Severe Acute Malnutrition (SAM) is a life-threatening form of undernutrition characterized by severe wasting or nutritional oedema resulting from prolonged deficiency of energy, protein and micronutrients.

Uncomplicated SAM refers to children who are severely malnourished but clinically stable and can be safely managed at outpatient level using community-based care rather than hospital admission.

A child is classified as uncomplicated SAM when ALL the following apply:

• Age ≥ 6 months

• Weight > 4 kg

• No bilateral pitting oedema

• Alert and responsive (not lethargic or unconscious)

• Has appetite and feeds well (passes appetite test)

• No danger signs or severe medical complications

2. Pathophysiology

In SAM, the body adapts to prolonged starvation:

1. Glycogen stores depleted within 24 hours

2. Fat breakdown becomes primary energy source

3. Muscle protein catabolism occurs

4. Immune system becomes severely suppressed

5. Electrolyte imbalance develops (↓ potassium, ↓ magnesium)

6. Gut mucosal atrophy causes malabsorption

Children with uncomplicated SAM remain metabolically fragile but stable — deterioration can occur rapidly if infections develop.

3. Risk Factors

Child Factors

• Low birth weight

• Prematurity

• Inadequate breastfeeding

• Early cessation of breastfeeding

• Recurrent infections (diarrhoea, pneumonia, malaria)

• HIV exposure or infection

• Tuberculosis

Feeding Practices

• Late introduction of complementary feeding (>6 months)

• Diluted porridge diets

• Low protein diets

• Food taboos

Household & Social Factors

• Poverty

• Food insecurity

• Poor sanitation

• Large family size

• Orphanhood

• Maternal illness or depression

4. Signs and Symptoms

Children with uncomplicated SAM appear severely wasted but stable.

General Appearance

• Very thin (visible ribs)

• Loss of buttock fat (“baggy pants”)

• Prominent bones

• Old-man face

• Sparse hair

Behaviour

• Irritable or quiet

• Alert

• Interested in food

• Appetite preserved

Skin & Hair

• Dry skin

• Hair thinning

• Possible depigmentation

5. Diagnostic Criteria

Diagnosis is based on anthropometric measurements:

Appetite Test (Key for Outpatient Care)

Child must successfully eat Ready-to-Use Therapeutic Food (RUTF) under observation.

Failure = complicated SAM → Admit

6. Investigations

Routine laboratory testing is usually not required in uncomplicated SAM unless clinically indicated.

Recommended Screening

• HIV testing

• TB screening

• Haemoglobin (if pallor)

• Malaria test in endemic areas

When complications suspected

• Blood glucose

• Electrolytes

• Stool microscopy

• Chest X-ray

7. Management

Management follows the Community-based Management of Acute Malnutrition (CMAM) model.

A. Nutritional Therapy (Core Treatment)

Provide Ready-to-Use Therapeutic Food (RUTF)

Typical dose:200 kcal/kg/day

Examples:

• Peanut-based paste therapeutic foods

Caregiver instructions:

• Give small frequent feeds

• Continue breastfeeding

• Provide clean drinking water

• Do not share RUTF

B. Follow-Up Schedule

C. Discharge Criteria

Child is discharged when:

• WHZ > –2 for 2 consecutive visits ≥ 1 month apart OR

• MUAC ≥ 11.5 cm (preferably ≥ 12 cm)

• Clinically well

• Feeding adequately

8. Non-Pharmacological Care

• Nutrition counselling (IMCI guidelines)

• Hygiene education

• Feeding demonstration

• Psychosocial stimulation

• Immunization review

• Long-term growth monitoring

• Social support referral

9. Pharmacological Treatment

(Do not repeat if already given during inpatient stabilization)

Vitamin A Supplementation

Indications:

• Eye signs of deficiency

• Recent measles

Schedule:Day 1 → Day 2 → Day 15 (or discharge)

Deworming

Mebendazole

Other Routine Treatments (Program Dependent)

• Antibiotics (some protocols give routine amoxicillin)

• Malaria treatment if positive

• Iron supplementation ONLY after weight gain phase

10. When to Refer Urgently (Becomes Complicated SAM)

Immediate admission required if:

• Fails appetite test

• Oedema develops

• Persistent vomiting

• Hypothermia

• Hypoglycaemia

• Severe anaemia

• Pneumonia

• Convulsions

• Lethargy or unconsciousness

11. Prevention

Infant Feeding

• Exclusive breastfeeding for 6 months

• Appropriate complementary feeding at 6 months

• Continue breastfeeding up to 2 years

Nutrition Practices

• Energy-dense foods

• Protein daily intake

• Micronutrient supplementation

Public Health Measures

• Immunization

• Deworming programs

• Malaria prevention

• HIV PMTCT programs

• Food security programs

12. Prognosis

Key Clinical Message