Management of moderate acute malnutrition in children in resource-limited settings

INTRODUCTION — Undernutrition is a leading cause of morbidity and mortality in children throughout resource-limited settings, particularly in tropical regions where children frequently suffer from a combination of prenatal malnutrition, pervasive poverty, food insecurity, and repeated bouts of vector-borne and fecal-oral infectious diseases. Chronic undernutrition, manifested as underweight and stunting, may begin in the prenatal period and continue over the lifetime of a child. This can lead to significant developmental and cognitive deficits [1] and significantly increases the risk of death [2].

Although the evidence base for the diagnosis, management, and prognosis for children with moderate acute malnutrition (MAM) is overall less well delineated compared with severe acute malnutrition (SAM) [3], there have been significant advances in this domain sufficient to develop general diagnosis and management recommendations [4,5]. Among these advances has been the development of Integrated Management of Acute Malnutrition approaches that screen and provide care for children with both MAM and SAM within the same setting and often using similar protocols [6].

Other aspects of clinical management of malnutrition in resource-limited settings are covered in the following topic reviews:

●(See "Malnutrition in children in resource-limited settings: Clinical assessment".)

●(See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings".)

●(See "Management of complicated severe acute malnutrition in children in resource-limited settings".)

●(See "Micronutrient deficiencies associated with protein-energy malnutrition in children".)

CLASSIFICATION OF MALNUTRITION

●Acute versus chronic malnutrition – Acute malnutrition represents undernutrition that occurs over a relatively short period of time, frequently superimposed on chronic micronutrient and macronutrient deficiencies [7]. Chronic malnutrition is characterized by faltering linear growth (stunting) and head circumference and/or poor weight gain. This is a somewhat arbitrary distinction made to simplify and facilitate treatments in the field. Most children classified as acutely malnourished also have some degree of chronic malnutrition. (See "Malnutrition in children in resource-limited settings: Clinical assessment".)

●Severity of acute malnutrition – Children with acute malnutrition may be categorized as having moderate acute malnutrition (MAM) or severe acute malnutrition (SAM) [8] (table 1). These categories are based on weight-for-height or mid-upper arm circumference (MUAC), both of which reflect acute weight loss. It should be emphasized, however, that MAM and SAM are simply useful diagnostic aids that help identify undernourished children who are at increased risk for short-term morbidity and mortality, rather than distinct disease processes [9]. (See 'Diagnosis' below.)

The World Health Organization (WHO) has proposed changes in nomenclature, such that SAM will be termed "severe wasting and/or nutritional edema" [10]. MAM will be termed "moderate wasting." Pending widespread adoption of this terminology, we will continue to use the traditional terms, SAM and MAM, for simplicity and consistency with the historical literature.

EPIDEMIOLOGY

●Prevalence of MAM – Worldwide in 2019, approximately 4.8 percent of children under five years of age were estimated to have MAM, a total of 32.7 million children [11]. Nearly all of these children (32.0 million) live in places classified by the United Nations Children's Fund as "developing regions." Given the very large population and limited resources in many countries in South Asia, a majority of children affected by MAM (17.4 million) live in that region. Many children with MAM have underlying chronic malnutrition, manifested as stunted linear growth. (See "Malnutrition in children in resource-limited settings: Clinical assessment", section on 'Epidemiology'.)

●Associated risks – In the short term, children 6 to 59 months of age with MAM have a mortality risk approximately three times higher than children without wasting. For children with both wasting and stunting, the risk of death is 12-fold higher compared with those without wasting or stunting, a mortality rate similar to children with severe acute malnutrition (SAM) [7,12]. In the medium term, children with MAM have a high risk of further deterioration and progression to SAM, which carries a nearly 10-fold risk of death compared with children without acute wasting [13]. In the long term, children who do recover from MAM are at high risk of relapse [14-16], faltering growth [17], and cognitive deficits [18]. Much of this risk appears to stem from a significant degree of acquired immunodeficiency (at barrier, humoral, and cell-mediated levels), which likely persists even after recovery to healthy weight and height [19]. For these reasons, it is important to proactively screen for and treat MAM whenever resources are available.

EVALUATION — Wherever possible, vulnerable children in resource-limited settings should be screened on a regular basis for acute malnutrition as part of routine well-child care at the community or village level. For example, monitoring of growth should be performed at periodic clinics for young children ("under-five" clinics), in conjunction with other routine preventive health care (immunizations, deworming, vitamin A supplementation, etc).

The identification of acute malnutrition in children is based on straightforward anthropometry and does not require any type of laboratory testing or imaging studies. Ideally, anthropometry should be performed whenever a child presents to a medical facility or is visited by a community health worker for evaluation of any illness. Children with acute malnutrition often have concomitant micronutrient deficiencies, but, in general, modern supplementary food products used to treat MAM have been designed to compensate for these expected deficiencies. (See "Micronutrient deficiencies associated with protein-energy malnutrition in children".)

Anthropometry — Systematic anthropometry to monitor for malnutrition includes accurate assessment of the following parameters [20] (see "Malnutrition in children in resource-limited settings: Clinical assessment"):

●Height, ideally using a rigid length board accurate to at least the nearest 0.5 cm (if not better) (figure 1 and figure 2)

●Weight, ideally measured naked with a digital scale accurate to at least the nearest 0.1 kg (if not better)

●Mid-upper arm circumference (MUAC), measured using a flexible paper or plastic tape accurate to the nearest 0.1 cm

●Assessment for bilateral pitting edema of the feet

These parameters are then used to make the diagnosis of MAM or severe acute malnutrition (SAM) (algorithm 1).

Diagnosis

Children 6 to 59 months of age — The World Health Organization defines MAM in children between 6 and 59 months of age as:

●MUAC 115 to 124 mm, or

●Weight-for-height Z-score (WHZ) -2 to -3, and

●No bilateral pitting edema

Definitions of different degrees of acute and chronic malnutrition are outlined in the table (table 1). MUAC has many advantages over WHZ [21], including simplicity [22], without the need for cumbersome equipment, and the ability to identify a population of moderately malnourished children at higher risk for death [23]. MUAC can be used for children six months of age or older, regardless of length or other anthropometric characteristics [24]. The presence of pitting edema (in a clinical setting where it is likely to be caused by malnutrition) warrants a diagnosis of the edematous form of SAM (also called "kwashiorkor"), regardless of other anthropometric variables.

Links to WHZ charts and calculators, and the evidence underlying these definitions, are provided separately. (See "Malnutrition in children in resource-limited settings: Clinical assessment".)

Other age groups — For infants under six months of age, there is no consensus on definitions for malnutrition. For this age group, it is reasonable to define MAM as weight-for-age Z-score or WHZ between two and three standard deviations below the median [25]. For children over 59 months of age, MAM may be defined as a body mass index-for-age Z-score between two and three standard deviations below the median. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Classification by age and severity'.)

Triage — Children who are ill appearing, with signs and symptoms of altered mental status (including lethargy or listlessness), dehydration, respiratory distress, hypoxia, or hypothermia, should also be evaluated for any acute life-threatening conditions, including sepsis, pneumonia, or diarrheal diseases. These occur with greater frequency, and have a higher risk of progression, in malnourished children compared with their well-nourished counterparts living in similar conditions. Children with any such conditions will likely need to be referred for inpatient management where the associated condition can be addressed urgently, followed by nutritional rehabilitation once the child's condition has stabilized. (See "Management of complicated severe acute malnutrition in children in resource-limited settings".)

Indications for community-based management — Most children with MAM can and should be managed in their home as part of a community-based supplementary feeding program if such a program is available in the area. These programs have proven to be cost-effective for the management of children with MAM [26]. If a supplementary feeding program is not available, then some of these patients should be hospitalized for nutritional rehabilitation. Specifically, children are eligible for a supplementary feeding program if the child:

●Is at least six months old. Protocols are established primarily for those 6 through 59 months of age. For older children, it is reasonable to use the same protocols as an extension of established practice. However, for these older children, it is particularly important to do a thorough evaluation for underlying diseases that may have triggered the malnutrition, such as HIV, tuberculosis, or malignancy, since isolated MAM is less common in this age group.

●Demonstrates an appropriate appetite for the supplementary food to be used in the supplementary feeding program.

●Does not have any complications or acute life-threatening conditions that require urgent medical intervention.

●If infected with HIV, effective HIV treatment has been initiated or the child has been appropriately referred for HIV services with close follow-up. Given the high rate of HIV infection among malnourished children [27], it is further advisable that all children with acute malnutrition be tested for HIV in high-burden areas, as long as local culture and stigma do not preclude this.

●Has a reliable and engaged caregiver who can feed the child at home and bring the child back to the supplementary feeding program center for regular follow-up.

Indications for inpatient care — A small minority of children with MAM will require inpatient care. Indications include:

●Medical problems – Concomitant acute conditions that require inpatient care, such as sepsis, diarrhea with dehydration, or focal infection. Chronic conditions such as HIV or tuberculosis also may require hospitalization for initial stabilization and treatment.

●Social or environmental barriers – Difficulties with home care or follow-up, or lack of a community-based supplementary feeding program.

●MAM identified in an inpatient – Many children who are hospitalized for non-nutritional medical or surgical concerns may be identified as having MAM and should begin nutritional rehabilitation while still hospitalized whenever possible.

Infants under six months of age — Infants younger than six months of age with MAM or older infants who live some distance from the facility generally will benefit from hospitalization at a facility where an intensive effort to reestablish exclusive breastfeeding can be attempted. The care for infants under six months with MAM is essentially identical to those with SAM. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Infants <6 months'.)

In resource-constrained settings, it may not be possible to admit all young infants with MAM, because this can place a tremendous burden on hospitals and staff. In this case, these infants may be managed as outpatients if they can demonstrate weight gain with some combination of breastfeeding and supplementary feeds of commercial infant formula (ideally, exclusive breastfeeding) before hospital discharge and if close, frequent follow-up can be assured.

COMMUNITY-BASED MANAGEMENT OF MODERATE ACUTE MALNUTRITION — Most children with MAM can be treated as outpatients in a supplementary feeding program [4]. These programs are effective for the vast majority of children with MAM and often work in parallel with community-based programs for severe acute malnutrition (SAM). Supplementary feeding programs for MAM also offer services to a much larger population and at lower costs compared with inpatient care [26]. (See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings", section on 'Community-based management of acute malnutrition'.)

No universally accepted protocol exists for the management of MAM either in the community or inpatient setting [28], but general principles focus on nutrition counselling and education in addition to supplementary feeding, as outlined below. While many children with MAM may eventually recover spontaneously, this specialized community-based care clearly improves rates of nutritional recovery and decreases mortality [29].

Nutrition counselling and education — This component of care seeks to educate caregivers about the importance of a healthy diet, while assuming that sufficient quality and quantity of appropriate foods are available in the community [30]. However, the effectiveness of this approach is limited by this very assumption because lack of access to diverse and sufficient food is often the primary reason that the child has become malnourished. This is particularly true in the setting of food shortages during the "hungry" or "lean" seasons or in populations impoverished or displaced by natural disasters, war, and human conflict (eg, ethnic "cleansing,") resulting in a refugee crisis [31]. Nevertheless, in areas where supplementary feeding programs and inpatient care for acute malnutrition are not available, counselling and education alone is a reasonable option, although it is generally not as effective as supplementary feeding [32,33]. Counseling regarding family planning and contraception may also help to reduce the risk of relapse in this child and their siblings.

Supplementary feeding — Specially formulated food products form the backbone of therapy for MAM. A wide variety of products are available; these are given to the family in a specified ration, with follow-up at the health center or through visits to the household by a community health worker [34,35]. Follow-up visits continue at periodic intervals to reassess clinical status and progress until anthropometric recovery criteria are met.

Choice of supplementary food — Community-based feeding programs may distribute different types of foods that are specifically designed to meet the needs of malnourished children:

●Ready-to-use therapeutic food (RUTF) – This therapeutic food is designed to meet all of the nutritional needs of a child with SAM, but can also be used for children with MAM as a supplement to their usual diet. It is well suited to outpatient management because it does not require refrigeration and resists spoilage. The most common form is based on peanut paste, supplemented with a vitamin and mineral mixture, and provides 500 kcal per 92-gram sachet [8]. (See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings", section on 'Ready-to-use therapeutic food'.)

●Ready-to-use supplementary food (RUSF) – This is a lipid-nutrient spread similar to RUTF, designed to provide supplemental energy and micronutrients to children with MAM who are also eating other foods. Like RUTF, RUSF is energy-dense, has a long shelf life, is resistant to bacterial contamination, and does not require any preparation by the end user [8]. It has been shown to be effective in the treatment of MAM in both operational [36] and research [37-46] contexts and is accepted well by moderately malnourished children and their caregivers [47-50]. The obvious limitation of RUSF is its relatively high cost, but early results generally demonstrated that it has some small benefits over fortified flours in terms of nutritional recovery [41] and in decreasing the risk of relapse in the months after nutritional recovery [14,15].

The RUSF formulation is based upon the RUTF recipe but with different macronutrient sources as a cost-cutting measure [51-53]. This is a practical solution because of the large number of children with MAM and relatively lower severity of malnutrition compared with those with SAM. The main change is to decrease or eliminate the amount of animal-source protein (ie, milk powder) in the RUSF formulation compared with the RUTF recipe [37,53], sometimes replacing the milk powder with whey protein and/or whey powder [16,54]. The most commonly used commercial RUSF formulation is Plumpy'Sup, which provides 500 kcal per 100-gram sachet [54]. An attempt at modifying this formula with a lower-cost formulation in Ghana proved slightly less effective in children with both MAM and SAM [55].

●Fortified flours – These are flours consisting of various formulations of corn (maize), corn-soy blends, or wheat-soy blends fortified with milk, oil, sugar, and micronutrient mixtures [51]. These products have evolved over the last several decades to optimize fat, protein, and micronutrient content, as well as to lower antinutrients such as phytates, while improving overall energy density. The more recent iteration of these fortified blended flours was developed by the United Nations World Food Programme and is called Super Cereal Plus [56]. This product provides approximately 400 kcal/100 g. Compared with RUSF or RUTF, fortified flours have the disadvantage of requiring cooking (which includes having cooking vessels and instruments, firewood or other fuel source, clean water, etc) multiple times per day. Additionally, they are at higher risk of contamination and have lower energy density, so that larger volumes must be consumed to meet nutritional goals. Nevertheless, their similarity to common local weaning foods may increase their acceptance by young children.

RUTF, RUSF, and most fortified flours include the complete World Health Organization vitamin and mineral mix (table 2 and table 3). Providing additional micronutrient supplementation beyond these is generally unnecessary. In particular, children who are eating these supplementary foods do not require additional zinc for the treatment of diarrhea.

Having separate nutritional products for children with SAM (RUTF) and children with MAM (RUSF or a fortified blended flour) has proven to be a logistic challenge for field programs that manage both conditions. Having separate clinics, staff, and supply chains for the two conditions is increasingly being recognized as inefficient and counterproductive. As a result, some programs have found it cost-effective to use RUTF for children with both SAM and MAM, despite the higher cost of RUTF. Use of only one product simplifies staff training and supply chain management and improves access to care for families of children with either SAM or MAM at the same site [57]. The clinical efficacy and cost effectiveness of this combined approach has been reported in at least three trials [6,58,59] and has been identified by the United Nations as an important component of the future approach to child wasting [60]. This movement, known as the Integrated Management of Acute Malnutrition, provides for a continuum of care for children with MAM and SAM, both as outpatients and inpatients.

Supplementary feeding regimens — The amount of supplementary feeding to provide to children with MAM is not included in consensus guidelines, and several different strategies are used. In order to achieve a weight gain of approximately 5 g/kg/day and to achieve recovery in approximately 30 days, it is estimated that children with MAM need approximately 82 kcal/kg/day of supplementation [61]. For practical reasons, some supplementary feeding program sites provide a fixed dose of supplementation to each child, typically 500 kcal/day; this dose is convenient because one typical sachet of RUSF or RUTF contains 500 kcal. This fixed-dose regimen of 500 kcal/day has been shown to provide sufficient supplemental caloric intake for 95 percent of children with MAM across five countries, assuming that the home diet provides 50 percent of the child's daily calories [62]. If resources (both human and material) are available, weight-based dosing of supplementation, typically 50 to 100 kcal/kg/day, can be used to more accurately individualize therapy based on the expected availability and contribution of traditional home foods to the diet, although there may not be much benefit of this extra effort.

Another approach used by some programs that rely on fortified flour has been to provide a larger fixed allotment of the flour to the entire family of children with MAM, rather than the allotment needed for the malnourished child alone. This strategy recognizes that the flour is likely to be shared within the family in any case. There is no clear evidence that any particular approach is preferable over the others. However, supplementary feeding programs with limited resources may prefer focused supplementation specifically only for the malnourished child rather than for the entire family because recovery rates are quite similar with each of these approaches.

Unlike in the treatment of SAM, the supplementary feeding provided as part of the care for MAM is not intended to be a complete diet, but rather a supplement to the child's usual diet (see "Management of uncomplicated severe acute malnutrition in children in resource-limited settings"). Ideally, nutritional counselling and education will take place simultaneously with strategies to improve the home diet.

Counselling of caregivers — To ensure successful rehabilitation of a child with MAM, the parent or caregiver in the home should have thorough counselling and extensive support throughout the process. Important messages to include in the counselling are:

●Supplementary feeding should be provided in frequent, small feedings throughout the day, as driven by the child's appetite (on-demand feeding).

●The supplementary food is a medical treatment for a specific medical condition (MAM). Therefore, like a medication, it should be carefully given as directed, and should not be shared with others.

●The caregiver should continue to offer breast milk and other nutritious foods to the child in addition to the supplementary food. These other foods can be provided at the same meal times as the supplementary food, or they can be saved for the end of the day after the daily allotment of supplementary food has been completed. If the child is not hungry for other foods beyond the supplementary food, they will likely have a more difficult time recovering. If this occurs, the caregiver should be encouraged to bring this situation to the attention of the supplementary feeding program's staff.

●The child's appetite may wax and wane over the course of therapy.

●If the child finishes the complete allotment of supplementary food prior to the next scheduled visit, then the child can be given a balanced local diet until their next visit.

●The caregiver should ensure that the child and other household members use clean water, practice good hand hygiene, and limit the child's ingestion of dirt and contaminated materials during therapy and beyond.

Caregivers of malnourished children are often under significant stress and may feel depressed about their child's condition [63-66]. They should be provided with frequent, compassionate encouragement and emotional support during the several weeks of intensive feeding and care they must provide their child.

Antibiotics — We do not recommend routine empiric antibiotic treatment in the management of MAM. Instead, antibiotics should be prescribed only to children with signs and symptoms of an acute or chronic infection, and should be directed at their specific illness in a manner consistent with that provided to nonmalnourished children in the same clinical setting.

While universal antibiotic therapy in addition to nutritional therapy has been shown effective and important in improving recovery and decreasing mortality among children with SAM [67-69], such trials have not been conducted among children with MAM. Moreover, routine distribution of antibiotics to the large population of children with MAM may have some short-term benefits but likely induces antibiotic resistance [70-72] and would also be costly. Thus, routine distribution of antibiotics is only recommended for highly selected populations that meet specific criteria, as outlined in a guideline from the World Health Organization [73]. (See "Resistance of Streptococcus pneumoniae to the macrolides, azalides, and lincosamides", section on 'Prevalence of resistance'.)

Follow-up and monitoring — Children with MAM should be followed closely because they have a small but real risk of clinical decompensation or further progression to SAM and death. At the time of enrollment in the supplementary feeding program, children should be provided with a sufficient amount of food to last until the next follow-up visit, which is typically scheduled every one to two weeks.

At each follow-up visit, anthropometric measurements should be performed and the caregiver asked to report on the child's appetite and supplementary food intake. The child is assessed for concomitant medical conditions (eg, fever, diarrhea, respiratory distress). The observations should be documented in a longitudinal record to monitor the response to therapy. Children who are losing weight or who are not making steady progress over two to four weeks should have a careful clinical and social assessment to identify confounding illnesses and any other barriers to recovery. Children whose anthropometry indicates that they have deteriorated to SAM (ie, weight-for-height Z-score [WHZ] has fallen to less than -3, and/or mid-upper arm circumference [MUAC] has fallen to less than 11.5 cm, and/or edema has developed) should receive more aggressive treatment. (See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings", section on 'Community-based management of acute malnutrition'.)

Children who have lost their appetite for the supplementary food and/or who have developed other medical complications may need to be admitted to the hospital for care. (See 'Inpatient management of moderate acute malnutrition' below.)

Discharge criteria — Children with MAM should receive supplementary feeding and monitoring until they no longer meet anthropometric criteria for the condition. In general, the anthropometric criterion used for discharge should be the one that was used for admission to the treatment program: children who were diagnosed as having MAM based upon a WHZ of less than -2 should continue supplementary feeding until they achieve a WHZ of at least -2. Similarly, those who were enrolled with a MUAC of 11.5 to 12.4 cm should continue until they achieve a MUAC of 12.5 cm (table 4) [74].

In some supplementary feeding programs with very limited clinical staff, it is not practical to have frequent follow-up visits. In this case, the program may plan a fixed duration of supplemental feeding (generally 8 to 12 weeks) at the time of enrollment. The supplementary food is provided (either all at once or in periodic allotments) to last the planned duration without a requirement for repeat clinical assessments and anthropometry. While this approach has the advantage of decreasing the burden on supplementary feeding program staff, the disadvantage is that children undergoing treatment do not receive as many clinical assessments to ensure that they are improving and do not have the opportunity to receive as much counselling about optimal diets and other important health education.

Failure to respond — Most children with MAM recover within six to eight weeks of starting supplementation, if not sooner. There is no consensus on how to optimally manage children with MAM who fail to achieve nutritional recovery within 8 to 12 weeks of treatment in a supplementary feeding program. The causes of failure to respond in this context may be biologic (eg, undiagnosed HIV infection) or social (eg, food insecurity in the household leading to inadequate intake due to sharing of the supplementary food with others in the household or no additional food provided beyond the supplementary food). If human and logistic resources permit, the supplementary feeding program should assess the reason(s) for failure to respond and address them as needed. This often necessitates visits to the child's home to try to understand the home environment better and to observe feedings. In some programs, this may include daily visits to the home by a community health worker.

The possibility of HIV and tuberculosis should always be considered in the case of any malnourished child, and especially for those who do not improve or have difficulty gaining weight despite optimal nutrition therapy. We recommend a low threshold for testing and treatment for both of these infections according to usual local practice, both at the initial presentation with MAM, and for children who fail to respond to treatment. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Other medications and immunizations' and "Tuberculosis infection (latent tuberculosis) in children".)

If the specific cause of the treatment failure cannot be identified and addressed, our practice has been to then treat children as if they had SAM. Specifically, after failure to achieve anthropometric discharge criteria after 12 weeks, children who remain with MAM are treated with RUTF at a dose of 150 to 200 kcal/kg/day (or 1000 kcal/day for simpler dosing) as their exclusive diet (see "Management of uncomplicated severe acute malnutrition in children in resource-limited settings"). Even in a well-functioning supplemental feeding program with adequate staffing, approximately 5 percent of children may persist with MAM at the end of 12 weeks.

INPATIENT MANAGEMENT OF MODERATE ACUTE MALNUTRITION — The overwhelming majority of children with MAM have no medical complications and can be effectively managed as outpatients. However, a small percentage have additional health issues that would benefit from a course of hospitalization. Similarly, children who are admitted to the hospital for primarily non-nutritional reasons often have concomitant MAM [75], and thus a proactive approach should be taken for screening and treatment of all hospitalized children in resource-limited settings.

Our approach to triage and management of inpatients with MAM is outlined in the algorithm (algorithm 2). As with community-based care for MAM, this is not an area where universally accepted protocols exist. We suggest a management strategy that is a hybrid of the outpatient care for MAM along with the inpatient care for severe acute malnutrition (SAM). (See "Management of complicated severe acute malnutrition in children in resource-limited settings".)

Clinical stabilization — Some children with MAM are identified when they present with acute life-threatening conditions such as sepsis, diarrhea with severe dehydration, pneumonia, or other focal infections. Suggestive symptoms include ill appearance, poor appetite, listlessness, apnea or respiratory distress, hypothermia (body temperature <35.5°C [95°F]). If any of these clinical signs are present, glucose levels should be checked to evaluate for hypoglycemia. Evaluation and management of these conditions is similar to that for a child with SAM. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Initial stabilization phase'.)

If any of these medical conditions is present, the first step is to stabilize the child and initiate treatment. Nutritional rehabilitation can then begin soon after these issues are addressed.

Nutritional supplementation — If a hospitalized child with MAM demonstrates a sufficient appetite, we recommend supplementary feeding with the same type of foods that would be used in outpatient care in an outpatient supplementary feeding program (ready-to-use therapeutic food [RUTF], ready-to-use supplementary food [RUSF], or fortified blended flour) and at the same doses (either one 500-kcal sachet per day or 50 to 100 kcal/kg/day) (algorithm 2) (see 'Supplementary feeding' above). One way to assess appetite is to offer supplementary food (RUTF, RUSF, or a preparation of fortified blended flour) in a supervised, calm setting. The child passes the test if they consume approximately 30 grams of the supplementary food without vomiting or significant distress. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Ready-to-use therapeutic food appetite test'.)

Breastfeeding should continue and be encouraged throughout this period of supplementation. Additional micronutrient and vitamin supplementation is generally not needed if the supplemental food used contains the complete set of micronutrients recommended.

If the child does not have a good appetite for the supplementary food, or in cases where specially designed supplementary foods are not available, it is reasonable to use the cow milk-based formulas that are designed for inpatient care of children with complicated SAM, known as F-75 and F-100 (table 5). If a child has significant diarrhea at admission or is so ill as to have anorexia, then it may be more prudent to start with F-75 formula instead of F-100. Once the child's diarrhea and/or appetite improves, the child can be advanced to F-100. The protocol for feeding with these formulas is similar to that for children with complicated SAM, except that children with MAM may require only supplemental quantities of these feeds (500 kcal/day or 50 to 100 kcal/kg/day) if they are also taking breast milk or other foods. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'F-75 and F-100 formula diets' and "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Feeding advancement'.)

Transfer to outpatient care — Children with MAM who are treated as inpatients should be transferred to outpatient care as soon as feasible. Criteria for discharge to a supplementary feeding program include resolution of any acute medical complications, good appetite for supplementary food, adequate weight gain, and that the family has been educated about nutritional care for the child and is comfortable caring for the child at home.

Where a fully functioning supplementary feeding program is not available, care should be continued in the inpatient setting until all anthropometric discharge criteria are achieved.

Failure to respond — For children with MAM who fail to respond to inpatient treatment, the approach is similar to that for SAM, including a careful evaluation for causes of treatment failure, and intensification of nutritional therapy (see "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Failure to respond'). For nutrition therapy, our approach is to begin treating these as if they had SAM, with therapeutic foods (F-100 or RUTF) at a dose of 150 to 200 kcal/kg/day as their exclusive diet. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Initial nutrition'.)

Cognitive and family rehabilitation — Children with MAM probably suffer delayed neurocognitive development, although this is still an early area of investigation, especially relative to children with SAM. For practical purposes, the same principles of rehabilitation in this regard as would apply to children with SAM can be applied to children with MAM as well. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Cognitive and family rehabilitation'.)

RELAPSE — Children who recover from MAM remain at high risk of relapse in the months to year following recovery [14]. The risk of relapse ranges from 30 to 50 percent within one year in different reports, depending on the population, duration of the feeding intervention, and follow-up support [14,15,76]. This is because they return to the same high-risk environments wherein they initially developed MAM, generally with continued poverty, poor diet and sanitation, and frequent infections [77]. The high relapse rate speaks to the importance of combining supplementary feeding with comprehensive nutritional and health counselling in an effort to improve the home environment.

Only a few studies have formally investigated how to decrease the risk of relapse. In Malawi, a cluster-randomized trial of a package of interventions following recovery did not significantly improve the rate of relapse in the year following discharge from a supplementary feeding program [15]. The package used for this study consisted of a bed net, albendazole, two weeks of zinc, and two courses of micronutrient supplementation provided at discharge, along with three months of malaria prophylaxis during the rainy season. In this population, there was some evidence that households with improved sanitation practices were less likely to have children that relapsed [78].

There is also evidence to suggest that higher anthropometric discharge criteria (specifically, weight-for-height Z-score [WHZ] of at least -1.5 instead of -2, and mid-upper arm circumference [MUAC] of 13 cm instead of 12.5 cm) are correlated with significantly reduced rates of relapse [76]. This makes intuitive sense as it provides children with a greater nutritional "reserve" as they resume their usual home diets once supplementary feeding ends. Nevertheless, this protective benefit has not yet been demonstrated prospectively in a randomized trial, and the cost implications for additional weeks of supplementary feeding to achieve these higher discharge criteria are not yet understood.

Given this high risk of relapse among children who recover from MAM, it is prudent to schedule children for several follow-up visits to a clinic where anthropometry can be repeated by trained health workers. An additional option that may prove even more effective is to provide caregivers with MUAC tapes that they can keep at home for monitoring their children [22]. This does not require the caregiver to have any particular clinical skill or training, or even that they be literate as the tapes are color-coded to identify which children have MAM or severe acute malnutrition (SAM). In a study in Niger, this approach was effective in identifying children with acute malnutrition at an earlier stage, which permitted early intervention and reduced the need for hospitalization [79].

PREVENTION OF MODERATE ACUTE MALNUTRITION — The same principles for decreasing the risk of children developing severe acute malnutrition (SAM) apply to MAM. (See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings", section on 'Community-based preventive care'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric malnutrition".)

SUMMARY AND RECOMMENDATIONS

●Diagnosis – In children 6 to 59 months of age, moderate acute malnutrition (MAM), also termed "moderate wasting," is defined by anthropometric criteria (table 1):

•Mid-upper arm circumference (MUAC) of 11.5 to 12.4 cm or

•Weight-for-height Z-score (WHZ) of -2 to -3 and

•No pitting edema

More severe abnormalities in MUAC or WHZ, or the presence of bilateral pitting edema, are classified as severe acute malnutrition (SAM), also known as "severe wasting and/or nutritional edema." (See 'Diagnosis' above and 'Classification of malnutrition' above.)

●Triage – Most children with MAM can be effectively and safely treated as outpatients in a structured supplementary feeding program. This type of program increases access to care by reducing costs and avoiding travel and other treatment burdens on the family. A small percentage of children with MAM, generally those who have concomitant acute medical conditions, who have anorexia, or who are under six months of age, should be managed initially in an inpatient setting, then transferred to outpatient care when acute medical conditions have been addressed and nutritional recovery has begun (algorithm 1). (See 'Triage' above.)

●Community-based management – Key components of supplementary feeding programs include (algorithm 1) (see 'Community-based management of moderate acute malnutrition' above):

•Nutrition counselling and education – Long-term recovery and sustenance of recovery are most likely to occur if the child's home diet is improved to include a sufficient quantity and variety of foods appropriate for their stage of development. (See 'Nutrition counselling and education' above.)

•Supplementary feeding – The feeding program provides supplemental foods consisting of either a fortified blended flour or a lipid-nutrient spread known as ready-to-use supplementary food (RUSF). These foods provide a balanced mix of micronutrients and macronutrients to supplement the usual home diet. Ready-to-use therapeutic food (RUTF) may be used instead for simplicity. (See 'Supplementary feeding' above.)

•Regular follow-up – Children treated in supplementary feeding programs should have regular follow-up and monitoring by community-based health workers, typically every one to two weeks. Most children recover within six weeks. (See 'Follow-up and monitoring' above.)

•Endpoint – Children are eligible for discharge from the outpatient supplementary feeding program when they reach target anthropometric goals and social and nutritional supports seem adequate to prevent relapse (table 4). (See 'Discharge criteria' above.)

Other interventions are required for selected patients:

•Antibiotics – Antimicrobial therapy should not be universally provided to all children with MAM; it should be given only to those with specific signs and symptoms of infection, as should be done for nonmalnourished children. (See 'Antibiotics' above.)

•Failure to respond – Children who are not making progress within two to three weeks of entering the feeding program, or who do not achieve their anthropometric goals within 12 weeks, should be reevaluated to determine the cause. In most cases, these children should be treated with more aggressive interventions similar to those used for children with SAM, which may require transfer to a separate treatment program. (See 'Failure to respond' above.)

●Inpatient management – For children who are admitted to the hospital for care, the first step is to assess and treat any acute medical conditions, including hypoglycemia, hypothermia, dehydration, and acute infections. Hospitalized children with an adequate appetite should receive the same nutritional supplementation as children treated in an outpatient supplementary feeding program (algorithm 2). If this is not possible, or if the child fails an appetite test, then therapeutic foods or formulas used for SAM can be used safely instead. (See 'Clinical stabilization' above and 'Nutritional supplementation' above.)

●Relapse – Relapse after discharge from the treatment program is common (30 to 50 percent) in many settings; strategies to reduce this risk need further investigation. (See 'Relapse' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges the help of Diana L Culbertson, MS, MMSc, PA-C, for her help in preparing this article.