10.2  Management of severe acute malnutrition

It will not always be easy for you to decide who should be referred to a higher level, or who you should treat yourself at the health post. As you read above this will mainly (but not only) depend on whether the child’s severe acute malnutrition is ‘complicated’ or ‘uncomplicated’. Certain criteria have been established to help you decide whether a child has severe complicated or severe uncomplicated malnutrition:

  • Age: all infants under six months of age with SAM need to be treated in an in-patient facility
  • The presence of any medical complications, including any of the general danger signs, pneumonia/severe pneumonia, blood in the stool, fever or hypothermia mean that the severely malnourished child is classified as severe complicated malnutrition and must be treated in an in-patient facility. The IMNCI Module looks at each of these complications in more detail. Table 10.2 below gives you a summary of the key complications that you should look for when helping to treat children with severe acute malnutrition.

> means greater than or equal to. < means less than or equal to.

Table 10.2  Complications and indicators for referral of children with SAM.

ComplicationReferral to in-patient care when:

General danger sign

If one of the following is present: vomiting everything, convulsion, lethargy, unconscious, or unable to feed


Fast breathing

For child six-12 months 50 breaths per minute and above

For a child 12 months-five years 40 breaths per minute and above

For a child older than five years 30 breaths per minute and above

Severe pneumonia

A child with fast breathing as indicated above and chest in-drawing


If blood in the stool

Fever or

Low body temperature

T > 37.5 or febrile to touch

T < 35°C or cold to touch

Children with poor appetite are also classified as having severe complicated malnutrition and need to be referred to in-patient care. Details on how to test for appetite will be explained briefly below.

10.1  Severe acute malnutrition: deciding patient management

10.2.1  The appetite test