Doctors Revision

IMCI · Age: 6 months - 5 years

Uncomplicated Severe Acute Malnutrition

Classification for a child aged 6 months or older with severe wasting (low WFH/L Z-score or low MUAC) OR nutritional oedema, who has NO medical complications AND passes an appetite test (is able to finish RUTF portion). Managed in Outpatient Therapeutic Program (OTP).

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Care priority and warning signs

Care priority

Routine Management / Outpatient Therapeutic Program (OTP)

Red flags

  • Development of any medical complication (danger signs, fever, dehydration, respiratory distress).
  • Loss of appetite / Refusal of RUTF.
  • Increasing oedema.
  • Significant weight loss despite RUTF.
  • Failure to gain weight adequately over several weeks.

Assessment

  • Look/Feel: Look for oedema of both feet.
  • Look/Feel: Determine Weight-for-Height/Length (WFH/L) Z-score.
  • Look/Feel: Measure MUAC (in mm).
  • Confirm Age is 6 months or older.
  • Confirm Absence of Medical Complications: No General Danger Signs? No Severe Classification? No Pneumonia with chest indrawing?
  • Confirm Appetite Test PASSED: Offered RUTF and child was able to finish the prescribed test amount.

Classification

  • [ (Oedema of both feet) OR (WFH/L < -3 Z-score) OR (MUAC < 115 mm) ] AND (Age >= 6 months) AND (No medical complication) AND (Able to finish RUTF) -> UNCOMPLICATED SEVERE ACUTE MALNUTRITION

Key features

  • Presence of bilateral pitting oedema OR WFH/L < -3 Z-score OR MUAC < 115 mm.
  • AND Child is 6 months or older.
  • AND Absence of any medical complication.
  • AND Passes appetite test.
  • Eligible for outpatient management with RUTF.

Management

Non-pharmacological management

  • Provide Ready-to-Use Therapeutic Food (RUTF) to take home.
  • Calculate weekly RUTF requirement based on weight: See amounts on page 21 (e.g., 4.0-4.9kg: 2 packets/day = 14/week; 5.0-6.9kg: 2.5 packets/day = 18/week; 7.0-8.4kg: 3 packets/day = 21/week, etc.).
  • Counsel the mother on how to give RUTF: Wash hands. Give small, frequent feeds directly from sachet. Encourage child to eat often (5-6 times/day). Continue breastfeeding on demand, offer breastmilk BEFORE RUTF. Do not mix RUTF with water. Store RUTF safely.
  • Counsel on hygiene.

Pharmacological treatment

  • Give routine oral antibiotic: Amoxicillin twice daily for 5 days (assume infection). Dose: Age 6m-<12m (4-<10kg): 250mg (1 tab or 5ml) per dose. Age 12m-5y (10-<19kg): 500mg (2 tabs or 10ml) per dose (using dosages from page 14).
  • Give Vitamin A dose on first visit if >= 6 months and not received in past month (Page 20). Dose: Age 6-11m: 100,000 IU. Age 12m-5y: 200,000 IU. (Do not give if oedema present - check local OTP guidelines).
  • Give Mebendazole 500mg single dose if child >= 1 year and not dewormed in past 6 months (Page 20).
  • Check for TB: Assess symptoms, contact history (Page 9). Refer for TB investigation if indicated.
  • Provide Folic Acid (typically given routinely in OTP, often 5mg once weekly - check local protocol).
  • Do NOT give Iron initially (usually started later in OTP when gaining weight).

Follow-up

  • Follow up weekly initially, then bi-weekly as per OTP protocol.
  • At each follow-up (e.g., weekly): Assess for danger signs/complications (Refer if present). Check appetite. Measure weight, MUAC, check oedema. Check RUTF intake and adherence. Monitor progress.
  • Follow-up for complications (Refer to Page 24/25 for guidance):
  • If develops complications -> Refer URGENTLY.
  • If fails appetite test -> Refer URGENTLY.
  • If transitions to MAM criteria (WFH/L between -3 and -2 Z, MUAC 115-125mm, no oedema) -> Transition to SFP (Supplementary Feeding Program) or continue OTP for consolidation phase per protocol.
  • If recovers (WFH/L >= -2 Z, MUAC >= 125mm, no oedema for specified period) -> Discharge from OTP, counsel on prevention.

Counselling points

  • Explain the child is severely malnourished but can be treated at home with special food (RUTF) and medicine.
  • Teach how to give RUTF correctly (amount per day, frequency, hygiene, storage).
  • Teach how to give Amoxicillin for 5 days.
  • Explain schedule for follow-up visits and importance of attending.
  • Counsel on continued breastfeeding.
  • Counsel on hygiene.
  • Advise WHEN TO RETURN IMMEDIATELY: Child develops fever, diarrhoea, vomiting, difficulty breathing, refuses RUTF, seems sicker, develops danger signs.
  • Counsel on preventing future malnutrition (feeding, hygiene, illness prevention).

Differential diagnosis

  • Complicated Severe Acute Malnutrition
  • Moderate Acute Malnutrition
  • Stunting

Complications

  • Development of medical complications requiring inpatient care.
  • Treatment failure / Non-response.
  • Relapse after recovery.

Prevention

  • Improved infant and young child feeding practices.
  • Prevention and prompt management of childhood illnesses.
  • Micronutrient supplementation.
  • Food security.
  • Maternal health and nutrition.
  • Early detection and management of moderate malnutrition.

References

IMCI Chart Booklet - Page 6, Page 9 (TB), Page 14 (Amox), Page 20 (Vit A, Mebendazole), Page 21 (RUTF amounts), Page 24/25 (Follow-up general principles), Pages 25-30 (Feeding Counselling principles)

For learning and professional reference. Use current local guidance and clinical judgement.

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