Complicated severe acute malnutrition — DTM&H MCQ

Correct answer: E — Refer for inpatient stabilisation of complicated severe acute malnutrition

The correct answer is E, refer for inpatient stabilisation of complicated severe acute malnutrition. This child has severe acute malnutrition (MUAC well below the 11.5 cm cut-off, plus bilateral pitting oedema confirming kwashiorkor-type SAM) and has failed the appetite test with poor appetite. WHO guidance is explicit that children with poor appetite (failed appetite test), severe oedema, IMCI danger signs, or other medical complications must be treated as inpatients rather than in outpatient therapeutic feeding programmes, because they are at high risk of sudden death from hypoglycaemia, hypothermia, infection, and electrolyte derangement during refeeding. The absence of an inpatient bed at the nearest clinic does not remove this requirement; the child must be referred onward to the stabilisation centre, even though it is two hours away, with attention to keeping them warm, treating hypoglycaemia if present, and arranging safe transport. Why the other options are wrong: B. Give routine outpatient ready-to-use therapeutic food: outpatient RUTF protocols are reserved for uncomplicated SAM with a passed appetite test and no danger signs; this child has failed the appetite test. C. Provide deworming and review in 1 month: deworming is a routine outpatient adjunct, not appropriate when a child has complicated SAM needing urgent stabilisation; a one month delay risks death. D. Start high-protein family diet at home: unmonitored high-protein feeding in SAM with oedema risks refeeding syndrome and does not address the need for controlled, low-osmolarity F75-based stabilisation. A. Give oral antibiotics without nutrition care: antibiotics alone ignore the metabolic instability of complicated SAM and omit the structured feeding and monitoring that prevents death in the stabilisation phase. Key point: Failed appetite test or severe oedema in a child with SAM mandates inpatient stabilisation regardless of bed availability at the nearest facility; referral must proceed to the next appropriate centre.

Reference: WHO, Guideline: Updates on the management of severe acute malnutrition in infants and children, 2013 (children with poor appetite/failed appetite test, severe oedema, or IMCI danger signs should be treated as inpatients) - https://www.ncbi.nlm.nih.gov/books/NBK190317/