Q2 LONG ANSWER 10M ★ High-yield

Define Management of Severe Acute Malnutrition (SAM) — WHO 10 Steps. Describe its clinical features, management, prevention and treatment.

Pediatrics · Final Professional

Severe Acute Malnutrition (SAM) is diagnosed by any one of the following in a child 6–59 months:

The appetite test (offering RUTF) decides the route of care — a child who eats it has a preserved appetite.
Uncomplicated SAM (good appetite, alert, no danger signs) → community-based management with Ready-to-Use Therapeutic Food (RUTF).
Complicated SAM (poor appetite OR any danger sign) → inpatient (facility) care.

Anorexia / failed appetite test; severe oedema (+++); lethargy or unconsciousness; convulsions.
Hypothermia; high fever; severe dehydration/shock; severe anaemia; severe pneumonia/LRTI; persistent vomiting.

Stabilisation (days 1–7): steps 1–7 + start of 8 → transition → rehabilitation (weeks 2–6): catch-up growth → follow-UP

Step	Intervention	Key point
1	Treat/prevent hypoglycaemia	Glucose < 54 mg/dL → 50 mL of 10% dextrose orally/NG; feed 2-hourly
2	Treat/prevent hypothermia	Keep warm (skin-to-skin, cover, warm room); temp < 35.5 °C → active warming
3	Treat/prevent dehydration	Use ReSoMal (low-Na, high-K) 5–10 mL/kg/hr orally; rehydrate slowly (heart-failure risk)
4	Correct electrolytes	Extra potassium & magnesium; low sodium; NO diuretics for oedema
5	Treat/prevent infection	Broad-spectrum antibiotics for all (signs are masked); update measles vaccine
6	Correct micronutrients	Vitamin A, folic acid, zinc, copper, multivitamins — NO iron in this phase
7	Start cautious feeding	F-75 (75 kcal/100 mL), small & frequent (2–3 hourly), low protein/Na — maintenance only
8	Achieve catch-up growth	Transition to F-100 / RUTF (100 kcal/100 mL); high energy & protein; add iron now
9	Provide sensory stimulation	Play, emotional support, structured stimulation, maternal involvement
10	Prepare for follow-up	Counsel on feeding; plan discharge & regular follow-up to prevent relapse

Feed	Energy	Use
F-75	75 kcal/100 mL	Stabilisation — maintenance only; does not push growth
F-100	100 kcal/100 mL	Rehabilitation — catch-up growth (inpatient)
RUTF	~520–550 kcal/100 g	Community rehabilitation; energy-dense paste, needs no water

Monitor weight daily, oedema, temperature, feeds, stools and danger signs.
Expected weight gain in rehabilitation ≈ 5–10 g/kg/day.
Failure to respond → look for missed infection (TB, HIV, UTI), inadequate feeding, or micronutrient deficiency.

Good appetite, alert, oedema fully resolved, consistent weight gain.
Weight-for-height ≥ −2 SD / MUAC ≥ 12.5 cm; immunisation completed; caregiver counselled on home feeding.

Exclusive breastfeeding, timely complementary feeding, immunisation, vitamin A & deworming.
Community MUAC screening and early identification/referral (ICDS / Anganwadi).

Weight gain	Interpretation	Action
< 5 g/kg/day	Poor	Full re-evaluation — missed infection, inadequate feeding, wrong feed
5–10 g/kg/day	Moderate	Check intake & ongoing infection
> 10 g/kg/day	Good	Continue current management

Refeeding syndrome — if feeding is too aggressive early → dangerous drops in phosphate, potassium & magnesium; hence cautious F-75 first.
Heart failure — from over-hydration or too-rapid feeding/transfusion (the child has a small, compromised heart).
Hypoglycaemia, hypothermia and overwhelming infection remain the main early killers.

Never give iron in the stabilisation phase — it worsens infection.

All questions in Nutrition