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Nutrition

SAM: Management of Associated Conditions

Specific management considerations for common associated problems encountered during the treatment of Severe Acute Malnutrition (SAM), including eye problems, skin lesions, severe anaemia, and persistent diarrhoea.

Also known as: SAM Comorbidity Management

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Referral and warning signs

When to refer

Severe eye complications need Ophthalmology. Persistent diarrhoea may need specialist investigation.

Red flags

  • Corneal clouding/ulceration
  • Signs of heart failure during transfusion
  • Persistent diarrhoea with dehydration
  • Extensive infected skin breakdown

Signs and symptoms

  • Eye Signs (Vit A Deficiency): Xerosis, Bitot's spots, Corneal ulceration, Keratomalacia.
  • Skin Lesions (Kwashiorkor Dermatosis): Flaky paint dermatosis, Ulceration, Secondary infection.
  • Severe Anaemia: Severe pallor, Heart failure signs.
  • Persistent Diarrhoea (>14 days).

Risk factors

  • Severe malnutrition itself predisposes.

Diagnosis

Clinical assessment

  • Examination of eyes, skin. Assessment for severe pallor. History of diarrhoea duration.

Investigations

  • Hb measurement.
  • Stool microscopy (persistent diarrhoea).

Diagnostic criteria

  • Clinical identification of the condition.

Management

Non-pharmacological management

  • Skin Lesions: Gentle cleansing, Potassium Permanganate soaks (0.01%), Barrier cream (Zinc oxide/petroleum jelly), Avoid nappies.
  • Severe Anaemia: Minimize procedures, gentle handling.
  • Persistent Diarrhoea: Continue feeding (F-75/F-100/RUTF), hydration (ReSoMal).

Pharmacological treatment

  • Eye Problems (Vit A signs/Measles): Therapeutic Vitamin A PO (Day 1, 2, 14 - dose by age: <6m 50k, 6-11m 100k, >=12m 200k IU). If Corneal Ulcer: Chloramphenicol/Tetracycline eye drops/oint + Atropine drops + Eye pad.
  • Skin Lesions: Zinc (in therapeutic food), Gentian Violet/Nystatin cream (if fungal), Treat secondary bacterial infection.
  • Severe Anaemia (Hb<4 OR Hb 4-6 + Resp Distress): Blood Transfusion (CAUTIOUSLY): Whole Blood 10ml/kg OR Packed Cells 5-10ml/kg SLOWLY over 3h + Furosemide 1mg/kg IV at start. Monitor closely for fluid overload.
  • Persistent Diarrhoea: Rule out/Treat Giardiasis (Metronidazole 7.5mg/kg PO TID x 7d). Consider Lactose Intolerance (rare, trial lactose-free/yoghurt). Consider Osmotic Diarrhoea (reduce sugar/feed osmolality).

Monitoring

Monitor resolution of eye/skin lesions. Monitor Hb post-transfusion. Monitor stool consistency. Monitor feed tolerance.

Complications

  • Blindness.
  • Severe skin breakdown.
  • Heart failure (anaemia/transfusion).
  • Chronic diarrhoea/malabsorption.

Prevention

  • Routine Vit A supplementation.
  • Adequate zinc.
  • Prevent severe anaemia.
  • Manage acute diarrhoea.

Patient education

  • How to administer eye/skin treatments.
  • Hygiene.
  • Recognizing improvement/worsening.
  • Dietary advice (persistent diarrhoea).

Uganda-specific notes

Vit A deficiency signs/Kwashiorkor dermatosis seen. Cautious blood transfusion vital. Giardia possible cause persistent diarrhoea. Therapeutic foods fortified.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 19, Section 19.2.2.4

  • Integrated Management of Acute Malnutrition Guidelines, MOH Uganda

    (Detailed protocols)

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