Severe Acute Malnutrition (SAM)

SAM is defined as:

Important points in history

• Anorexia or lack of appetite (< 75% of expected food intake in 20 minutes)
• HIV status of child and parents Current medication (ART's, CPT)
• Vomiting or diarrhoea
• Oedema (distribution, duration, onset)
• CP

Important points on examination

SAM-children are immune-compromised, and hence show limited or no signs of infection and inflammation.

• Assess ABC, and Blantyre Coma Score (=D) and temperature (=E)
• Weight and Height/Length, and MUAC (use WHO "MOYO" charts found in MOYO)
• Asses for "WHO danger signs" suggestive of systemic infection
• Hypothermia (common) or fever (rare)
• Pallor
• Oedema (+ up to ankle, ++ up to knee, +++ generalised oedema)
• Flaky paint dermatitis, hair texture and colour
• Oral candidiasis (look in the diaper as well)
• Liver size (many kwashiorkor children have this as 'sign' of SAM)
• Abdominal distension (small bowel bacterial overgrowth could present like this)
• Signs of dehydration (see below)
• HIV disease / TB: lymphadenopathy (rare in malnutrition), skin changes, Kaposi etc.
• Look for changes in the eye and/or photophobia

Relevant Investigations

• Blood Sugar (if: lethargic, irritable, low BCS, diarrhoea or vomiting, hypothermic)
• HIV test
• Blood Culture (always when initiating antibiotics in IN-patients)
• MPs
• PCV
• Urinalysis (proteinuria as a cause of edema?)
• Screen and test all admitted children for TB

Indications for Admission to Moyo ward

Complicated Severe Acute Malnutrition

Remember SAM is defined as:

• Bipedal nutritional oedema present OR
• Weight/ Height lower than -3SD (WHO-criteria) OR
• MUAC <11.5 in children older than 6 months

Complicated SAM: presence of “DANGER” signs, suggestive for systemic infection or significant social issues at home.

Monitoring during admission

Daily monitoring of malnourished children entails (use MOYO CCP):

• Daily temperature, respiratory rate and heart rate as a minimum
• Assess intake to estimate appetite
• Daily weight
• (Loss of) Oedema
• Stool frequency/ Diarrhoea, vomiting
• Urine output

In addition sick children monitored in HDU require regular (ideally 6 hourly) assessments of:

• BCS
• Heart rate and capillary refill time
• Respiratory rate and oxygen saturation
• Fluid intake and urine output