiology

In complicated SAM, adaptive starvation mechanisms fail:

Children often die from occult sepsis, not dehydration.

3. Risk Factors

Child-related

• Low birth weight

• Prematurity

• HIV infection

• Tuberculosis

• Recurrent infections

• Chronic diarrhoea

• Congenital disease

Feeding factors

• Early cessation of breastfeeding

• Diluted formula

• Food insecurity

• Poor complementary feeding

Social determinants

• Poverty

• Maternal illness

• Orphanhood

• Neglect

• Poor sanitation

4. Clinical Features

Diagnostic Definition (Age 6–59 months)

Presence of ANY:

Complicated SAM = SAM + ANY danger sign

General

• Lethargy / unconsciousness

• Not feeding

• Persistent vomiting

• Hypothermia

• Hypoglycaemia

Circulatory

• Shock

• Weak pulse

• Cold extremities

Respiratory

• Fast breathing

• Severe pneumonia

• Respiratory distress

Neurological

• Convulsions

• Coma

Gastrointestinal

• Severe dehydration

• Persistent diarrhoea

• Jaundice

Skin

• Weeping dermatosis

• Skin breakdown

5. Immediate Actions (Before

Referral or Admission)

All children must be stabilised immediately

A. Prevent Hypoglycaemia

If child can swallow:

• Breastfeed OR give F-75

• Give 30–50 ml immediately

If unable to swallow:

• NG tube → 50 ml F-75 or sugar water

If glucose <3 mmol/L:

• NG: 10 ml/kg 10% glucose

• IV: 2 ml/kg 10% glucose

Sugar water preparation20 g sugar in 200 ml clean water

Give every 2 hours during transfer

B. Keep Warm

• Skin-to-skin

• Warm clothing

• Warm room

C. Urgent Referral

Start treatment while arranging transport

6. Investigations (Hospital Setting)

Baseline

• Blood glucose

• Haemoglobin

• Malaria test

• HIV test

• TB screening

Advanced

• Electrolytes

• Blood culture

• Chest X-ray

• Urine test

7. Hospital Management (WHO 10-Step Approach)

Management occurs in three phases

PHASE 1 — STABILIZATION (Days 1–7)

Goal: prevent death

1. Treat Hypoglycaemia

Feed every 2–3 hours (F-75)

2. Treat Hypothermia

Keep warm, frequent feeding

3. Treat Dehydration (Very Carefully)

Use oral/NG:

ReSoMal solution

IV fluids ONLY if shock

15 ml/kg/hour

Monitor every 10 minutes

4. Treat Infection (Always)

Give empiric antibiotics even without fever

5. Correct Electrolytes

Do NOT give excess sodium

Give:

• Potassium

• Magnesium

6. Micronutrients

Give all except iron initially

Therapeutic Feeding (F-75)

Low protein, low sodium, low osmolarity formula

Prevents refeeding syndrome

PHASE 2 — TRANSITION (2–3 Days)

When appetite returns:

Switch from F-75 → F-100 gradually

PHASE 3 — REHABILITATION

Goal: rapid weight gain

Use:

• F-100 OR RUTF

Start iron supplementation

8. Fluid Management in Shock

Give IV fluids ONLY in septic shock:

Options:

• Ringer Lactate + 5% Dextrose

• 0.45% saline + 5% Dextrose

If no improvement after 1 hour:→ Blood transfusion 10 ml/kg over 3 hrs

9. Blood Transfusion Indications

Only within first 24 hrs

10. Pharmacological Treatment

Vitamin A

Repeat day 2 and day 15 if eye signs/measles

Antibiotics

(All complicated SAM)

Broad spectrum empiric therapy

Deworming

After stabilization phase

Iron

Start only during rehabilitation phase

11. Monitoring

12. Discharge Criteria

Child moves to outpatient care when:

• Appetite returns

• No oedema for 2 weeks

• Clinically stable

• Transitioned to RUTF

13. Complications

• Septic shock

• Heart failure

• Electrolyte imbalance

• Refeeding syndrome

• Hypoglycaemic death

14. Prevention

Nutrition

• Exclusive breastfeeding 6 months

• Adequate complementary feeding

Health

• Immunization

• Deworming

• HIV care

• TB screening

Social

• Food security programs

• Maternal education

• Growth monitoring clinics

Key Clinical Message

1. .