Management of uncomplicated severe acute malnutrition in children in resource-limited countries
- Indi Trehan, MD, MPH, DTM&H
Indi Trehan, MD, MPH, DTM&H
- Medical Director, Lao Friends Hospital for Children, Luang Prabang, Laos
- Associate Professor of Pediatrics, Washington University in St. Louis
- Mark J Manary, MD
Mark J Manary, MD
- Helene B Roberson Professor of Pediatrics,
- Washington University in St. Louis
- Section Editors
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
- B UK Li, MD
B UK Li, MD
- Section Editor — Pediatric Gastroenterology
- Professor of Pediatrics
- Medical College of Wisconsin
Community-based management of acute malnutrition (CMAM) is a structured system of outpatient care for children with uncomplicated severe acute malnutrition (SAM). Key components of CMAM programs are provision of a therapeutic food that is of high nutritional quality and has minimal spoilage, known as ready-to-use therapeutic food (RUTF), and regular follow-up at home or in decentralized health centers ideally in proximity to where children live by trained community-based health workers. Using this strategy, more than 90 percent of children with SAM can be treated as outpatients, provided that the child has a good appetite and no obvious acute infection or other medical complications . Children with anorexia or complications are initially treated in inpatient programs, but are transferred to outpatient care as soon as possible .
Over the past two decades, an increasing number of countries and relief agencies have adopted CMAM with remarkable success, leading to widespread acceptance and dissemination of this approach worldwide. Where CMAM is available, nutritional recovery rates can be expected to regularly exceed 80 percent, and case fatality rates can be expected in the 5 to 10 percent range, or even better in particularly well-functioning programs. Effective CMAM requires the presence of trained staff, reliable supply chains for RUTF and medications, and the possibility of referral for inpatient care if needed. Because of the increasing availability of RUTF, CMAM has mostly replaced the historical system of universal inpatient management, which was plagued by limited access, poor outcomes, and high costs. There certainly remains an important role for hospitalization for children with complicated SAM. However, CMAM allows most acutely malnourished children to "skip" the inpatient phase of treatment and allows for an orderly transition of care once children with complicated SAM have recovered sufficiently.
Treatment of children with uncomplicated SAM using CMAM is described in this topic review. Treatment of complicated SAM and the evaluation of a child with malnutrition are discussed separately. (See "Management of complicated severe acute malnutrition in children in resource-limited countries" and "Malnutrition in children in resource-limited countries: Clinical assessment".)
The initial evaluation of a child at a feeding center is described in detail separately. (See "Malnutrition in children in resource-limited countries: Clinical assessment".)
Classification — In children 6 through 59 months of age, severe acute malnutrition (SAM) is defined by anthropometric criteria using mid-upper arm circumference (MUAC) <11.5 cm (115 mm), or weight-for-height Z-score <-3, or bilateral pitting edema (table 1). The malnutrition is considered uncomplicated if the child has no clinically obvious acute infections or other medical complications and has a good appetite, determined by an "appetite test" during the initial evaluation. (See 'Indications for community-based management' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- - Indications for community-based management
- - Indications for inpatient care
- - Infants <6 months
- COMMUNITY-BASED MANAGEMENT OF ACUTE MALNUTRITION
- Ready-to-use therapeutic food
- - Formulations
- - Efficacy
- Feeding protocol
- Follow-up and monitoring
- Discharge from treatment
- COMMUNITY-BASED PREVENTIVE CARE
- Recognition of at-risk populations
- - Diarrheal illness
- - HIV
- Supplementation strategies for prevention of malnutrition
- - Generalized food distribution
- - Targeted supplementation strategies
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS