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PE10.1-5 | Severe Acute Malnutrition — SDL Guide (Part 3)
Counselling Parents and Community-Based Rehabilitation
Counselling the parents of a child with SAM is a clinical skill that requires empathy, clarity, and practical guidance. Parents often carry guilt about their child's condition; the counselling encounter must address this while delivering actionable information about cause, home management, danger signs, and the community follow-up pathway.
The structured counselling encounter for SAM should cover five domains. First, explaining the cause without blame: frame SAM as a combination of dietary insufficiency, frequent infections, and poverty-related factors — not parental neglect. Use simple language: 'Your child's body did not get enough food at the right time to grow properly. This is a problem we can correct together, but it will take time.' Second, explaining the treatment plan: describe the NRC admission, the feeding protocol (frequent small feeds, therapeutic food), and the expected timeline (stabilisation 1-2 weeks, rehabilitation 4-6 weeks). Third, teaching home feeding techniques for post-discharge: energy-enriched foods (add a teaspoon of oil/ghee to every meal), protein sources (dal, egg, dairy), meal frequency (5-6 times per day), continued breastfeeding if still breastfeeding, and how to maintain RUTF if provided for home use. Fourth, danger signs requiring immediate return: unconsciousness or extreme lethargy, refusal to feed for more than 4 hours, high fever, fast breathing, extensive skin peeling, convulsions, or not gaining weight after 2 weeks of home treatment. Fifth, outlining the follow-up schedule: NRC discharge criteria (WHZ > −2 SD, no oedema, good appetite, medically stable) and community follow-up with the ASHA/AWW worker weekly for at least 4-6 weeks.
The National Health Mission NRC programme in India provides 14-day inpatient stays with daily caregiver education sessions, nutritional counselling, and graduated feeding. Post-discharge, the child is enrolled in the community supplementary nutrition programme via Anganwadi Centres (AWC). Understanding this pathway allows the hospital clinician to hand over care effectively and follow the child's recovery trajectory.
SELF-CHECK
A 2-year-old with severe marasmus is admitted to the NRC. On day 1 he is lethargic and his axillary temperature is 34.8°C. He was found in a cold room. What is the FIRST priority action?
A. Start F-100 at 200 mL/kg/day to reverse the starvation rapidly
B. Give standard ORS 20 mL/kg for dehydration
C. Initiate warming with kangaroo care, check blood glucose, feed 10% glucose if hypoglycaemic, and start F-75 feeds every 2 hours
D. Give 50% dextrose IV bolus for presumed hypoglycaemia
Reveal Answer
Answer: C. Initiate warming with kangaroo care, check blood glucose, feed 10% glucose if hypoglycaemic, and start F-75 feeds every 2 hours
This child has hypothermia (axillary <35.5°C), which is a SAM emergency. The first priority is warming with kangaroo care and a warm room. Simultaneously, blood glucose must be checked and if <3 mmol/L, 10% dextrose 5 mL/kg IV or 10% glucose 50 mL by NGT must be given — NOT 50% dextrose (which causes osmotic injury). F-75 feeds every 2-3 hours are then initiated for stabilisation — NOT F-100, which would cause refeeding syndrome. Standard ORS is contraindicated in SAM (use ReSoMal instead). The two-phase principle: F-75 in stabilisation, F-100 only after oedema resolves and appetite returns.
Self-Assessment
Review your mastery of the most clinically critical points from this module. These are the facts that directly affect patient survival. Can you state the three WHO diagnostic criteria for SAM without reference? Can you list the 10 steps of SAM management from memory in sequence and divide them into stabilisation and rehabilitation phases? Can you distinguish F-75 from F-100 by energy density, phase, and volume? Can you state the correct treatment for hypoglycaemia in a conscious and unconscious child with SAM — including the concentration of dextrose to use and the volume? Can you explain why standard ORS is contraindicated and what to use instead? Can you describe the appetite test procedure and its clinical significance? Can you counsel a parent whose child has been discharged from an NRC about home feeding and danger signs?
Key numbers to have memorised:
• SAM MUAC threshold: <11.5 cm | MAM MUAC: 11.5-12.5 cm
• SAM WHZ: < −3 SD | MAM WHZ: −2 to −3 SD
• F-75 energy density: 75 kcal/100 mL | F-100: 100 kcal/100 mL | RUTF: 500 kcal/92g sachet
• Hypoglycaemia in SAM: blood glucose <3 mmol/L (54 mg/dL) → 10% dextrose 5 mL/kg IV
• ReSoMal sodium: 45 mmol/L (vs standard ORS 75 mmol/L)
• F-75 volume (stabilisation): 100-130 mL/kg/day; F-100 (rehabilitation): 150-220 mL/kg/day