e-Library of Evidence for Nutrition Actions (eLENA)

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

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)


This is a summary of one of several WHO recommendations on the management of SAM in infants and children. The full set of recommendations can be found in 'Full set of recommendations' and in the guidelines and guidance documents under ‘WHO documents’ below.

WHO documents

WHO documents

GRC-approved guidelines
Other guidance documents


Systematic reviews used to develop the guidelines
Clinical trials

Last update:

24 August 2016 17:01 CEST

Category 1 intervention

Guidelines have been recently approved by the WHO Guidelines Review Committee

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.

Global targets

Implementation of this intervention may contribute to the achievement of the following targets:

Global nutrition targets

Target 6: Reduce and maintain childhood wasting to less than 5%