SAM Management

Barnali Chakraborty, PhD, MPH, MSc (Nutrition)

North South University (Dept. of Public Health), Bangladesh
22 March 2024
Recaps
Methods of Nutritional Assessment
• Anthropometry-child growth standards, indicators
• Biochemical
• Clinical
• Dietary
 SAM Children (6 to 59 months)

• Occurs when infants and children do not have adequate energy,

protein and micronutrients in their diet, combined with other
health problems such as recurrent infections

• Presence of edema of both feet or severe wasting (weight-for-

height/length <-3SD or mid-upper arm circumference < 115 mm)
Recaps: Children with SAM

Photo: Geno Teofilo, Oxfam

Photo: WHO. 2002. Training Course on the Management of
Severe Malnutrition. Geneva: WHO.

The pictures are reprinted from NACS training module

SAM- Primary and Secondary
Primary- mostly due to nutritional deficiency

• Causes due to the combined effect of multiple factors including low birth weight,
lack of adequate food, frequent infections and environmental enteropathy

• Commonly seen in developing countries

• Can be managed at home with interventions such as counseling of parents on

continued breastfeeding and appropriate complementary feeding, micronutrient
supplementation, periodic deworming, ensuring household food security, etc.
Secondary SAM

• Secondary malnutrition results from an underlying disease that

compromises growth directly or through its deleterious effect on appetite or
the absorption of nutrients (Shahrin et al 2015)

• Example of infectious diseases: Persistent diarrhea ( ≥14 days), dysentery,

repeated episodes of acute respiratory infection, Tuberculosis

• Example of noninfectious diseases/other problems: low birth weight, cleft

lip/palate, hepatitis diseases, renal diseases, cardiac diseases
SAM Treatment (Impatient and Outpatient)

• Inpatient Treatment- when there are medical complications, no

appetite, weight loss or deteriorating oedema, Caregiver unable to
provide homecare, not capable to return in 1 week for follow-up

• Outpatient Treatment- when there are no medical complications,

appetite is ok, caregiver is available and capable of coming for follow-
up with 1 week
SAM Assessment
SAM Management (Three phases)
SAM Management: Stabilization
What is F-75 or RUTF (Ready-to-use therapeutic food)
• F-75 is milk-based starter formula, containing 75 kcal/100 ml and 0.9 g
protein/100 ml.

• Low in protein, fat, and sodium and rich in carbohydrates

• Ingredients: milk powder, vegetable fat, sugar, and a mineral and

vitamin complex

• Used during initial management of malnutrition, beginning as soon as

possible and continuing for 2-7 days until the child is stabilized

• If the child is anorexic and oral intake does not reach 80 kcal/kg/day,
give the remaining feed by a nasogastric tube
F100

• Developed for phase 2 (transition and rehabilitation) treatment of SAM

• Contains milk powder, vegetable fat, sugar, and a vitamin and mineral complex

• For 2 days start with F100 for catch up growth

• Then increase by 10 ml each day, 8 feeds per day

What is RUTF
• Lipid based energy-dense, micronutrient-fortified, and
designed to accelerate weight gain

• Similar nutrient composition of F-100 but is more energy dense

and does not contain any water

• Made of peanut paste, milk powder, vegetable oil and a

mineral and vitamin mix as per WHO recommendations

• Available in a sachet (1 Sachet-500 K Cal) - 200 KCal./Kg/day

• Can be prepared using local ingredients. For example, rice,

lentil, and chickpeas, coupled with milk powder
Composition of RUTF

% weight
Full fat milk 30
Sugar 28
Veg. Oil 15
Peanut 25
butter
Vitamin- 1.6
mineral mix
Appetite test

Initial: 80-100 Kcal/kg/day

Target: 220-225 Kcal/Kg/Day
Increase: 15/20 Kcal/day
Rehabilitation Phase and Follow up

• Readiness to enter the rehabilitation phase is signaled by a return of appetite,

usually about 1 week after admission

• A gradual transition is recommended to avoid the risk of heart failure, which can
occur if children suddenly consume huge amounts
•
• During the nutritional rehabilitation phase, F-75 can be continued, and, if
possible, relactation should be done

• Appetite test, oedema assessment, weight monitoring and medical checks on

each visit
Rehabilitation Phase and Follow up

• Play therapy, Loving care-emotional and physical stimulation

• Exit criteria are: weight-for-height z-score ≥ -2 and no edema for at least 2 weeks;
or MUAC ≥ 125 mm and no edema for at least 2 weeks
If not responding:
• System Readiness (staff shortages, lack of training and skill)

• Undiagnosed infection

• Insufficient nutrition
Points to remember about RUTF
• Debate or lack of consensus
• Costing issues
• Recommended to prepare using local ingredients by local
manufacturing company
• Recommended only for severe acute malnourished children
Secondary SAM
• For the management of secondary malnutrition, it is crucial to identify the
underlying disease by proper history taking, examination and suggestive
laboratory investigations
Children <6 Months

▪ Only breast milk, unless they are in inpatient treatment for SAM

▪ During inpatient care, prioritize establishing, or re-establishing,

effective exclusive breastfeeding by the mother or other caregiver

▪ Therapeutic foods (F-75 and F-100 diluted with water)

▪ Supplementary foods are not appropriate or nutritionally adequate

for infants under 6 months of age.
Children <6 Months

Can be transferred to outpatient care when:

All clinical conditions or complications, including oedema, are resolved

The infant has good appetite, is clinically well and alert

Weight gain on either exclusive breastfeeding or replacement feeding is satisfactory, (e.g. above the
median of the WHO growth velocity standards or more than 5 g/kg/day for at least 3 successive
days)

Checked for immunizations and other routine interventions

The mother or caregiver is linked with needed community-based follow-up and support
Treatment for MAM
▪ Treatment of concurrent illnesses on an outpatient basis
▪ Food/micronutrient supplementation and nutrition education intervention
▪ RUSF is one kind of supplementation that provides 40–60% of energy
▪ Counseling on the optimal use of locally available food to improve nutritional
status and prevent SAM
▪ Monitoring health and nutritional status
▪ Anaemia assessment (supplementation if necessary)
▪ Deworming
▪ Monthly follow-up
RUSF (Ready-to-use Supplementary Food)

• Contains oil, dried skim milk or soy protein isolate,

groundnuts, sugar, a vitamin and mineral premix, and
maltodextrin ( white powder made from corn, rice,
potato starch, or wheat)
• RUSF includes Plumpy’Sup, in sachets.
Prevention of micronutrient deficiencies
• Vitamin A supplementation every 4–6 months
• zinc for 10−14 days for any episodes of diarrhea.
• If the prevalence of anemia is 20% or higher in children 2–15 years of age, WHO
recommends intermittent iron supplementation to reduce the risk of anemia
• Complementary foods are sometimes fortified with MNPs (micronutrient
powder)
Nutritional Care for normal nutritional status

▪ Counselling to prevent infection and malnutrition

– Optimal infant and young child feeding
– Child spacing and reproductive health
– ANC /PNC
▪ Micronutrient supplementation
▪ Growth monitoring and promotion
▪ Deworming
▪ Disease prevention
IYCF
• Early initiation of breastfeeding, immediately within a birth,
preferably within an hour

• Exclusive breastfeeding for first 6 months of life (ORS, syrups, vit and
minerals are allowed

• Timely initiation of complementary feeding after 6 months (180 days)

• Continued breastfeeding till 2 years of age

BF
• Early initiation-colostrum-immune system ↑

• Breastmilk contains all the water and nutrients that an infant need

• Breastfed infants are likely to have fewer diarrheal, respiratory, and ear infections

• Exclusive breastfeeding helps space births by delaying the return of fertility

• A mother who has a cold, flu, or diarrhea may continue

• Intelligent quotient by feeding

CF

• Add complementary food after 6 months, enriched and varied, increasing the
quantity, frequency, and density, in addition to breastfeeding

• Increase the frequency of feeding and the amount of food as the child gets older

• Recommended (Frequency):
• 2–3 times a day for infants 6–8 months old
• 3–4 times a day for young children 9–24 months old, with nutritious snacks
(between meals) 1–2 times a day.
CF

• At 6 months –liquid to pureed, mashed, and semi-solid foods, adding animal and
plant protein-rich foods such as power flour, beans, soya, chick peas, groundnuts,
eggs, liver, meat, chicken, and milk

• At 8 months-foods that the infant can eat alone, such as cut-up fruit and
vegetables (mangoes, papayas, leafy greens, oranges, bananas, pumpkins,
carrots, and tomatoes)

• By 12 months the mother or caregiver gives the child family foods

CF
• Responsive feeding: The mother or caregiver interacts with the child during
feeding

• Helps the child ingest food and stimulates verbal and intellectual development

• The mother or caregiver feeds the infant directly and helps the older child eat

• Experiments with food combinations, tastes, textures

• Hygiene and safe food preparation

Z Score Formula
Tutorial
• A mother came to the clinic with concerns about her 2-year-old son. For the past
2 months, the child has not been feeding properly and has become listless,
apathetic, and irritable. The mother notes that he has had repeated bouts of
diarrhea for the past year and has developed swelling in the legs. On physical
examination, the child appears pale and withdrawn, and small for his age. His hair
is dry, brittle, and reddish. Based on this assessment, how do you describe the
nutritional status of the child and why?
References

• Shahrin, L., Chisti, M.J., Ahmed, T., 2015. Primary and Secondary Malnutrition 113, 139–146.
https://doi.org/10.1159/000367880
• USAID, FANTA, FHI 360 and PEPFAR 2016. Nutrition Assessment, Counseling, and Support (NACS): A User’s
Guide. Available at: https://www.fantaproject.org/tools/NACS-users-guide-modules-nutrition-assessment-
counseling-support
• Cloete, J., 2015. Management of severe acute malnutrition. SAMJ South Afr. Med. J. 105, 605–605.
https://doi.org/10.7196/SAMJNEW.7782
• WHO and UNICEF. WHO child growth standards and the identification of severe acute malnutrition in infants
and children: A joint Statement by WHO and UNICEF. Availabel at:
https://apps.who.int/iris/bitstream/handle/10665/44129/9789241598163_eng.pdf
• Hossain, M.I., Huq, S., Islam, M.M., Ahmed, T., 2020. Acceptability and efficacy of ready-to-use therapeutic
food using soy protein isolate in under-5 children suffering from severe acute malnutrition in Bangladesh: a
double-blind randomized non-inferiority trial. Eur. J. Nutr. 59, 1149–1161. https://doi.org/10.1007/s00394-
019-01975-w