Severe acute malnutrition (SAM) is a nutritional deficiency resulting from either inadequate energy or protein intake. SAM is defined by a very low weight-for-height/weight-for-length, or clinical signs of bilateral pitting oedema, or a very low mid-upper arm circumference. SAM can lead to biochemical changes based on metabolic, hormonal, and glucoregulatory mechanisms. Children with primary acute malnutrition are common in developing countries as a result of inadequate food supply caused by social, economic, and environmental factors. Secondary acute malnutrition is usually due to an underlying disease causing abnormal nutrient loss, increased energy expenditure, or decreased food intake. SAM can lead to severe complications such as severe diarrhea, hypoglycemia, hypothermia, pneumonia, urinary tract infection, sepsis, etc. .
The World Health Organization (WHO) describes SAM as Global Acute Malnutrition (GAM) below 70% . In these guidelines, SAM is defined as the presence of oedema of both feet or severe wasting (weight-for-height/length <-3SD or mid-upper arm circumference < 115 mm) . No distinction is made between the clinical conditions of kwashiorkor or severe wasting because their treatment is similar. Children with SAM should first be assessed with a full clinical examination to confirm whether they have any general danger sign, medical complications, and an appetite. Children with SAM with loss of appetite or any medical complication have complicated SAM and should be admitted for inpatient care. Children who have a good appetite and no medical complications can be managed as outpatients. Nutritional treatment is based on the use of specialized nutritious foods enriched with vitamins and minerals: F-75 and F-100 therapeutic milks, and ready-to-use therapeutic food (RUTF) . Nutritional treatment is organized into phases: stabilization and rehabilitation.
Inpatient treatment of severely malnourished children can be costly and disruptive to families in settings with limited resources. Minimizing unnecessary hospitalization while ensuring that those children requiring inpatient treatment get the care they need represents the best use of resources. Community-based management of SAM could prevent the deaths of hundreds of thousands of children if properly combined with a facility-based approach for those malnourished children with medical complications and implemented on a large scale.
