Malnutrition in emergencies
Acute malnutrition makes every infection more dangerous, and every infection makes malnutrition worse. In a crisis, the most useful thing primary care can do is to find malnourished children early, check them for medical problems, and get them into the right care: at home with therapeutic food, or in hospital if they are ill.
- For clinicians, nurses, nutrition staff and community health workers in humanitarian settings
- Reviewed October 2026
Screen every young child, every time
- Measure mid-upper arm circumference (MUAC) in every child aged 6 to 59 months at every contact: clinic, vaccination, home visit.
- Check both feet for pitting oedema: press both feet with your thumbs for three seconds. A dent that stays on both feet is nutritional oedema.
- Weigh and measure length or height where you can, to calculate weight-for-height.
- Ask about appetite, feeding, diarrhoea, cough and fever, and check vaccinations.
- Families can be taught to check MUAC themselves.
Nutritional status must never be judged on its own: a full health assessment, including triage for emergency signs, decides where a child is treated.
Source: WHO wasting and nutritional oedema guideline, 2023; Sphere Handbook 2018
Classify: children 6 to 59 months
| Finding | Classification |
|---|---|
| MUAC under 115 mm, or weight-for-height below −3 z, or nutritional oedema of both feet | Severe wasting and/or nutritional oedema (severe acute malnutrition) |
| MUAC 115 to under 125 mm, or weight-for-height −3 to −2 z | Moderate wasting (moderate acute malnutrition) |
| MUAC 125 mm or more and weight-for-height −2 z or above, no oedema | Not acutely malnourished |
Source: WHO wasting and nutritional oedema guideline, 2023; Sphere Handbook 2018
Severe wasting or oedema: inpatient or outpatient?
| The child has | Decision |
|---|---|
| Any of: an IMCI general danger sign; an acute medical problem; severe oedema (+++); poor appetite (failed the appetite test) | Refer and admit for inpatient care |
| None of the above, but any of: a problem that needs further investigation (for example bloody diarrhoea, low blood glucose, HIV-related problems); a long-term condition linked with nutrition (heart disease, cerebral palsy or other disability, HIV, TB); not gaining weight or improving as an outpatient; a previous episode of severe malnutrition | In-depth assessment to decide whether to refer |
| All of: good appetite (passed the appetite test); no danger signs or acute medical problems; no criteria for in-depth assessment, or that assessment is done and admission is not needed | Enrol and treat as an outpatient |
Trained and supervised community health workers can manage children 6 to 59 months with wasting or oedema in the community, including nutritional treatment and medical care that fits the setting.
Source: WHO guideline on the prevention and management of wasting and nutritional oedema, 2023, recommendation B2
Outpatient care for uncomplicated severe malnutrition
- Ready-to-use therapeutic food (RUTF) that meets the Codex specification, in the amount set by your national protocol.
- A course of an oral antibiotic such as amoxicillin for children with uncomplicated severe wasting or oedema managed as outpatients; dose per national guideline or formulary.
- Treat other illnesses (malaria, diarrhoea, pneumonia) following IMCI; check vaccinations, especially measles.
- See the child regularly, usually weekly or every two weeks as your programme directs: weight, MUAC, oedema, appetite, illness.
- Refer at once if danger signs appear, appetite is lost, oedema worsens or weight falls.
Source: WHO 2023 guideline (recommendations retained from WHO 2013 SAM update)
Moderate wasting
- Every child with moderate wasting needs a health assessment to find any medical problem that is causing it.
- They need access to a nutrient-dense home diet. Not every child needs a specially formulated food.
- In high-risk settings such as humanitarian crises, and for children with extra individual or social risks, prioritise specially formulated foods (RUTF, ready-to-use supplementary food or an improved fortified blended food) through the feeding programme.
- Follow up until recovered, and treat infections promptly.
Source: WHO 2023 guideline, briefing note June 2023
Medical cautions in severe malnutrition
- Look for and treat low blood glucose, low body temperature and infection; severely malnourished children may not show the usual signs.
- Dehydration: do not use the standard rapid IV rehydration plans. Follow the WHO inpatient protocol, or the GTFCC job aid for cholera with severe malnutrition, and seek senior help.
- Keep the child warm and fed during referral.
Source: WHO 2023 guideline; GTFCC job aid on cholera and severe acute malnutrition
Infants under 6 months
- Identify infants at risk of poor growth and development early, and care for mother and infant together.
- Breastfeeding support is the most important part of care, and one of the best ways to prevent wasting later in childhood.
- Check the mother's health and nutrition, and her mental health, too.
- Refer infants who are ill or not feeding for in-depth assessment.
Source: WHO 2023 guideline, briefing note June 2023
Pregnant and breastfeeding women, older people and adults
| Group | Acute malnutrition (Sphere) |
|---|---|
| Pregnant and breastfeeding women | MUAC under 23 cm (under 21 cm in some settings). MUAC changes little during pregnancy. |
| Older people | MUAC under 21 cm; severe if under 18.5 cm |
| Adults (including people with HIV or TB) | BMI under 18.5; severe if under 16 |
Sphere suggests MUAC under 21 cm as a reasonable cut-off for selecting pregnant women at risk during emergencies. Oedema in adults has many causes besides malnutrition, so examine for them.
Source: Sphere Handbook 2018, food security and nutrition appendix
Linking with the nutrition programme
- Know where the outpatient therapeutic programme, the inpatient stabilisation centre and the supplementary feeding programme are, and how to refer to each.
- Report MUAC and oedema findings: rates of low MUAC help the nutrition team plan.
- Make sure children who leave inpatient care are linked to outpatient care, and that the family can cope at home.
- Measles vaccination and vitamin A for children 6 to 59 months are part of preventing malnutrition deaths.
Your child is too thin and needs special food and medicine. This food is medicine for your child only. Please bring them back every week, and come at once if they stop eating or become sick.
Sources
- World Health Organization. WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. 2023.
- World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and children. 2013.
- Sphere Association. The Sphere Handbook, fourth edition (food security and nutrition chapter). 2018.
- Global Task Force on Cholera Control (GTFCC). Job aid: treatment of children with cholera and severe acute malnutrition. 2024.