REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls (NCBI Bookshelf NBK559224) - https://www.ncbi.nlm.nih.gov/books/NBK559224/
Severe acute malnutrition is diagnosed with a tape measure and a scale, not a blood test, and the whole primary-care value is measuring the arm and spotting the child who needs an inpatient bed rather than a food parcel. Feeding a severely wasted child too fast can kill him, so the feeding regimens below are quoted for recognition and are not offered as a clinic prescription.
- THE THREE THRESHOLDS, ANY ONE OF WHICH MAKES THE DIAGNOSIS - meet any one of these and the child has SAM: a weight-for-height z-score (WHZ) below -3 standard deviations (SD); a mid-upper arm circumference (MUAC) under 115 mm, or a MUAC-for-age z-score below -3 SD; or bilateral pitting oedema of nutritional origin.
- MEASURE THE ARM PROPERLY - anthropometry means measuring accurately: standing or lying length to 0.5 cm, weight to 0.1 kg, that is 100 g, and MUAC to 2 mm or better. The arm measurement applies to a child of 6 to 59 months.
- WEIGHT-FOR-AGE IS THE WRONG TOOL AND WILL MISS CHILDREN - it is used often, but a weight-for-age under the third percentile is not a dependable marker of SAM, because it takes no account of what stunting has done to the child's linear growth.
- OEDEMA HIDES THE WASTING AND FALSIFIES THE NUMBERS - a child with kwashiorkor has bilateral pitting oedema, and that oedema can push the weight and the mid-upper arm circumference up falsely. Swollen as they look, these children are usually malnourished to a profound degree.
- REFEEDING SYNDROME IS THE COMPLICATION OF TREATING, NOT OF THE DISEASE - bring nutrition back too fast after a stretch of severe malnutrition and the child can develop refeeding syndrome, which can kill. What happens is that electrolytes shift - the phosphate falls above all, and the potassium, the magnesium and the fluid balance are all disturbed - and from that come cardiac, neurological and respiratory complications. A wasted child sent home with a bag of food and no supervision is exposed to exactly this.
- WHAT DECIDES INPATIENT VERSUS COMMUNITY CARE - SAM is uncomplicated when the child still has a good appetite and shows no clinical sign - no oedema, no acute medical problem - that would raise the risk and call for admission. SAM is complicated when the child needs admitting: for rehydration, to stop infection running on to sepsis, and to keep the treatment itself from causing refeeding syndrome. Test the appetite before deciding.
- COMMUNITY TREATMENT IS A PROGRAMME, NOT A PRESCRIPTION - treating this in the community takes a structured programme: staff who are trained, ready-to-use therapeutic foods (RUTFs), plus follow-up at regular intervals. The quantities the article records are 2 sachets a day where the MUAC is under 115 mm or there is oedema, and 1 a day where the MUAC falls between 115 and 125 mm, aiming at 175 kcal/kg/day. Those belong to a supervised feeding programme.
- ORDINARY REHYDRATION FLUIDS ARE THE WRONG FLUIDS HERE - normal saline given intravenously carries sodium in excess and potassium in short supply, and will not rehydrate these children properly. ReSoMal - Rehydration Solution for Malnutrition - is the oral rehydration solution made for dehydration in a child with SAM, and it holds less sodium and more potassium than the standard WHO oral rehydration solution does.
- THE FIRST DAYS ARE ABOUT STABILISING, NOT GAINING WEIGHT - nutritional rehabilitation in severe acute malnutrition starts with cautious refeeding on a therapeutic milk such as F-75, which is made for the stabilisation phase - typically the first 2 to 7 days. These milks are not there to put weight on. They are there to steady the metabolism, put the electrolytes right, and make it possible to treat the infections underneath.
- LOOK FOR THE INFECTION THAT IS DRIVING IT - ascites should send you looking hard for what lies beneath: tuberculosis (TB), HIV, sepsis, malaria. The core WHO tests listed are haemoglobin with a blood smear; blood glucose, to catch hypoglycaemia; serum albumin and electrolytes; stool microscopy and culture; an HIV test; and urine microscopy and culture.
- ANTIBIOTICS AND VITAMIN A ARE PART OF THE PROTOCOL, AND THE ARTICLE STATES NO AMOUNT - children with SAM so often carry a bacterial infection below the surface that the WHO advises treating them all with a broad-spectrum antibiotic, amoxicillin for instance. The WHO also advises vitamin A, because deficiency is common and it raises the risk of infection, viral and bacterial alike, of blindness, and of death. No milligram figure for either appears in the article, so none is printed.
- WHAT THE EXAMINATION SHOWS, AND WHAT ELSE TO LOOK FOR - in marasmus the muscle is markedly wasted and the subcutaneous fat has all but gone, with a low blood pressure, a low temperature and a slow pulse. Look also for dry eyes and Bitot's spots, which mean vitamin A deficiency; koilonychia and pallor, which mean iron deficiency anaemia; and the signs of a low calcium - Chvostek's or Trousseau's.
- MEASURE THE ARM OF EVERY THIN CHILD, BECAUSE THE STAKES ARE THIS HIGH - undernutrition in all its forms - SAM, being underweight, chronic malnutrition - is reckoned to account for 35% to 45% of child deaths worldwide.