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Nutrition

Management of Complicated Severe Acute Malnutrition (SAM) - Inpatient

Inpatient management of children with Severe Acute Malnutrition (SAM) who have medical complications or fail the appetite test, following the 10 steps of care, typically divided into stabilization and rehabilitation phases.

Also known as: Inpatient SAM Treatment, Therapeutic Feeding Centre (TFC) Care

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Referral and warning signs

When to refer

This IS the referral level.

Red flags

  • Signs of shock
  • Persistent hypoglycaemia/hypothermia
  • Severe respiratory distress / Heart failure signs
  • Altered consciousness / Seizures
  • Severe dehydration
  • Lack of response

Signs and symptoms

  • Meets SAM criteria (Oedema OR MUAC<115mm OR WFH/L<-3z).
  • AND Presence of medical complication (Any IMCI Danger Sign, Hypoglycaemia <3, Hypothermia <35.5, Severe Dehydration/Shock, Severe Anaemia <4 or 4-6+resp distress, Severe LRTI, High fever >39, Severe dermatosis, Vit A eye signs).
  • OR Failed Appetite Test.
  • OR SAM in infant <6 months.

Risk factors

  • See NUT004.

Diagnosis

Clinical assessment

  • Classification based on anthropometry, oedema, appetite test, presence of medical complications (See NUT005).

Investigations

  • Assessment for complications (glucose, temp, hydration, infection).
  • Baseline labs (Hb, malaria, HIV, electrolytes).
  • Other tests as indicated.

Diagnostic criteria

SAM plus medical complication or failed appetite test.

Management

Non-pharmacological management

  • Inpatient Admission.
  • Warmth (KMC).
  • Gentle Handling.
  • Hygiene.
  • Therapeutic Feeding (F-75 -> F-100/RUTF via cup/NGT).
  • Close Monitoring (intake, output, weight, vitals).
  • Sensory Stimulation / Play Therapy.
  • Emotional Support / Caregiver Involvement.

Pharmacological treatment

  • The 10 Steps (Integrated Management):
  • Phase 1: Stabilization (Day 1-7): 1. Hypoglycaemia (Tx/Prevent - Feed Q2-3H F-75). 2. Hypothermia (Tx/Prevent - Warmth, Feed). 3. Dehydration (Tx/Prevent - ReSoMal SLOWLY). 4. Electrolytes (Correct - ReSoMal/F-75, NO diuretics for oedema). 5. Infection (Tx - ROUTINE Broad-spectrum Abx: Amp/Gent IV/IM x 7d). 6. Micronutrients (Correct cautiously - Vit A if eye signs/measles; NO Iron). 7. Cautious Feeding (Initiate - F-75 100kcal/kg/d).
  • Transition Phase: Gradually switch F-75 to F-100/RUTF.
  • Phase 2: Rehabilitation (Wk 2-6): 8. Catch-up Growth (Feed F-100/RUTF ad lib, 150-220kcal/kg/d). 9. Stimulation/Support. 10. Prepare for Follow-Up (Ready for discharge? Start Iron 3mg/kg/d, continue Folic Acid 1mg/d, Deworm).
  • (See NUT009 for specific associated conditions management).

Monitoring

Daily: Weight, Temp, Intake, Output, Oedema, Clinical status. Monitor RR/Pulse during rehydration/refeeding. Monitor glucose/electrolytes.

Complications

  • Refeeding Syndrome.
  • Fluid Overload / Heart Failure.
  • Sepsis.
  • Hypoglycaemia.
  • Hypothermia.
  • Severe electrolyte disturbances.
  • Death.

Prevention

  • See NUT004.

Patient education

  • (To Caregiver): Explanation of condition. Inpatient care need. Specialized feeding. How to participate. Hygiene. Medications. Expected recovery. Discharge planning.

Uganda-specific notes

Requires dedicated staff/resources (therapeutic feeds, meds). F-75/F-100/ReSoMal preparation needs care. Close monitoring vital.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 19, Section 19.2.2.3 (Management of Complicated SAM, 10 Steps Table)

  • Integrated Management of Acute Malnutrition Guidelines, MOH Uganda

    (Detailed inpatient protocols)

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