Severe acute malnutrition in low- and middle-income countries

Low- and middle-income countries bear the greatest burden of malnutrition, especially those in sub-Saharan Africa and Asia. Children are particularly vulnerable. This article provides an overview for healthcare professionals working with children, giving definitions and practical advice for intervention and management. Severe acute malnutrition (SAM) is diagnosed in under 5s with severe wasting (“marasmus”) and/or nutritional oedema (“kwashiorkor”). Wasting is identified using weight-for-height and comparing the child's value with WHO reference data or by measurement of mid-upper arm circumference. SAM is thought to result from a complex interaction between infections and poor diet or feeding practices occurring in the context of multiple adverse social-economic factors, with poor sanitation and hygiene increasing exposure to infection. The clinical management of SAM depends on whether there are complications such as anorexia and infections. Children with uncomplicated SAM are best managed in community programmes using ready-to-use therapeutic food and with close monitoring. The management of complicated SAM requires in-patient care and presents a huge challenge especially in health facilities with limited resources. Management guided by the WHO “Ten Steps”, which account for the reductive adaptation that occurs in malnutrition reduces case-fatality but this often remains high. Prevention of SAM requires addressing the multifactorial underlying causes associated with poverty and food insecurity. Addressing malnutrition in children is essential to achieving many of the UN Sustainable Development Goals.