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is the most extreme and visible form of undernutrition. Its face is a child – frail and skeletal – who requires urgent treatment to survive. Children with severe acute malnutrition have very low weight for their height and severe muscle wasting.

Severe underweight

• WHZ < -3 (usually clinically reflective of marasmus) where no other explanation is present, and/or clinically severe wasting (usually clinically reflective of marasmus – thin arms, thin legs, “old man” appearance, baggy pants folds around buttocks, wasted buttocks)

Nutritional oedema:

• Supported by findings of skin changes, fine pale sparse hair, enlarged smooth soft liver, moon face.

Risk Factors

Signs and symptoms

Any child with SAM who has any ONE of the following features:

• < 6 months of age or weighs < 4 kg
• Bilateral pitting oedema
• Refusing feeds or is not eating well (poor appetite)
• Any of the danger signs listed below

Danger Signs

• Dehydration
• Hypoglycaemia
• Vomiting
• Hypothermia
• Respiratory distress (including fast breathing)
• Convulsions
• Not able to feed
• Shock
• Lethargy (not alert)
• Jaundice
• Weeping skin lesions

All children with complicated SAM are at risk of complications or death.

• Refer urgently!
• Stabilise before referral.
• Initiate treatment while waiting for transport to hospital

Diagnostic criteria

Diagnostic criteria for SAM in children aged 6-59 months (any one of the following):

Indicator - Severe wasting
Measures - Weight for height Z-Score (WHZ)
Cut off - <-3

Indicator - Mid upper arm circumference
Measures - MUAC
Cut off - <11.5cm

Indicator - Bilateral pitting oedema
Measures - Clinicasign
Cut off - ______



  • Non-pharmacological

    • Keep the child warm.
    • Test for and prevent hypoglycaemia in all children.

    If the child is able to swallow:

    • If breastfed: ask the mother to breastfeed the child, or give expressed breastmilk.
    • If not breastfed: give a breastmilk substitute (F-75). Give 30–50 mL before the child is referred.
    • If no breastmilk substitute is available, give 30–50 mL of sugar water

    To make sugar water:

    • Dissolve 4 level teaspoons of sugar (20 g) in a 200 mL cup of clean water. Repeat 2 hourly until the child reaches hospital.

    If the child is not able to swallow:

    • Insert a nasogastric tube and check the position of the tube.
    • Give 50 mL of milk or sugar water by nasogastric tube (as above).
    If blood sugar < 3 mmol/L treat with 10% Glucose
    • Nasogastric tube: 10 mL/kg.
    • Intravenous line: 2 mL/kg.


    • The only indication for intravenous infusion in a child with severe acute malnutrition is circulatory collapse caused by severe dehydration or septic shock when the child is lethargic or unconscious (excluding cardiogenic shock);
    • All children with severe acute malnutrition with signs of shock with lethargy or unconsciousness should be treated for septic shock. This includes especially children with signs of dehydration but no history of watery diarrhoea, children with hypothermia hypoglycaemia, and children with both oedema and signs of dehydration;
    • In case of shock with lethargy or unconsciousness, intravenous rehydration should begin immediately, using 15 mL/kg/h of one of the recommended fluids;
    • It is important that the child is carefully monitored every 5–10 min for signs of overhydration and signs of congestive heart failure.
    • If signs of overhydration and congestive heart failure develop, intravenous therapy should be stopped immediately;
    • If a child with severe acute malnutrition presenting with shock does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg slowly over at least 3 h) should be given;
    • Children with severe acute malnutrition should be given blood if they present with severe anaemia, i.e. Hb <4 g/dL or <6 g/dL if with signs of respiratory distress;
    • Blood transfusions should only be given to children with severe acute malnutrition within the first 24 h of admission.
  • Pharmacological

    Children with SAM and signs of shock or severe dehydration, and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either:

    • Ringer’s lactate solution + Dextrose 5%
    • If neither is available, 0.45% saline + Dextrose 5% should be used

    Give an additional dose of Vitamin A: Vitamin A (retinol) (PO)

    Age range - Infants 6–11 months

    Dose unit - 100,000U

    Capsule - 1

    Age range - Children 12 months–5 years

    Dose unit - 200,000U

    Capsule - 2


Updated on,

20 Novemba 2020 11:58:24


    1. STG
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