Management of severe acute malnutrition in low-income and middle-income countries

Abstract

Kwashiorkor and marasmus, collectively termed severe acute malnutrition (SAM), account for at least 10% of all deaths among children under 5 years of age worldwide, virtually all of them in low-income and middle-income countries. A number of risk factors, including seasonal food insecurity, environmental enteropathy, poor complementary feeding practices, and chronic and acute infections, contribute to the development of SAM. Careful anthropometry is key to making an accurate diagnosis of SAM and can be performed by village health workers or even laypeople in rural areas. The majority of children can be treated at home with ready-to-use therapeutic food under the community-based management of acute malnutrition model with recovery rates of approximately 90% under optimal conditions. A small percentage of children, often those with HIV, tuberculosis or other comorbidities, will still require inpatient therapy using fortified milk-based foods.

Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries

“…Active surveillance and case finding of children with SAM can lead to earlier identification of SAM and community-based treatment for the majority of children, 19,25 highlighting the need for TB guidelines to also include screening for acute malnutrition and defining referral pathways. Recent guidance on community-based management of acute malnutrition has led to the scale-up of interventions to diagnose and treat acute malnutrition, from screening in the community to hospitalization for SAM with complications, 19,26 providing opportunities at multiple levels of the health care system to evaluate for comorbidities, including TB (Table 3).…”

Management of severe acute malnutrition

“…If it is present, the patient should be actively managed, preferably with oral feeds or fluids, as mortality can thus be prevented. [4,9] Prevention and treatment of hypothermia As hypothermia is associated with mortality, it is important to monitor body temperature on admission and during rewarming. This should occur 2-hourly until the child's temperature remains >36.5 o C. Prevention of hypothermia, by ensuring that the patient is covered at all times and kept away from draughts, and avoiding prolonged exposure during bathing and medical examination, is critical.…”

“…Effective screening to correctly enrol patients in outpatient programmes has been shown to improve survival. [3][4][5][6][7][10][11][12][13][14] Classifying patients according to anthropometry, presence or absence of symmetrical bilateral pitting Malnutrition remains a global health concern and contributes significantly to childhood mortality. Nearly half of all deaths in children <5 years of age are attributed to undernutrition, especially in developing countries.…”

“…Stool losses should be replaced with approximate volumes of oral rehydration solution, which is much safer than intravenous fluids. [3,4,7,8,10,11,[19][20][21] All children with profuse watery diarrhoea should be assumed to be dehydrated and managed with rehydration measures. These patients have low cardiac reserves -intravenous fluids may lead to volume overload and possibly cardiac failure.…”

“…This has been documented in numerous studies as being successful in rural regions of Africa and Asia. [1,[3][4][5][6][7] Acute malnutrition develops when undernutrition occurs in an essential period of childhood growth, and is exacerbated by coexistent infection and metabolic abnormalities.…”