Complicated Severe Acute Malnutrition — 2 months - 5 years | IMCI

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Care priority and warning signs

Refer URGENTLY

Look/Feel: Look for oedema of both feet (Check by pressing thumb gently for 3 seconds).
Look/Feel: Determine Weight-for-Height/Length (WFH/L) Z-score using WHO growth charts.
Look/Feel: Measure Mid-Upper Arm Circumference (MUAC) in mm (for children 6 months or older).
Check for Medical Complications: Any General Danger Sign (see IMCI_2M5Y_001)? Any Severe Classification (e.g., Severe Pneumonia, Severe Dehydration)? Pneumonia with chest indrawing?
Check Appetite (only if SAM criteria met AND child >= 6 months AND no other medical complication present): Offer Ready-to-Use Therapeutic Food (RUTF). Is the child able to finish the prescribed amount based on weight?
Check Breastfeeding (only if SAM criteria met AND child < 6 months AND no other medical complication present): Assess breastfeeding (attachment, suckling). Does the child have a breastfeeding problem?

(Oedema of both feet) OR (WFH/L < -3 Z-score) OR (MUAC < 115 mm [if >=6m]) AND [ (Any medical complication present) OR (Not able to finish RUTF [if >=6m]) OR (Breastfeeding problem [if <6m]) ] -> COMPLICATED SEVERE ACUTE MALNUTRITION

Presence of bilateral pitting oedema (any grade) automatically classifies as SAM.
OR WFH/L Z-score < -3.
OR MUAC < 115 mm (in child >= 6 months).
AND Presence of ANY of the following indicates COMPLICATED SAM: Any medical complication (General danger sign, severe classification, pneumonia w/ chest indrawing) OR Failed appetite test (for child >= 6 months) OR Breastfeeding problem (for child < 6 months).

Give first dose of an appropriate IM antibiotic (e.g., Ampicillin 50mg/kg + Gentamicin 7.5mg/kg or Ceftriaxone - see page 12 for doses). Assume infection even if not obvious.
Treat to prevent low blood sugar (Hypoglycemia): Give 50ml of 10% glucose/sucrose solution (or usual sugar water: 4 tsp sugar in 200ml water) orally or by NG tube. If possible, check blood sugar. Follow with feeding.
Give Vitamin A dose if child is >= 6 months (unless given in last month). Dose: Age 6-11m: 100,000 IU. Age 12m-5y: 200,000 IU (Page 20). Do NOT give Vitamin A if oedema is present (often given during stabilization phase under supervision). Check local inpatient protocol.
Do NOT give iron in the initial phase.
Provide rehydration fluid carefully if dehydration present (use ReSoMal if available, or half-strength ORS with added potassium/glucose as per inpatient protocols; standard ORS can worsen electrolyte imbalance in SAM). Give fluids slowly, orally or NG. Avoid IV fluids unless signs of shock are present, give cautiously.

To be managed in an inpatient therapeutic feeding center / hospital stabilization phase.

Explain that the child is very severely malnourished and has complications requiring urgent hospital treatment.
Explain treatments given (antibiotic, sugar solution, Vit A if given).
Advise on keeping child warm during transport.
Reassure mother about therapeutic feeding program.
Write a detailed referral note indicating Complicated SAM, specific complications, WFH/L or MUAC/oedema status, and treatments given.

Uncomplicated Severe Acute Malnutrition
Moderate Acute Malnutrition
Stunting (Chronic malnutrition - low Height-for-Age)
Oedema due to other causes (renal disease, heart failure - less common, clinical context important)

Hypoglycemia
Hypothermia
Dehydration / Shock
Severe electrolyte imbalance
Infection / Sepsis
Heart failure (especially during refeeding)
Severe anaemia
Vitamin/Mineral deficiencies (esp. Vit A, Zinc, Potassium, Phosphate, Magnesium)
Refeeding syndrome

Improved infant and young child feeding practices (exclusive breastfeeding, appropriate complementary feeding).
Prevention and prompt management of childhood illnesses.
Micronutrient supplementation.
Food security.
Maternal health and nutrition.

IMCI Chart Booklet - Page 6, Page 12 (Antibiotic, Sugar), Page 14 (Antibiotic reference), Page 20 (Vit A)