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Referral and warning signs
When to refer
Children with SAM require referral for specialized therapeutic care.
Red flags
- Bilateral pitting oedema
- Visible severe wasting
- MUAC < 115 mm
- WFH/L < -3 Z-score
- Any general danger sign in malnourished child
Signs and symptoms
- Clinical Features:
- - Marasmus (Wasting): Severe weight loss, muscle/fat wasting ('skin and bones', 'old man' face), prominent ribs, loose skin folds, apathy/irritability, good appetite.
- - Kwashiorkor (Oedematous): Bilateral pitting oedema (feet/legs first), misery/apathy, poor appetite, skin changes (flaky paint dermatosis, pigment changes, ulcers), hair changes (sparse, light colour, easily pluckable), hepatomegaly (fatty liver), moon face.
- - Marasmic-Kwashiorkor: Both wasting AND oedema.
- General signs: Growth failure (underweight, stunting), Increased infection susceptibility, Impaired development.
- Specific Micronutrient Deficiency Signs.
Risk factors
- Immediate Causes: Inadequate diet (quantity/quality), Disease (infections, parasites).
- Underlying Causes: Food insecurity, Poor care practices, Unhealthy environment (WASH), Poor health access.
- Basic Causes: Poverty, Lack of education, Poor governance, Conflict, Disasters.
Diagnosis
Clinical assessment
Assessment based on clinical features (wasting, oedema, skin/hair changes) and anthropometry.
Investigations
- Anthropometry (Weight, Height/Length, MUAC).
- Clinical examination for oedema and signs of complications/co-morbidities.
Diagnostic criteria
Classification: - Acute Malnutrition (Wasting): Assessed by Weight-for-Height/Length (WFH/L) Z-score or MUAC. Includes Moderate (MAM) and Severe (SAM). Kwashiorkor (oedema) = SAM. - Chronic Malnutrition (Stunting): Assessed by Height/Length-for-Age (HFA/LFA) Z-score (<-2z = stunted). - Underweight: Low Weight-for-Age (WFA) Z-score (<-2z).
Management
Non-pharmacological management
- See specific management entries (NUT006-NUT010).
Pharmacological treatment
- See specific management entries (NUT006-NUT010).
Monitoring
- Regular growth monitoring.
- Monitoring response to nutritional rehabilitation.
Complications
- Impaired growth (stunting).
- Impaired cognitive/physical development.
- Weakened immunity -> Increased infections.
- Increased mortality.
- Increased adult chronic disease risk.
- Inter-generational cycle.
Prevention
- Food security.
- Optimal IYCF.
- Improved WASH.
- Prevent/treat childhood illness.
- Micronutrient programs.
- Health education.
- Poverty reduction.
Patient education
- Importance of balanced diet.
- Optimal IYCF.
- Hygiene/sanitation.
- Immunization/health checks.
- Recognizing malnutrition signs.
Uganda-specific notes
Double burden exists. Kwashiorkor seen. Poverty, food insecurity, infections significant underlying causes.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 19, Section 19.2, 19.2.1, 19.2.1.1