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Management of complicated severe acute malnutrition in children in resource-limited countries

Indi Trehan, MD, MPH, DTM&H
Mark J Manary, MD
Section Editors
Kathleen J Motil, MD, PhD
Deputy Editor
Alison G Hoppin, MD


Severe acute malnutrition (SAM) is a pervasive problem throughout resource-limited ("developing") countries. Severely malnourished children are often identified when brought to medical attention for an acute issue such as diarrhea or fever, but should also be sought through community-wide screenings of vulnerable children in high-risk settings. In some cases SAM is precipitated by political disruptions like war or natural disasters like drought, which interfere with the food supply. However, more often SAM is simply a disease of pervasive poverty and poor hygienic conditions, compounded by seasonal shortages of food and spikes in illnesses such as malaria or infectious diarrhea.

This topic review will discuss treatment of children with SAM with complications such as intercurrent infections. Affected children are treated as inpatients in hospitals or feeding centers, using protocols promoted by the World Health Organization (WHO). In the past, this approach was used for most children with SAM. However, experience over the last 15 to 20 years has demonstrated that children with uncomplicated SAM, constituting the vast majority of malnourished children, can and should be treated at home with support from outpatient feeding programs. This community-based management of acute malnutrition (CMAM) approach appears to produce equal or better recovery and case fatality rates, to widen population coverage, and has been successfully implemented worldwide by governments and relief organizations. As a result, CMAM has become the international standard of care for uncomplicated cases of severe malnutrition [1-3]. (See "Management of uncomplicated severe acute malnutrition in children in resource-limited countries".)

Other UpToDate topic reviews with related content are:

(See "Malnutrition in children in resource-limited countries: Clinical assessment".)

(See "Micronutrient deficiencies associated with malnutrition in children".)

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Literature review current through: Nov 2017. | This topic last updated: Sep 20, 2017.
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  1. World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and children, 2013. Available at: http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf (Accessed on July 17, 2017).
  2. Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Children's Fund, 2007. Available at: http://www.who.int/nutrition/publications/severemalnutrition/978-92-806-4147-9_eng.pdf (Accessed on July 17, 2017).
  3. Trehan I, Manary MJ. Management of severe acute malnutrition in low-income and middle-income countries. Arch Dis Child 2015; 100:283.
  4. WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization, United Nations Children's Fund, Geneva 2009. http://apps.who.int/iris/bitstream/10665/44129/1/9789241598163_eng.pdf (Accessed on July 10, 2017).
  5. Kerac M, Mwangome M, McGrath M, et al. Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research. Food Nutr Bull 2015; 36:S30.
  6. Angood C, McGrath M, Mehta S, et al. Research priorities to improve the management of acute malnutrition in infants aged less than six months (MAMI). PLoS Med 2015; 12:e1001812.
  7. Mwangome M, Ngari M, Fegan G, et al. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr 2017.
  8. Pocket book of hospital care for children: Guidelines for the management of common childhood illnesses, 2nd ed, World Health Organization, Geneva 2013. http://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_eng.pdf (Accessed on July 10, 2017).
  9. Management of severe malnutrition: a manual for physicians and other senior health workers, WHO, Geneva 1999. www.who.int/nutrition/publications/malnutrition/en/index.html (Accessed on August 02, 2017).
  10. Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for the inpatient treatment of severely malnourished children. World Health Organization, Geneva, 2003. Available at: http://www.who.int/nutrition/publications/severemalnutrition/9241546093_eng.pdf.
  11. Saitoria, EP, Mswata, A, Sanders, D, et al. Treating severe Malnutrition. Child Health Dialogue 2000:19 www.healthlink.org.uk/PDFs/chd19.pdf (Accessed on September 13, 2007).
  12. Puoane T, Sanders D, Ashworth A, et al. Improving the hospital management of malnourished children by participatory research. Int J Qual Health Care 2004; 16:31.
  13. Ashworth A. The impact of the TMRU on the treatment of severe malnutrition. In: The Tropical 18. Metabolism Research Unit, The University of the West Indies, Jamaica, Forrester T, Picou D, Walker S (Eds), Ian Randle Publishers, Kingston 2006. p.285.
  14. Brewster DR. Inpatient management of severe malnutrition: time for a change in protocol and practice. Ann Trop Paediatr 2011; 31:97.
  15. Wharton B. Hypoglycaemia in children with kwashiorkor. Lancet 1970; 1:171.
  16. Reed RP, Wegerhoff FO, Rothberg AD. Bacteraemia in malnourished rural African children. Ann Trop Paediatr 1996; 16:61.
  17. Friedland IR. Bacteraemia in severely malnourished children. Ann Trop Paediatr 1992; 12:433.
  18. Wilkinson D, Scrace M, Boyd N. Reduction in in-hospital mortality of children with malnutrition. J Trop Pediatr 1996; 42:114.
  19. Jones KD, Berkley JA. Severe acute malnutrition and infection. Paediatr Int Child Health 2014; 34 Suppl 1:S1.
  20. Prudhon C, Golden MH, Briend A, Mary JY. A model to standardise mortality of severely malnourished children using nutritional status on admission to therapeutic feeding centres. Eur J Clin Nutr 1997; 51:771.
  21. Management of the child with a serious infection or severe malnutrition: guidelines for care at first referral level in developing countries. Geneva, World Health Organization, 2000.
  22. Optimising antibiotic treatment for sick malnourished children (FLACSAM-PK), University of Oxford, 2017 https://clinicaltrials.gov/ct2/show/NCT02746276 (Accessed on July 10, 2017).
  23. A study to compare antibiotics used to treat children with severe acute malnutrition, 2017 https://www.isrctn.com/ISRCTN18051843 (Accessed on July 10, 2017).
  24. The treatment of diarrhea: A manual for physicians and other senior health workers, WHO 1995.
  25. Iannotti LL, Trehan I, Clitheroe KL, Manary MJ. Diagnosis and treatment of severely malnourished children with diarrhoea. J Paediatr Child Health 2015; 51:387.
  26. Levine AC, Shah SP, Umulisa I, et al. Ultrasound assessment of severe dehydration in children with diarrhea and vomiting. Acad Emerg Med 2010; 17:1035.
  27. Jauregui J, Nelson D, Choo E, et al. The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study. Crit Ultrasound J 2014; 6:15.
  28. Ogden CL, Kuczmarski RJ, Flegal KM, et al. Centers for Disease Control and Prevention 2000 growth charts for the United States: improvements to the 1977 National Center for Health Statistics version. Pediatrics 2002; 109:45.
  29. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl 2006; 450:76.
  30. Versloot CJ, Voskuijl W, van Vliet SJ, et al. Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi. BMC Pediatr 2017; 17:112.
  31. Vygen SB, Roberfroid D, Captier V, Kolsteren P. Treatment of severe acute malnutrition in infants aged <6 months in Niger. J Pediatr 2013; 162:515.
  32. Barennes H, Sengkhamyong K, René JP, Phimmasane M. Beriberi (thiamine deficiency) and high infant mortality in northern Laos. PLoS Negl Trop Dis 2015; 9:e0003581.
  33. Manary MJ, Brewster DR. Intensive nursing care of kwashiorkor in Malawi. Acta Paediatr 2000; 89:203.
  34. Collins S, Myatt M, Golden B. Dietary treatment of severe malnutrition in adults. Am J Clin Nutr 1998; 68:193.
  35. Hossain M, Chisti MJ, Hossain MI, et al. Efficacy of World Health Organization guideline in facility-based reduction of mortality in severely malnourished children from low and middle income countries: A systematic review and meta-analysis. J Paediatr Child Health 2017; 53:474.
  36. Grantham-McGregor SM, Stewart M, Desai P. A new look at the assessment of mental development in young children recovering from severe malnutrition. Dev Med Child Neurol 1978; 20:773.
  37. Grantham-McGregor SM. Assessments of the effects of nutrition on mental development and behavior in Jamaican studies. Am J Clin Nutr 1993; 57:303S.
  38. Oyedeji GA, Olamijulo SK, Osinaike AI, et al. Head circumference of rural Nigerian children--the effect of malnutrition on brain growth. Cent Afr J Med 1997; 43:264.
  39. Daniel AI, Bandsma RH, Lytvyn L, et al. Psychosocial stimulation interventions for children with severe acute malnutrition: a systematic review. J Glob Health 2017; 7:010405.
  40. World Health Organization (WHO) and United Nations Children's Fund (UNICEF). WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization Press; Department of Child and Adolescent Health and Development, Geneva, 2009.
  41. Dale NM, Myatt M, Prudhon C, Briend A. Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children. PLoS One 2013; 8:e55404.