e-Library of Evidence for Nutrition Actions (eLENA)


An online library of evidence-informed guidelines for nutrition interventions and single point of reference for the latest nutrition guidelines, recommendations and related information.

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Identification of severe acute malnutrition in infants under 6 months of age

Intervention | Last updated: 9 August 2023

In infants who are under 6 months of age, severe acute malnutrition is defined by a very low weight-for-length or the presence of bilateral pitting oedema. Severe acute malnutrition is increasingly being recognized in infants under 6 months of age and is often associated with higher mortality in young infants than in older infants and children.

While requiring nutritional intervention, not all severely malnourished infants require hospitalization. However, given the difficulty in identifying and interpreting clinical signs of infection, hydration status and other physiological outputs in infants, criteria for admitting and discharging infants with severe acute malnutrition have not been adequately defined. To address this, WHO has developed a set of recommendations for the identification and management of severe acute malnutrition in infants who are under 6 months of age.

WHO Recommendations

Severe acute malnutrition in infants who are 0–5 months of age is defined as:

  • weight-for-length <–3 Z-scores of the WHO Child Growth Standards median, or
  • presence of bilateral pitting oedema.

Infants who are under 6 months of age with severe acute malnutrition with any of the following complicating factors should be admitted for inpatient care:

  • any serious clinical condition or medical complication for infants 6 months of age or older with severe acute malnutrition as outlined in Recommendation 1.3 of the updated guideline on the management of severe acute malnutrition in infants and children (see WHO documents below)
  • recent weight loss or failure to gain weight
  • ineffective feeding (attachment, positioning and suckling) directly observed by healthcare workers for 15–20 min, ideally in a supervised separated area
  • any pitting oedema
  • any medical or social issue needing more detailed assessment or intensive support (e.g. disability, depression of the caregiver, or other adverse social circumstances)


Cost-effectiveness Learn More Alternate Text

Cost-effectiveness analyses

The analyses listed below were conducted to assess the overall cost-effectiveness of inpatient and/or outpatient management of SAM, of which the intervention listed on this webpage is a component. The analyses do not assess the cost-effectiveness of this specific intervention alone.

Costs, cost-effectiveness and financial sustainability of community-based management of acute malnutrition in northern Nigeria

Frankel S, Roland M, Makinen M. Washington DC: Results for Development Institute; 2015.

Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia

Tekeste A, Wondafrash M, Azene G, Deribe K. Cost Eff Resour Alloc. 2012; 10:4.

Cost-effectiveness of the community-based management of severe acute malnutrition by community health workers in southern Bangladesh

Puett C, Sadler K, Alderman H, Coates J, Fiedler JL, Myatt M. Health Policy Plan. 2013; 28(4):386-99.

Economic Cost of Community-Based Management of Severe Acute Malnutrition in a Rural District in Ghana

Abdul-Latif A-M C, Nonvignon J. Health. 2014; 6: 886-899.

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Goudet S, Jayaraman A, Chanani S, Osrin D, Devleesschauwer B, Bogin B, et al. PLoS One. 2018; 13(11):e0205688.

Cost-effectiveness of community-based management of acute malnutrition in Malawi

Wilford R, Golden K, Walker DG. Health Policy Plan. 2012; 27(2):127-37.

The cost-effectiveness of forty health interventions in Guinea

Jha P, Bangoura O, Ranson K. Health Policy Plan. 1998; 13(3):249-62.

Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model

Bachmann MO. Cost Eff Resour Alloc. 2009 Jan; 7:2.

Category 1 Intervention

Guidelines have been recently approved by the WHO Guidelines Review Committee

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Essential Nutrition Actions

This intervention is a component of managing children with SAM, which is an Essential Nutrition Action targeting the first 1000 days of life.

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