Community medicine chapters
Severe and moderate acute malnutrition (SAM and MAM)
How acute malnutrition is defined and measured, the MUAC, weight-for-height and oedema criteria for severe and moderate acute malnutrition, how community-based management works, and the WHO principles of treating complicated cases.
- Acute malnutrition (wasting) in children aged 6–59 months is SAM if weight-for-height < −3 SD, or MUAC < 11.5 cm, or bilateral pitting oedema; MAM if WHZ between −3 and −2 SD or MUAC 11.5 to < 12.5 cm.
- Uncomplicated SAM with a good appetite is treated at home with RUTF (outpatient therapeutic programme); complicated SAM needs inpatient care in a stabilisation centre with F-75, then F-100 or RUTF.
- MAM is managed in supplementary feeding programmes; Pakistan's National Nutrition Survey 2018 found wasting 17.7% and stunting 40.2% in children under five.
On this page
Overview
Malnutrition in children takes several forms. Acute malnutrition (wasting) develops quickly from lack of food or illness and carries a high risk of death, especially when severe.
Pakistan has high rates: the National Nutrition Survey 2018 reported, in children under five, stunting 40.2%, wasting 17.7% and underweight 28.9% (check newer surveys for current figures).
Forms of undernutrition
| Form | Measure | Meaning |
|---|---|---|
| Wasting (acute malnutrition) | Low weight-for-height | Recent, rapid weight loss or failure to gain |
| Stunting (chronic malnutrition) | Low height-for-age | Long-term undernutrition and repeated infection; largely irreversible after about 2 years |
| Underweight | Low weight-for-age | A mix of wasting and stunting |
"Low" means below −2 SD (z-score) of the WHO Child Growth Standards; below −3 SD is severe.
Wasting = weight-for-height (acute). Stunting = height-for-age (chronic).
Criteria for SAM and MAM (children 6–59 months)
| Measure | SAM | MAM |
|---|---|---|
| Weight-for-height z-score | < −3 SD | −3 to < −2 SD |
| MUAC (mid-upper arm circumference) | < 11.5 cm (115 mm) | 11.5 to < 12.5 cm |
| Bilateral pitting oedema | Present (any grade) | Absent |
A child meeting any one criterion is classified accordingly.
Any bilateral pitting oedema of nutritional origin means SAM, whatever the weight-for-height or MUAC.
MUAC is a quick, simple screening tool used by lady health workers in the community, and MUAC < 11.5 cm independently predicts a high risk of death.
Child A: MUAC 11.2 cm, WHZ −2.4, no oedema → MUAC < 11.5 → SAM
Child B: MUAC 12.1 cm, WHZ −2.5, no oedema → MAM (both in MAM range)
Child C: MUAC 13.0 cm, WHZ −1.5, bilateral pitting oedema → SAM (oedema alone)
Child D: MUAC 12.8 cm, WHZ −1.8, no oedema → not acutely malnourished
Clinical types of SAM
| Marasmus | Kwashiorkor |
|---|---|
| Severe wasting: "skin and bones", old-man face | Oedema (feet, legs, face) |
| No oedema | Skin changes (flaky-paint dermatosis), sparse pale hair (flag sign), apathy, enlarged fatty liver |
| Usually under 1 year; good appetite at first | Usually 1–3 years, often after weaning; poor appetite |
Marasmic kwashiorkor has both wasting and oedema.
Community-based management of acute malnutrition (CMAM)
CMAM brings treatment close to the family. Its parts:
- Community mobilisation and screening (MUAC by community health workers).
- Outpatient therapeutic programme (OTP): for uncomplicated SAM with a good appetite. Weekly or fortnightly visits; RUTF at home; routine medicines (antibiotic, deworming, measles vaccine, vitamin A as per protocol).
- Inpatient care (stabilisation centre): for complicated SAM.
- Targeted supplementary feeding programme (TSFP): for MAM, with fortified foods or supplements.
Who needs inpatient care?
- Failed appetite test (cannot eat RUTF).
- Medical complications: severe oedema (+++), hypothermia, hypoglycaemia, severe dehydration, high fever, severe anaemia, pneumonia, lethargy or unconsciousness, convulsions, persistent vomiting.
- Infants under 6 months with SAM.
Appetite test: the child is offered RUTF under supervision; eating the required amount means the appetite is adequate for outpatient care.
Uncomplicated SAM with appetite → OTP with RUTF. Complicated SAM or no appetite → stabilisation centre.
Ready-to-use therapeutic food (RUTF)
An energy-dense, nutrient-rich paste (often peanut-based) that needs no water or cooking, so it is safe at home. Given at about 200 kcal per kg per day in OTP.
Child weight = 6 kg; target about 200 kcal/kg/day
Energy needed = 6 × 200 = 1,200 kcal per day
One RUTF sachet (92 g) gives about 500 kcal
Sachets per day = 1,200 ÷ 500 = about 2.4 (in practice 2 to 3 sachets daily, using the programme's weight-band table)
Inpatient treatment: WHO principles
Treatment has two phases:
- Stabilisation (first few days): treat life-threatening problems; feed little and often with F-75 (75 kcal per 100 mL, low protein and sodium).
- Rehabilitation (catch-up growth): F-100 (100 kcal per 100 mL) or RUTF, increasing until the child gains weight fast.
The WHO ten steps:
- Treat or prevent hypoglycaemia.
- Treat or prevent hypothermia.
- Treat or prevent dehydration (use ReSoMal, a low-sodium rehydration solution; avoid IV fluids unless in shock).
- Correct electrolyte imbalance (extra potassium and magnesium; children with SAM have excess body sodium).
- Treat or prevent infection (give antibiotics routinely, as infection is often silent).
- Correct micronutrient deficiencies (do not give iron in the first phase).
- Start cautious feeding (F-75).
- Achieve catch-up growth (F-100 or RUTF).
- Provide sensory stimulation and emotional support.
- Prepare for follow-up after recovery.
Iron is not started in the stabilisation phase; it can worsen infection and oxidative damage. It is added in rehabilitation.
Feeding too much too fast early on can cause refeeding syndrome (low phosphate, heart failure).
Discharge from OTP (typical criteria)
MUAC 12.5 cm or more and/or WHZ −2 or more, and no oedema for at least two weeks (exact criteria follow the national protocol).
Prevention
Exclusive breastfeeding for 6 months, good complementary feeding, immunisation, treatment of diarrhoea with ORS and zinc, clean water and sanitation, birth spacing, and social protection for poor families.
Expect: the SAM and MAM cut-offs (WHZ −3 and −2; MUAC 11.5 and 12.5 cm; oedema), wasting vs stunting vs underweight, marasmus vs kwashiorkor, CMAM components, who goes to OTP vs a stabilisation centre, the appetite test, RUTF, F-75 vs F-100, the WHO ten steps and why iron is delayed.
Quick revision
- SAM: WHZ < −3, MUAC < 11.5 cm, or bilateral oedema.
- MAM: WHZ −3 to −2, MUAC 11.5 to < 12.5 cm.
- Wasting: weight-for-height. Stunting: height-for-age. Underweight: weight-for-age.
- Uncomplicated SAM + appetite → OTP with RUTF (about 200 kcal/kg/day).
- Complicated SAM → stabilisation centre: F-75, then F-100 or RUTF.
- Ten steps start with hypoglycaemia, hypothermia, dehydration (ReSoMal); no iron early.
- Pakistan NNS 2018: stunting 40.2%, wasting 17.7%.
Written by The House Job from Excel Community Medicine and Park's Textbook of Preventive and Social Medicine (named in the UHS PGET syllabus), with criteria from the WHO Child Growth Standards and WHO guidance on severe acute malnutrition, and Pakistani figures from the National Nutrition Survey 2018. Follow the current national CMAM protocol for treatment details.
FAQ
What MUAC defines severe acute malnutrition?
A mid-upper arm circumference below 11.5 cm in a child aged 6–59 months.
How is a child with bilateral pitting oedema classified?
As severe acute malnutrition, whatever the weight-for-height or MUAC.
Which children with SAM can be treated as outpatients?
Those without medical complications who pass the appetite test.
What is F-75?
A therapeutic milk with 75 kcal per 100 mL, used in the stabilisation phase of treating complicated severe acute malnutrition.