Who / when
- Every child aged 6 to 59 months at every sick or well visit: MUAC and both feet.
- Infants under 6 months who are underweight, wasted, not gaining weight or feeding poorly: see the infant box under Treat.
- Community health workers can screen, classify and manage or refer with training and supervision.
Red flags: refer now
Admit (refer urgently) a child with severe wasting or oedema who has any of:
- Any IMCI general danger sign (not able to drink, vomits everything, convulsions, lethargic or unconscious).
- An acute medical problem or severe classification (for example pneumonia with chest indrawing, severe dehydration).
- Severe oedema (+++): feet, legs, hands and face.
- Poor appetite: fails the RUTF appetite test.
Complicated severe acute malnutritionBefore transfer: first dose of an appropriate antibiotic, prevent low blood sugar (breastfeed, or milk or sugar water), keep the child warm, refer urgently.
Assess
- MUAC with a MUAC tape in every child 6 months and over.
- Oedema: press the tops of both feet with your thumbs; pitting on both feet is nutritional oedema.
- Weight-for-height/length z-score (WHZ) if you have scales, a height board and WHO charts.
- Danger signs and a full IMCI assessment; HIV status; TB contact.
- Appetite test (6 months and over, no complication): in a quiet corner offer RUTF for up to 30 minutes. Passes if the child eats at least one-third of a 92 g packet (or 3 teaspoons from a pot).
Classify
| Findings (6 to 59 months) | Classify as | Care |
|---|
| Oedema of both feet, or WHZ below -3, or MUAC below 115 mm, and a danger sign, medical complication, oedema +++ or failed appetite test | Complicated severe acute malnutrition | Inpatient care; refer urgently |
| Oedema (+ or ++), or WHZ below -3, or MUAC below 115 mm; passes appetite test; no complication | Uncomplicated severe acute malnutrition | Outpatient: RUTF, amoxicillin, review in 7 days |
| WHZ -3 to below -2, or MUAC 115 to under 125 mm, no oedema | Moderate acute malnutrition | Feeding counselling, treat illness; supplementary food if at high risk; review in 30 days |
| WHZ -2 or more, or MUAC 125 mm or more, no oedema | No acute malnutrition | Feeding advice if under 2 years |
Treat
Uncomplicated severe acute malnutrition (outpatient)
- RUTF to give 150 to 185 kcal/kg a day (one 92 g packet is 500 kcal). Example (IMCI 2014): 4 to 4.9 kg, 2 packets a day; 5 to 6.9 kg, 2.5 packets a day; 7 to 8.4 kg, 3; 8.5 to 9.4 kg, 3.5; 9.5 to 10.4 kg, 4; 10.5 to 11.9 kg, 4.5; 12 kg and over, 5. Use your national RUTF table.
- Oral antibiotic such as amoxicillin (dose per national formulary).
- Do not give iron or high-dose vitamin A to a child on RUTF: RUTF contains them.
- Malaria test in malaria areas; treat other illness. Dehydration: ReSoMal (or low-osmolarity ORS if none) given slowly; refer if you are not sure.
- Breastfeed first, then RUTF; offer plenty of clean water. Assess for TB.
Moderate acute malnutrition
Nutrient-dense diet and counselling for all. Add a specially formulated food (lipid-based supplement preferred) if MUAC 115 to 119 mm, under 24 months, past severe wasting, relapse, illness such as HIV or TB, or in a humanitarian crisis. No routine antibiotics unless there is infection.
Infants under 6 months at risk
Follow-up
- Uncomplicated severe: first review in 7 days, then every 14 days. Measure MUAC and weight the same way, check oedema and appetite. New complication, oedema appears, or fails appetite test: refer urgently.
- Moderate: review after 30 days, then monthly; refer if losing weight or MUAC falling.
- Exit treatment only when WHZ is -2 or more and MUAC is 125 mm or more on 2 consecutive visits, with no oedema for 2 visits. Weight-gain percentages are not exit criteria.
- After exit: periodic checks to prevent relapse.
Counsel
- RUTF is a medicine for this child only: do not share it. Give small meals often through the day.
- Wash hands before feeding; keep RUTF covered.
- Play with and talk to the child: stimulation helps recovery.
- Return at once if the child stops eating, has swelling, vomiting, diarrhoea, fever, or fast breathing.
This food is medicine for your child. Give it in small amounts many times a day, after breastfeeding, with clean water to drink. Do not share it. Come back in one week, or at once if she stops eating or gets sick.
When to refer
- Urgently: any danger sign, medical complication, oedema +++, or failed appetite test.
- Uncomplicated severe that is not improving, losing weight, or has had previous episodes.
- Infant under 6 months with severe wasting, oedema or recent weight loss.
- HIV, TB, disability or heart disease needing long-term care, or severe social problems: link to services.
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. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014.