Pediatrics
SAM and MAM: Nutritional Support
Severe and moderate acute malnutrition for MBBS: WHO criteria, MUAC and oedema, F-75, F-100, RUTF and the 10-step protocol, mapped to NMC codes PE10.1 to PE10.6.
MedNext Academy | 3 min read
SAM and MAM: Nutritional Support
Severe and moderate acute malnutrition for MBBS: WHO criteria, MUAC and oedema, F-75, F-100, RUTF and the 10-step protocol, mapped to NMC codes PE10.1 to PE10.6.
This chapter covers the definition, classification and management of severe and moderate acute malnutrition, including the WHO ten-step protocol, therapeutic feeds and the decision between community and facility care. It emphasises MUAC, oedema and the stabilisation-before-catch-up principle.
High-yield: SAM and MAM: Nutritional Support
- The WHO classification of acute malnutrition uses three independent gates: weight-for-height z score, mid-upper arm circumference and bilateral pitting oedema.
- Severe acute malnutrition (SAM) is defined by weight-for-height below minus 3 standard deviations, MUAC below 11.5 centimetres, or bilateral pitting oedema.
- Moderate acute malnutrition (MAM) is weight-for-height between minus 2 and minus 3 standard deviations or MUAC 11.5 to less than 12.5 centimetres without oedema.
- Any bilateral pitting oedema classifies a child as severe acute malnutrition regardless of other measurements.
- The clinical approach is to triage, classify, screen for complications, test appetite, decide the site of care and start safe feeding.
- Moderate acute malnutrition is managed mainly in the community, while complicated severe acute malnutrition requires facility (inpatient) care.
- The WHO 10-step SAM protocol treats, in order, hypoglycaemia, hypothermia, dehydration, electrolytes, infection, micronutrients, cautious feeding, catch-up growth, stimulation and follow-up.
- Stabilisation always comes before catch-up growth in SAM management.
- F-75 formula is used for the stabilisation phase and F-100 for the catch-up (rehabilitation) phase.
- Ready-to-Use Therapeutic Food (RUTF) is used for selected uncomplicated SAM managed as outpatient therapy.
- Under the Integrated Management of Neonatal and Childhood Illnesses (IMNCI), severe wasting, bilateral oedema, danger signs and very low MUAC trigger urgent referral.
- Marasmus is severe wasting from energy deficit, while kwashiorkor features oedema, and both fall under the SAM umbrella.
- Locally prepared energy-dense diets are central to managing moderate acute malnutrition, discharge and prevention of relapse.
- Parental counselling must include the diagnosis, a feeding demonstration, danger signs, a follow-up date and linkage to Anganwadi or community services with teach-back.
WHO acute malnutrition criteria
- **SAM:** Weight-for-height < -3 SD, MUAC < 11.5 cm, or bilateral pitting oedema.
- **MAM:** Weight-for-height -2 to -3 SD or MUAC 11.5 to < 12.5 cm, no oedema.
- **Therapeutic feeds:** F-75 for stabilisation, F-100 for catch-up, RUTF for uncomplicated outpatient SAM.
- **Site of care:** Community for MAM and uncomplicated SAM; facility for complicated SAM.
NMC competencies in this chapter
- **PE10.1:** Definition, etiopathogenesis, classification, features, complications and management of SAM and MAM
- **PE10.2:** Clinical approach to a child with SAM and MAM
- **PE10.3:** Assessment, diagnosis, classification and management planning including rehabilitation and prevention
- **PE10.4:** Identify undernutrition as per IMNCI criteria and plan referral
- **PE10.5:** Counsel parents of children with SAM and MAM
- **PE10.6:** Role of locally prepared therapeutic diets and ready-to-use therapeutic diets
Frequently Asked Questions
How is severe acute malnutrition defined?
Severe acute malnutrition is defined by any one of weight-for-height below minus 3 standard deviations, mid-upper arm circumference below 11.5 centimetres, or the presence of bilateral pitting oedema.
What is the difference between F-75 and F-100?
F-75 is a lower-energy therapeutic milk used in the stabilisation phase of SAM, while F-100 is a higher-energy feed used in the catch-up or rehabilitation phase. Stabilisation always comes before catch-up growth.
When is RUTF used?
Ready-to-Use Therapeutic Food is used for selected children with uncomplicated severe acute malnutrition who have a preserved appetite and no medical complications and can be managed as outpatients in the community.
Which malnutrition needs facility care?
Complicated severe acute malnutrition, meaning SAM with medical complications, poor appetite or danger signs, needs inpatient facility care, whereas moderate acute malnutrition and uncomplicated SAM are managed largely in the community.
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