Management of severe acute malnutrition in infants and children
Full set of WHO recommendations*
Admission and discharge criteria for children who are 6–59 months of age with severe acute malnutrition
WHO recommendations (1)
Criteria for identifying children with severe acute malnutrition for treatment
1. In order to achieve early identification of children with severe acute malnutrition in the community, trained community health workers and community members should measure the mid-upper arm circumference of infants and children who are 6–59 months of age and examine them for bilateral pitting oedema. Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm, or who have any degree of bilateral oedema should be immediately referred for full assessment at a treatment centre for the management of severe acute malnutrition.
2. In primary health-care facilities and hospitals, health-care workers should assess the mid-upper arm circumference or the weight-for-height/weight-for-length status of infants and children who are 6–59 months of age and also examine them for bilateral oedema. Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a weight-for-height/length <–3 Z-scores of the WHO growth standards (2), or have bilateral oedema, should be immediately admitted to a programme for the management of severe acute malnutrition.
Criteria for inpatient or outpatient care**
3. Children who are identified as having severe acute malnutrition should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite. Children who have appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients. Children who have medical complications, severe oedema (+++)***, or poor appetite (fail the appetite test****) or present with one or more IMCI danger signs† should be treated as inpatients.
Criteria for transferring children from inpatient to outpatient care*
4. Children with severe acute malnutrition who are admitted to hospital can be transferred to outpatient care when their medical complications, including oedema, are resolving and they have good appetite, and are clinically well and alert. The decision to transfer children from inpatient to outpatient care should be determined by their clinical condition and not on the basis of specific anthropometric outcomes such as a specific mid-upper arm circumference or weight-for-height/length.
Criteria for discharging children from treatment
5. a. Children with severe acute malnutrition should only be discharged from treatment when their:
- weight-for-height/length is ≥–2 Z-score and they have had no oedema for at least 2 weeks, or
- mid-upper-arm circumference is ≥125 mm and they have had no oedema for at least 2 weeks.
b. The anthropometric indicator that is used to confirm severe acute malnutrition should also be used to assess whether a child has reached nutritional recovery, i.e. if mid-upper arm circumference is used to identify that a child has severe acute malnutrition, then mid-upper arm circumference should be used to assess and confirm nutritional recovery. Similarly, if weight-for-height is used to identify that a child has severe acute malnutrition, then weight-for-height should be used to assess and confirm nutritional recovery.
c. Children admitted with only bilateral pitting oedema should be discharged from treatment based on whichever anthropometric indicator, mid-upper arm circumference or weight-for-height is routinely used in programmes.
d. Percentage weight gain should not be used as a discharge criterion.
Follow-up of infants and children after discharge from treatment for severe acute malnutrition
6. Children with severe acute malnutrition who are discharged from treatment programmes should be periodically monitored to avoid a relapse.
- visible severe wasting is not included as a diagnostic criterion (3). However, all malnourished children should be clinically examined when undressed, as part of routine management;
- all anthropometric indicators are assumed to be derived from the WHO growth standards (2);
- children with severe acute malnutrition with medical complications or failed appetite test1 should be admitted to hospital for inpatient care;
- admission may also be warranted if there are significant mitigating circumstances such as disability or social issues, or there are difficulties with access to care;
- children with severe acute malnutrition and without these signs or mitigating circumstances can be managed as outpatients by providing appropriate amounts of ready-to-use therapeutic food.
* This is an extract from relevant guidelines and guidance documents as listed in ‘References’. Additional guidance information can be found in these documents.
** Necessary resources and services need to be in place if children are referred to outpatient care.
*** Oedema can be categorized as:
Mild (+): oedema in both feet/ankles
Moderate (++): oedema in both feet plus lower legs, hands or lower arms
Severe (+++): generalized oedema including both feet, legs, hands, arms and face
**** Appetite test from http://www.fantaproject.org/downloads/pdfs/CMAM_Training_Mod4_ENGLISH_Nov2008.pdf
† Danger signs: unable to drink or breastfeed; vomits everything; has had convulsions (more than one or prolonged >15 min); lethargic or unconscious; convulsing now.
1. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva, World Health Organization; 2013 (http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_
2. WHO Multicentre Growth Reference Study Group. WHO child growth standards: methods and development. Growth velocity based on weight, length and head circumference. Geneva, World Health Organization; 2009 (www.who.int/childgrowth/standards/velocity/technical_report/en/index.html).
3. WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health Organization; 1999 (http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/).
4. WHO, WFP, UNSCN, UNICEF. Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, World Food Programme, United Nations Standing Committee on Nutrition, United Nations Children’s Fund. Geneva, World Health Organization; 2007 (http://www.who.int/nutrition/publications/severemalnutrition/9789280641479/en/).
5. WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint statement by the World Health Organization and the United Nations Children’s Fund. Geneva:, World Health Organization; 2009 (http://www.who.int/maternal_child_adolescent/documents/9789241598163/en/).
6. Integrated management of childhood illness: caring for newborns and children in the community. Geneva, World Health Organization; 2011 (http://www.who.int/maternal_child_adolescent/documents/imci_community_care/en/).