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Referral and warning signs
When to refer
Refer patients with complicated Severe Acute Malnutrition (adult or child) for inpatient care. Refer for investigation/management of persistent symptoms affecting nutrition (chronic diarrhoea, severe malabsorption) or suspected complex micronutrient deficiencies.
Red flags
- Signs of Severe Acute Malnutrition (very low BMI/MUAC, nutritional oedema).
- Significant recent unintentional weight loss (>10%).
- Inability to eat or drink.
- Signs of severe opportunistic infection or sepsis.
- Persistent vomiting or diarrhoea leading to dehydration.
Signs and symptoms
- Weight loss (unintentional).
- Wasting (loss of muscle and fat mass - visible thinness, loose skin).
- Reduced appetite / Anorexia.
- Micronutrient deficiency signs (e.g., pallor from anaemia, skin changes, angular stomatitis).
- Symptoms impacting nutrition: Diarrhoea (chronic), Nausea, Vomiting, Oral thrush/lesions, Abdominal pain, Difficulty swallowing (odynophagia).
Risk factors
- Increased energy and protein requirements due to HIV infection and opportunistic infections (OIs).
- Reduced food intake due to: Anorexia (illness, depression, medication side effects), Oral/oesophageal problems (thrush, ulcers), GI symptoms (nausea, pain, diarrhoea), Socio-economic factors (poverty, food insecurity).
- Malabsorption due to HIV enteropathy or gut OIs (cryptosporidiosis, microsporidiosis).
- Nutrient losses through chronic diarrhoea or vomiting.
- Side effects of certain Antiretroviral Therapy (ART) regimens.
- Metabolic changes induced by HIV.
Diagnosis
Clinical assessment
Regular nutritional assessment is key. Includes: Weight and Height measurement (calculate BMI for adults/adolescents), Mid-Upper Arm Circumference (MUAC) measurement, Clinical assessment for bilateral pitting oedema, Assessment for clinical signs of wasting/micronutrient deficiencies, Dietary history (adequacy, diversity, challenges), Assessment of GI symptoms or other factors affecting intake/absorption.
Investigations
- Anthropometry: Weight, Height/Length -> BMI (Adults), Weight-for-Height/Length Z-score (Children <5y), BMI-for-age Z-score (Children 5-19y).
- MUAC measurement (Adults & Children).
- Clinical check for bilateral pitting oedema.
- Haemoglobin (Hb) level (assess for anaemia).
- Assess for and investigate OIs impacting nutrition (e.g., oral exam for thrush, stool analysis for chronic diarrhoea).
- Monitor CD4 count and Viral Load (reflect overall disease control).
Diagnostic criteria
Diagnosis of malnutrition using standard anthropometric cutoffs: - Adult Severe Acute Malnutrition (SAM): BMI <16 kg/m2 OR Unintentional weight loss >10% in 6 months (UCG text mentions 2 months) OR MUAC <185mm (<210mm if pregnant/postpartum) OR Oedema of nutritional origin. (Consider also persistent diarrhoea/fever per UCG text). - Adult Moderate Acute Malnutrition (MAM): BMI 16-18.49 kg/m2 OR MUAC 185-219mm. - Child Malnutrition: Classified as SAM or MAM using WFH/L Z-scores, MUAC, and presence of oedema (See NUT005).
Management
Non-pharmacological management
- Nutritional Counseling (Essential): Emphasize importance of balanced diet, increased energy (~10% more) and protein needs (~50% more). Address safe water, food safety/hygiene. Manage symptoms affecting intake (e.g., small frequent meals for nausea, avoiding triggers). Promote locally available nutrient-dense foods.
- Management of Symptoms: Address oral thrush, diarrhoea, nausea etc. medically.
- Psychosocial Support: Address stigma, depression, economic barriers.
- Linkage to Support: Food assistance programs, livelihood support where available.
Pharmacological treatment
- Treat Opportunistic Infections (OIs): Aggressive treatment of OIs is crucial for improving nutritional status.
- Antiretroviral Therapy (ART): Early initiation and adherence to ART improves immune function and reduces nutritional demands/impact of HIV.
- Manage ART Side Effects: Modify regimen if side effects severely impact nutrition.
- Micronutrient Supplementation: Routine broad-spectrum multivitamin/mineral supplement often recommended. Specific supplements based on deficiency signs/diagnosis (e.g., Iron/Folate for anaemia AFTER OI treatment initiated). UCG notes potential benefit of Selenium + Moringa.
- Therapeutic Feeding (if SAM diagnosed):
- - Adults: Primarily focus on optimizing intake of regular nutrient-dense foods. RUTF may be used programmatically in specific contexts for SAM without complications (e.g., 2-3 sachets/day + meals). Admit if complicated SAM.
- - Children: Manage SAM/MAM according to standard protocols (See NUT006, NUT007, NUT008).
- Management of Anaemia: Treat underlying causes (OIs, HIV itself, nutritional deficiency). Iron/Folate supplementation if indicated.
- Appetite stimulants: Generally not recommended.
Monitoring
Regular monitoring (e.g., monthly initially, then quarterly if stable) of: Weight, BMI/MUAC, Clinical status (oedema, signs of deficiency/OIs), Appetite, GI symptoms, ART adherence and tolerance. Monitor Viral Load and CD4 count.
Complications
- Wasting syndrome.
- Increased risk, severity, and mortality from OIs.
- Poor ART tolerance and effectiveness.
- Reduced physical function and quality of life.
- Impaired immune recovery despite ART.
- Micronutrient deficiencies.
Prevention
- Early diagnosis and initiation of ART.
- Routine nutritional assessment, counseling, and support (NACS) integrated into HIV care.
- Prophylaxis and prompt treatment of OIs.
- Management of conditions affecting food security.
- Promotion of safe water and hygiene.
Patient education
- Explain the strong link between good nutrition, immune function, and HIV management.
- Specific advice on increasing energy and protein intake using local foods.
- Importance of food safety, hygiene, and safe water.
- Strategies to manage common symptoms affecting eating.
- Importance of adherence to ART and any prescribed nutritional supplements.
- When to seek care for nutritional problems, OIs, or worsening symptoms.
Uganda-specific notes
Nutrition Assessment, Counseling, and Support (NACS) is a key component of the national HIV care package. Food insecurity is a major challenge impacting adherence and outcomes. RUTF mainly prioritized for children. Emphasis on using diverse, local, nutrient-dense foods is important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 19, Section 19.1.2
- Consolidated Guidelines for Prevention and Treatment of HIV in Uganda, MOH
(Sections on Nutritional Care and Support)