e-Library of Evidence for Nutrition Actions (eLENA)

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.

WHO recommendations

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.

WHO documents

WHO documents

GRC-approved guidelines
Other guidance documents


Systematic reviews used to develop the guidelines
Clinical trials

Last update:

27 April 2017 14:47 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%