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Referral and warning signs
When to refer
ALL infants <6m with SAM require referral to hospital for inpatient management initially.
Red flags
- Any General Danger Sign
- Hypothermia / Hypoglycaemia
- Ineffective feeding
- Significant weight loss
- Signs of sepsis
Signs and symptoms
- Meets SAM criteria (usually WFH/L < -3z +/- Oedema).
- Ineffective breastfeeding.
- Weight loss / Failure to gain weight.
- May have medical complications.
Risk factors
- Maternal factors (illness, malnutrition, mental health, poor BF technique).
- Infant factors (prematurity/LBW, illness, anomalies).
- Inappropriate feeding practices.
Diagnosis
Clinical assessment
- Assessment WFH/L Z-score, Oedema check, Breastfeeding assessment (attachment/suckling), Assess for complications.
Investigations
- Anthropometry.
- Clinical assessment.
- Assess mother's health/BF capacity.
Diagnostic criteria
Usually WFH/L < -3z +/- Oedema in infant <6m. Admission often needed.
Management
Non-pharmacological management
- Inpatient Admission initially.
- Re-establish Effective Breastfeeding (KEY GOAL): Intensive lactation support, Address maternal issues.
- If BF Not Possible/Sufficient: Use Expressed Breast Milk (EBM) via cup/NGT.
- If EBM Unavailable/Insufficient: Use Commercial Infant Formula. Last resort: Therapeutic Milk F-75 / Diluted F-100.
- Supplementary Suckling Technique (SNS).
- Warmth (KMC/skin-to-skin).
- Hygiene.
- Support Mother.
Pharmacological treatment
- Treat Infections: Parenteral antibiotics (Ampicillin + Gentamicin) per neonatal sepsis guidelines.
- Micronutrients: Via breastmilk/formula/therapeutic milk.
- Vitamin K (at birth).
- Treat complications (hypoglycaemia, hypothermia, dehydration - ReSoMal cautiously).
Monitoring
Monitor feeding effectiveness, intake, Weight gain (daily), Temp, Output, Clinical condition. Monitor mother/BF progress.
Discharge Criteria (to Outpatient/Community Follow-up)
- Complications resolved.
- Clinically well/alert.
- Effective feeding established.
- Weight gain >5g/kg/d x 3d.
- Oedema resolved.
- Caregiver confident, follow-up arranged.
- WFL >= -2 Z-score.
Complications
- High mortality risk (infection, hypothermia, hypoglycaemia).
- Feeding failure.
- Long-term growth/development impairment.
Prevention
- Support exclusive BF from birth.
- Good maternal nutrition.
- Early ID/management feeding difficulties.
- PMTCT.
Patient education
- (To Mother/Caregiver): Explanation of condition. Lactation support. Safe alternative feeding (cup). Warmth (KMC). Danger signs. Hygiene. Follow-up. Maternal self-care.
Uganda-specific notes
Relies on re-establishing EBF with support. KMC vital. Safe replacement feeding critical if needed. Address maternal factors.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 19, Section 19.2.3
- Integrated Management of Acute Malnutrition Guidelines, MOH Uganda
(Specific protocols for infants <6m)