Paeds Cases · gastroenterology-hepatology-and-nutrition
Malnutrition: nutritional rehabilitation and monitoring — structured clinical encounter
Structured encounter testing the approach to a 16-month-old with severe acute malnutrition who refuses food: the anthropometric recognition of SAM, the complicated-versus-uncomplicated disposition decision, the WHO phased rehabilitation from F-75 stabilisation to F-100 catch-up, the prevention of refeeding syndrome through phosphate, potassium and magnesium monitoring and thiamine, the immediate threats of hypoglycaemia, hypothermia and infection, and the discharge and relapse-prevention plan.
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Station 1 — recognition and disposition
Asked for my assessment, I explain that a weight-for-height z-score below minus three together with a MUAC below 115 mm defines severe acute malnutrition, and that either criterion alone is sufficient. The decisive clinical finding is his refusal of food, which demonstrates loss of appetite and places him in the complicated SAM group, so he needs inpatient stabilisation rather than outpatient ready-to-use therapeutic food. I would check a bedside glucose, assess for hypothermia and infection, and admit him. [1]
References6ShowHide
- [1]Lenters LM; Wazny K; Webb P; et al Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health, 2013.PMID 24564235
- [3]Mogase T; Van Onselen A; Rodriguez-Sanchez N; et al The Identification and Management of Refeeding Syndrome in Inpatient Severely Acutely Malnourished Children Aged 6 to 59 Months in Sub-Saharan African Countries: A Systematic Review and Meta-Analysis. Children (Basel), 2025.PMID 41007088
- [6]Namusoke H; Hother AL; Rytter MJ; et al Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda. Am J Clin Nutr, 2016.PMID 26739034
- [8]Muzeyi W; Ochieng Andra T; Oriokot L; et al High Incidence of Refeeding Syndrome during the Transition from F75 to Ready-to-Use Therapeutic Feeds among Children 6 to 59 Months with Severe Acute Malnutrition at the Pediatric Nutritional Unit of Mulago Hospital. J Nutr Metab, 2024.PMID 39372094
- [4]Corsello A; Trovato CM; Dipasquale V; et al Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review. J Pediatr Gastroenterol Nutr, 2023.PMID 37705405
- [11]Rytter MJ; Babirekere-Iriso E; Namusoke H; et al Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study. Am J Clin Nutr, 2017.PMID 28031190