Severe Acute Malnutrition in Infants and Children

2.1 Children with severe acute malnutrition who have severe bilateral oedema (+++),1 even if they present with no medical complications and have appetite, should be admitted for inpatient care ( S, VL )

3.1 Children with uncomplicated severe acute malnutrition, not requiring to be admitted and who are managed as outpatients, should be given a course of oral antibiotic such as amoxicillin ( C, L )

3.2 Children who are undernourished but who do not have severe acute malnutrition should not routinely receive antibiotics unless they show signs of clinical infection ( S, L )

4.1 Children with severe acute malnutrition should receive the daily recommended nutrient intake of vitamin A throughout the treatment period. Children with severe acute malnutrition should be provided with about 5000 IU vitamin A daily, either as an integral part of therapeutic foods or as part of a multi-micronutrient formulation ( S, L )

4.2 Children with severe acute malnutrition do not require a high dose of vitamin A as a supplement if they are receiving F-75, F-1002 or ready-to-use therapeutic food that complies with WHO specifications (and therefore already contains sufficient vitamin A), or vitamin A is part of other daily supplements ( S, L )

4.3. Children with severe acute malnutrition should be given a high dose of vitamin A (50 000 IU, 100 000 IU or 200 000 IU, depending on age) on admission, only if they are given therapeutic foods that are not fortified as recommended in WHO specifications and vitamin A is not part of other daily supplements ( S, L )

5.1 Children with severe acute malnutrition who present with either acute or persistent diarrhoea, can be given ready-to-use therapeutic food in the same way as children without diarrhoea, whether they are being managed as inpatients or outpatients ( S, VL )

5.2 In inpatient settings, where ready-to-use therapeutic food is provided as the therapeutic food in the rehabilitation phase (following F-75 in the stabilization phase) Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into the rehabilitation phase, they should transition from F-75 to ready-to-use therapeutic food over 2–3 days, as tolerated. The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend on the number and skills of staff available to supervise feeding and monitor the children during rehabilitation Two options for transitioning children from F-75 to ready-to use therapeutic food are suggested: a. start feeding by giving ready-to-use therapeutic food as prescribed for the transition phase. Let the child drink water freely. If the child does not take the prescribed amount of ready-to-use therapeutic food, then top up the feed with F-75. Increase the amount of ready-to-use therapeutic food over 2–3 days until the child takes the full requirement of ready-to-use therapeutic food, or b. give the child the prescribed amount of ready-to-use therapeutic food for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of ready-to-use therapeutic food in the first 12 h, then stop giving the ready-to-use therapeutic food and give F-75 again. Retry the same approach after another 1–2 days until the child takes the appropriate amount of ready-to-use therapeutic food to meet energy needs. ( S, VL )

5.3 In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation Phase Children who have been admitted with complicated severe acute malnutrition and are achieving rapid weight gain on F-100 should be changed to ready-to-use therapeutic food and observed to ensure that they accept the diet before being transferred to an outpatient program ( S, VL )

6.1 Children with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children (5–10 mL/kg/h up to a maximum of 12 h) ( S, L )

6.2 Full-strength, standard WHO low-osmolarity oral rehydration solution (75 mmol/L of sodium) should not be used for oral or nasogastric rehydration in children with severe acute malnutrition who present with some dehydration or severe dehydration. Give either ReSoMal or half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and glucose, unless the child has cholera or profuse watery diarrhoea
Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2 L water (instead of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 ml of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration solution. In this situation, dilution can be revised to add 1 L. ( S, L )

6.3 ReSoMal2 (or locally prepared ReSoMal using standard WHO low-osmolarity oral rehydration solution) should not be given if children are suspected of having cholera or have profuse watery diarrhoea.1 Such children should be given standard WHO low- osmolarity oral rehydration solution that is normally made, i.e. not further diluted ( S, L )

6.4 Children with severe acute malnutrition and signs of shock or severe dehydration and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either: a. half-strength Darrow’s solution with 5% dextrose, or b. Ringer’s lactate solution with 5% dextrose. If neither is available, 0.45% saline + 5% dextrose should be used ( C, VL )

7.1 Children with severe acute malnutrition who are HIV infected and who qualify for lifelong antiretroviral therapy should be started on antiretroviral drug treatment as soon as possible after stabilization of metabolic complications and sepsis. This would be indicated by return of appetite and resolution of severe oedema. HIV-infected children with severe acute malnutrition should be given the same antiretroviral drug treatment regimens, in the same doses, as children with HIV who do not have severe acute malnutrition. HIV- infected children with severe acute malnutrition who are started on antiretroviral drug treatment should be monitored closely (inpatient and outpatient) in the first 6–8 weeks following initiation of antiretroviral therapy, to identify early metabolic complications and opportunistic infections ( S, VL )

7.2 Children with severe acute malnutrition who are HIV infected should be managed with the same therapeutic feeding approaches as children with severe acute malnutrition who are not HIV infected ( S, VL )

7.3 HIV-infected children with severe acute malnutrition should receive a high dose of vitamin A on admission (50 000 IU to 200 000 IU depending on age) and zinc for management of diarrhoea, as indicated for other children with severe acute malnutrition, unless they are already receiving F-75, F-100 or ready-to-use therapeutic food, which contain adequate vitamin A and zinc if they are fortified following the WHO specifications ( S, VL )

7.4 HIV-infected children with severe acute malnutrition in whom persistent diarrhoea does not resolve with standard management should be investigated to exclude carbohydrate intolerance and infective causes, which may require different management, such as modification of fluid and feed intake, or antibiotics ( S, VL )

8.1 Infants who are less than 6 months of age with severe acute malnutrition and any of the following complicating factors should be admitted for inpatient care:

• a. any serious clinical condition or medical complication as outlined for infants who are 6 months of age or older with severe acute malnutrition;
• b. recent weight loss or failure to gain weight;
• c. ineffective feeding (attachment, positioning and suckling) directly observed for 15–20 min, ideally in a supervised separated area;
• d. any pitting oedema;
• e. any medical or social issue needing more detailed assessment or intensive support (e.g. disability, depression of the caregiver, or other adverse social circumstances)

 ( S, VL )

8.2 Infants who are less than 6 months of age with severe acute malnutrition should receive the same general medical care as infants with severe acute malnutrition who are 6 months of age or older:

• a. infants with severe acute malnutrition who are admitted for inpatient care should be given parenteral antibiotics to treat possible sepsis and appropriate treatment for other medical complications such as tuberculosis, HIV, surgical conditions or disability;
• b. infants with severe acute malnutrition who are not admitted should receive a course of broad-spectrum oral antibiotic, such as amoxicillin, in an appropriately weight- adjusted dose

 ( S, VL )

8.3 Feeding approaches for infants who are less than 6 months of age with severe acute malnutrition should prioritize establishing, or re-establishing, effective exclusive breast- feeding by the mother or other caregiver ( S, VL )

8.4 Infants who are less than 6 months of age with severe acute malnutrition and who are admitted:
a. should be breastfed where possible and the mothers or female caregivers should be supported to breastfeed the infants. If an infant is not breastfed, support should be given to the mother orfemale caregiver to relactate. If this is not possible, wet nursing2 should be encouraged; b. should also be provided a supplementary feed:

• supplementary suckling approaches should, where feasible, be prioritized;
• for infants with severe acute malnutrition but no oedema, expressed breast milk should be given, and, where this is not possible, commercial (generic) infant formula or F-75 or diluted F-1003 may be given, either alone or as the supplementary feed together with breast milk;
• for infants with severe acute malnutrition and oedema, infant formula or F-75 should be given as a supplement to breast milk;

c. should not be given undiluted F-100 at any time (owing to the high renal solute load and risk of hypernatraemic dehydration); d. if there is no realistic prospect of being breastfed, should be given appropriate and adequate replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe preparation and use, including at home when discharged.