Essential information

Managing infants with SAM and at risk of poor growth and development

By the end of this module, you should be able to:

• Know how to identify and triage infants less than six months of age at risk of poor
growth and development
• Understand how to establish, re-establish or improve breastfeeding
• Provide care to an infant less than six months old with no option to breastfeed
• Provide needed support to the mother or carer
• Know the recent developments in the management of infants less than six months at
risk of poor growth and development

Identifying infants with growth and development concerns

At risk of poor growth and development Severe acute malnutrition

Infants with poor growth based on sequential/consecutive
measures.
• No weight gain or weight loss from one measurement to the
next
• Downward crossing of weight-for-age centile lines1
• Insufficient weight gain (velocity standards2 or grams/per
specific time period3)
1
≥1 growth centile space if birth weight <9th centile; ≥2 centile spaces if birth weight
9th-91st centile; ≥3 centile spaces if birth weight >91st centile

2
Less than 2 standard deviations (SD) below the median on the WHO growth velocity
standards from one measurement to the next.
Weight-for-length less than –3 Z-
3
Less than 500g/month, or if weekly measurements: birth to 3 months, less than 150- score,
200g/week and 3 to 6 months, less than 100-150g per week Current status/single
measure
Or
Infants with poor anthropometry based on a single measure.
The presence of bilateral pitting
• Weight-for-age z-score (WAZ) <-2 SD
oedema
• Weight-for-length z-score (WLZ) <-2 SD
• Nutritional oedema
• Mid-upper arm circumference (MUAC) <110mm for infants
between 6 weeks to less than 6 months of age.
Infants with known risk factors for poor growth and development
• Neurodevelopmental concerns
• Infant feeding concerns
• Maternal risk (physical or mental health problem (s) affecting
caring practices)
• History of hospitalisation
Infants at risk due to poor birth outcomes
• Preterm birth
• Low birth weight
• Small for gestational age
Measure the infant's weight using baby scales as they give more precise measurements and measure
their length lying down. Length cannot be measured if the infant is under 45 cm.
 Assessment and triage

• Look for IMCI danger signs and acute medical problems or conditions that are
classified as severe per IMCI. Refer any children with IMCI danger signs and acute
medical problems to inpatient care.
• Infants with oedema (nutritional) and recent weight loss should also be referred to
inpatient care.
• Prioritising the care for visibly sick infants should ensure warmth is provided through
Kangaroo Care and sugar water provided. Stabilise emergency signs to the extent
possible before transfer to inpatient care.
• Infants and children that do not meet the criteria for immediate inpatient referral as
above should have an in-depth assessment to consider if they need inpatient or
outpatient treatment based on the clinical judgment of an adequately trained health
worker.
• In an in-depth assessment, look out for the following characteristics:
I. medical problems that do not need immediate inpatient care but do need further
examination and investigation (e.g., HIV-related complications);
II. medical problems needing mid or long-term follow-up care and with a significant
association with nutritional status (e.g., congenital heart disease, HIV, tuberculosis,
cerebral palsy, or other physical disabilities);
III. specific anthropometric criteria from the list of criteria used to identify infants at risk of
poor growth and development: WAZ <-2 SD, WLZ <-3 SD, MUAC <110mm for infants
between 6 weeks and less than 6 months of age, failure to gain weight based on two
consecutive measurements.
IV. ineffective breastfeeding (e.g., attachment, positioning, suckling reflex) or perceived
breastmilk insufficiency
V. feeding concerns for non-breastfed Acute medical problems (as per IMCI classification) which need
infants (e.g., inappropriate and unsafe referral to inpatient care include:
use of breastmilk substitutes for
replacement feeding, milk refusal); o signs of possible serious bacterial infection in infants less than 2
months of age
VI. any maternal-related or social issue o shock
needing more detailed assessment or o oxygen saturation <90%
intensive support (e.g., disability, o pneumonia (with chest indrawing; and/or fast breathing; and if
possible to measure, oxygen saturation <94%)
depression of the caregiver, absent o dehydration (including some or severe dehydration)
mother, adolescent mother, or other o severe persistent diarrhoea (diarrhoea for 14 days or more plus
adverse social circumstances). dehydration)
o very severe febrile illness – in a malaria zone or with a positive
rapid diagnostic test (RDT), this is treated as severe malaria
Medical problems needing mid or long-term follow-up care and with a
significant association with nutritional status necessitating in-depth assessment
o very severe febrile illness – where there is no risk of malaria or
could be a medical problem that has just been diagnosed where a decision with a negative RDT, this is treated as bacterial disease, e.g.
needs to be made about whether they would benefit from initial inpatient care meningitis, etc.
(for a period of intensive observation, initiating treatment, investigations not o severe complicated measles
available in an outpatient setting, etc.) before commencing ongoing outpatient o mastoiditis
follow-up. o severe anaemia (severe palmar pallor or as per age-associated
haemoglobin levels)
It could also be that a child with a known medical problem needing ongoing o severe side effects from antiretroviral therapy (for HIV) – skin
follow-up has deterioration that does not involve any of the danger signs or rash, difficulty breathing and severe abdominal pain, yellow
signs and symptoms of the acute medical problems but that still might need an eyes, fever, vomiting
in-depth assessment to decide whether referral to inpatient care is appropriate. o open or infected skin lesions associated with nutritional oedema
o other stand-alone ‘priority clinical signs’ not classified as
Part of this in-depth assessment should involve evaluating how the dangers signs: hypothermia (<35°C axillary or 35.5°C rectal) or
mother/caregiver is coping and able to support the psychosocial impact of high fever (≥38.5°C axillary or 39°C rectal)
this medical problem on the infant themselves and the family.
 • Carry out a feeding assessment with the mother/carer and infant to establish whether the
mother is breastfeeding effectively or providing replacement feeds appropriately. Set up the
mother and infant ideally in a supervised but separate area, and take 15 to 20 minutes to
observe the pair as the infant feeding.
o Feeding assessments should include physical examinations of the mother/carer and
infant to identify abnormalities/pathologies which could interfere with feeding, a
specific breastfeeding examination of positioning, attachment/latch, frequency, the
effectiveness of suckling/swallowing, and an examination of the carers and infant’s
behaviour and attitude during feeding.
• Assess any medical or social issue needing more detailed assessment or intensive support
for both the mother or carer and the infant. This could include adverse social issues like
violence in the family, poverty, and social exclusion. Maternal physical, mental, and general
well-being should also be assessed.

Which infants to refer to outpatient care

• no danger signs or any of the criteria needing inpatient admission

• no criteria needing in-depth assessment or when criteria are present, but an in-depth
assessment has been completed and determined that no inpatient admission is needed (e.g.
feeding problems that can be managed in outpatient care, diarrhoea with no dehydration,
respiratory infections with no signs of respiratory distress, malaria with no signs of severity).

Medical management
Infants should receive the same general medical care as older children, which includes:

• Triage and emergency treatment to stabilise vital organ function following the standard
approach set out in the WHO Emergency Triage Assessment and Treatment (ETAT)
guidelines.
• Promptly identifying and treating common complications that infants with SAM present with
hypothermia, hypoglycaemia, shock, dehydration, severe anaemia, eye signs of vitamin A
deficiency
• Giving all infants with SAM who are inpatients intravenous (IV) or intramuscular (IM)
antibiotics to treat possible infections and sepsis.
• Initiating feeding early and cautiously as part of emergency stabilisation. This is essential for
correcting electrolytes and micronutrient imbalances and restoring normal metabolic
function.

Nutrition management

Promotion of breastfeeding where possible and supporting mothers to breastfeed their

infants. If an infant is not breastfed, support should be given to the mother to re-lactate.

Provision of supplementary feeding is as follows:

• Supplementary suckling approaches should, where feasible, be prioritized for infants
with SAM
• Infants at risk of poor growth and development may also need supplementary milk.
This decision should be based on their medical and nutritional needs and physical
and mental health of the carer
• The Supplementary Suckling Technique (SST) is used to help improve milk flow and
re-establish breastfeeding at the same time as providing the extra nutrition needed.
 a. For infants with SAM but no oedema, expressed breast milk should be given and,
where this is not possible, commercial infant formula or F-75 or diluted F-100 may
be given, either alone or as the supplementary feed together with breast milk
To make diluted F-100, add water to the F-100 formula up to 1.5 liters instead of 1 litre.
Undiluted F-100 should not be given to infants who are clinically unstable or have oedema
because of high renal solute load and risk of hypernatraemic dehydration.
b. For infants with SAM and oedema, infant formula or F-75 should be given as a
supplement to breast milk.

If there is no realistic prospect of being breastfed, provide appropriate and adequate

replacement feeds, such as commercial (generic) infant formula, with relevant support to
enable safe preparation and use, including at home when discharged.

During transition and rehabilitation, the basic principles for older children apply with respect
to the calorie, nutrient targets, route, and frequency of feeding. Because the development of
SAM in infants commonly reflects suboptimal feeding practices, especially breastfeeding
practices, continue to prioritise establishing effective feeding, particularly exclusive
breastfeeding in both transition and rehabilitation phases.

As the quantity of breast milk supply begins to increase, the quantity of supplementary milk
can be decreased and, eventually, stopped entirely.

Assessment of the physical and mental health of mothers or carers should be promoted,
and relevant treatment or support provided to support effective feeding.

Important information for infants who are not breastfed.

• Provide commercial infant formula, diluted F-100 (or F-75 if oedema) feed according
to guidance for the three phases of treatment (Stabilisation, Transition,
Rehabilitation)
• Carers should be prepared for discharge of the infant on commercial infant formula
and receive nutrition counselling.

The importance of close monitoring during each stage of treatment must be emphasized:

• Monitor clinical signs including for danger signs (See Module 6)

• Record and review the total intake of feeds and number of breastfeeds per 24 hours
• Monitor the progress of the infant by daily weighing, using a scale graduated to
within 10–20 g

Play and stimulation are critical to growth, development, and recovery. Mothers are key to
the infant’s recovery. Encourage mothers to play, talk, sing, and make regular eye contact
with infants, and be responsive to their needs.

Criteria to transfer infants from inpatient to outpatient care.

i. There have been no danger signs for at least 48 hours prior to transfer time, and
ii. all acute medical problems are resolved, and
iii. nutritional oedema is resolving; and
iv. the infant has good appetite; and
v. documented weight gain for at least 2-3 days is satisfactory on either exclusive breastfeeding
or replacement feeding; and
 vi. all attempts have been made to refer the infants with medical problems needing mid or long-
term follow-up care and with a significant association with nutritional status to appropriate
care/support services and/or the limits of inpatient care have been reached; and
vii. the infant has been checked for immunizations and other routine interventions delivered or
plans made for follow-up; and
viii. the mothers/caregivers are linked with needed follow-up care and support (e.g. for any health,
mental health or social issues identified during assessment).

Outpatient care for infants under six months

• Infants with SAM and those that are not growing well, can be managed in outpatient
care if there are no medical complications, there are able to feed, and no other
medical or social issue needs intensive inpatient care.
• The aim is to achieve weight gain through establishing effective feeding, supporting
physical and mental health and well-being for mother/carer, supporting play and
stimulation, and linking the family to social protection or other available support
services.

The following interventions should be prioritised in outpatient care:

Counselling and support for optimal infant and young child feeding should be provided
based on general recommendations for feeding infants and young children, including for
low-birth-weight infants. The goal is to achieve effective feeding
Weight gain of the infant should be monitored weekly to observe changes, if the infant
does not gain weight or loses weight while the carer is receiving support for breastfeeding,
then they should be referred to inpatient care
Assessment of the physical and mental health status of carers should be promoted, and
relevant treatment or support provided to ensure maternal/carer physical and mental
health and well-being
Refer the mother/carer to social protection and safety net programs that address poverty,
social exclusion, domestic violence, and other social determinants of health as
appropriate
As infants recover, they need increasing emotional and physical stimulation through play.
Teach carers the importance of care stimulation, include how to play with infants. Refer
the pair to play programmes if available

Infants less than 6 months of age at risk of poor growth and development can have reduced
frequency of outpatient visits when they:

• are breastfeeding effectively or feeding well with replacement feeds, and

• there have been no danger signs for at least 48 hours prior to transfer time; and

Outpatients exit criteria

• Are breastfeeding effectively or feeding well with replacement feeds

• Have adequate weight gain.
• Have a weight-for-length >-2 z-score
• Carer is linked with community-based follow-up and support and social protection
services e.g. cash transfers (if available)
• Carer is provided with counselling for feeding and other aspects of care, including
play and stimulation.
Follow up until infants reach six months.

Infants are still considered vulnerable even after the acute problem that necessitated their
enrollment into care has been resolved. Therefore, regular follow-up at reduced frequency is
recommended until they reach six months of age. Programme managers and health workers
should determine the frequency of follow-up for these infants, depending on their contexts.

Infants should be assessed once they reach six months of age to determine if they need
ongoing follow-up or referral to services for infants six months of age and older. An infant at
six months or older who meets the anthropometric and clinical criteria of MAM or SAM
should be referred to the appropriate services for medical management (if needed), health
and nutrition education and counselling, and nutritional treatment for SAM.