Identification of severe acute malnutrition requiring inpatient care in children 6–59 months of age
In children who are 6–59 months of age, severe acute malnutrition is defined by a very low weight-for-height/weight-for-length, or clinical signs of bilateral pitting oedema, or a very low mid-upper arm circumference. Severe acute malnutrition affects an estimated 19 million children under 5 years of age worldwide and is estimated to account for approximately 400,000 child deaths each year.
While requiring nutritional intervention, not all severely malnourished children require hospitalization. With the development of ready-to-use therapeutic foods, treatment of severe acute malnutrition in children 6 – 59 months of age without medical complications and with good appetite is increasingly provided on an outpatient basis.
Inpatient treatment of severely malnourished children can be costly and disruptive to families in settings with limited resources. Minimizing unnecessary hospitalization while ensuring that those children requiring inpatient treatment get the care they need represents the best use of resources. This can be achieved in part by establishing admission and discharge criteria based on careful consideration of medical condition.
Children who are 6–59 months of age with severe acute malnutrition 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.
Children who are 6–59 months of age with severe acute malnutrition who are admitted to hospital (inpatient care) 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.
*severe oedema generalized to feet, legs, arms and face
** unable to drink or breastfeed; vomits everything; has had convulsions (more than one or prolonged >15 min); lethargic or unconscious; convulsing now
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.
Updates on the management of severe acute malnutrition in infants and children
Pocket book of hospital care for children: second edition. Guidelines for the management of common illnesses with limited resources
Other guidance documents
WHO Integrated management of childhood illness: caring for newborns and children in the community
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
Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund
Management of severe malnutrition: a manual for physicians and other senior health workers
Systematic reviews used to develop the guidelines
Utilization of mid-upper arm circumference versus weight-for-height in nutritional rehabilitation programmes: a systematic review of evidence