Severe acute malnutrition triage — DTM&H MCQ

Correct answer: C — Refer for inpatient stabilisation

The correct answer is C, refer for inpatient stabilisation, because this child meets WHO criteria for complicated severe acute malnutrition (SAM). Bilateral pitting oedema alone defines SAM regardless of anthropometry, and a mid-upper arm circumference of 109 mm is well below the 115 mm severe cut-off, confirming the diagnosis. Critically, the child has failed the appetite test (poor appetite on test feeding), which is the key criterion WHO uses to separate children safe for outpatient therapeutic care from those who need inpatient stabilisation with F-75 therapeutic milk, careful rehydration and monitoring for complications such as hypoglycaemia, hypothermia and infection. Oedema plus failed appetite test together mandate admission because outpatient management in this state carries a high risk of refeeding complications and death. Why the other options are wrong: B. Give routine family diet at home: This ignores the diagnosis of SAM entirely; a standard family diet cannot correct severe malnutrition and gives no protection against the metabolic complications of oedematous malnutrition. E. Start intense exercise programme: Increasing energy expenditure in a catabolic, oedematous, anorexic child worsens muscle wasting and risks precipitating cardiovascular decompensation. D. Delay care until weight is repeated: Bilateral oedema and a failed appetite test are already diagnostic and mandate immediate action; delaying treatment to repeat weight measurement wastes time in a child at high mortality risk. A. Treat as mild undernutrition: The MUAC of 109 mm and bilateral oedema both place this child in the severe, not mild, category, so outpatient management for mild wasting is inadequate and unsafe. Key point: Bilateral oedema or a failed appetite test in a child with severe acute malnutrition means inpatient stabilisation is required, not outpatient therapeutic feeding.

Reference: World Health Organization. Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children, 2013 (basis for UK DTMH and tropical medicine teaching on SAM identification and inpatient admission criteria). https://www.who.int/publications/i/item/9789241506328