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Selection Criteria for Determining Acute Malnutrition

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Visible symptoms like those seen in the picture above can be used to suspect acute malnutrition and refer patients for additional testing. Anthropometric indicators are employed for making judgments or assessments, along with specific clinical signs, to measure the clinical phenomenon of acute malnutrition. For information on how to measure each of the following anthropometric indices, refer to our earlier blog on How to Conduct a Nutritional Assessment.

Identifying Acute Malnutrition in Infants Under Six (6) Months

Some indicators of SAM in infants under 6 months are bilateral pitting oedema, a weight-for-length z-score (WLZ) <-3z-scores, and being too weak to successfully suckle or feed. MAM is determined if the baby’s weight is stable or they are losing weight at home. Additionally, community-based treatment will be provided for infants with SAM or MAM, as well as infants who are at high risk of wasting, in order to support mother, infant, and young child feeding (MIYCF) practices and address any potentially linked insufficient feeding or care practices.

Identifying Acute Malnutrition in Infants between 6 and 59 Months

The primary screening and referral methods used to identify acute malnutrition in children aged 6 to 59 months, as well as pregnant and lactating women in the community and at all points of contact with the health system, should be the measurement of the mid-upper arm circumference (MUAC) and evaluation of bilateral pitting oedema.

The left mid-upper arm of the child is measured for the MUAC. For infants aged 6-59 months, MUAC <11.5 cm denotes SAM. MAM is indicated by MUAC values between ≥ 11.5 and < 12.5 cm for infants aged 6 to 59 months. When MUAC is utilized as a screening and admissions technique, a child’s age or date of birth is determined based on the caregiver’s documentation or memory, and no age-determining proxy of height is employed for infants and young children. A child who has a very low MUAC (<11.5 cm), which is associated with high mortality risk, should be admitted to a treatment program for severe acute malnutrition. For information on MUAC criteria to spot acute malnutrition in children aged 6 to 59 months, see the table below that shows the criteria for determining SAM, MAM, and those at risk of acute malnutrition. When taking weight and height measurements, a health facility with equipment and qualified staff uses the WHZ, BMI-for-age, and BMI criteria.

MUAC criteria to identify acute malnutrition of children 6 – 59 months

Severely Malnourished Moderately Malnourished At-Risk of Acute
Less than 11.5 cm 11.5 cm to 12.4cm 12.5 cm to 13.4 cm

A clinical sign of severe malnutrition, bilateral pitting oedema is brought on by an aberrant infiltration and excessive build-up of serous fluid in connective tissue or a serous cavity. The presence of a pit (indentation) in the foot following three seconds of thumb pressure on both feet is evidence of bilateral pitting oedema. All patients who have bilateral pitting oedema should be referred to a specialist and treated as though they have severe acute malnutrition.

A weight-for-height z-score (WHZ) can be calculated using the 2006 WHO Child Growth Standards for children aged 6-59 months to assess acute malnutrition. Using the criteria, the WHZ index compares a child’s weight to that of another child who is the same height and gender. Acute malnutrition is indicated by a weight-for-height standard deviation (SD) below the -2 z-score of the median (WHZ < -2 z-score of the WHO criteria). An indicator of severe acute malnutrition is a WHZ < -3 z-score. A WHZ score of ≥ -3 and <-2 indicates moderate acute malnutrition.

It is crucial to evaluate clinical signs since they might either signal or exacerbate the severity of acute malnutrition. When someone has acute malnutrition, it’s critical to evaluate the following clinical symptoms and treat them appropriately:

Clinical Signs & Descriptions of Medical Complications

  • Breathing obstruction – Any odd breathing pattern.
  • Severe respiratory distress – Pain from insufficient air entering the lungs.
  • Central cyanosis – (Bluish colouring of the skin’s mucous membrane) is a physical symptom caused by aortic blood with low haemoglobin.
  • Shock symptoms Extreme fatigue, lethargy, unconsciousness, chilled extremities, quick heartbeats, and infections or burns.
    • Fits or muscular spasms – Convulsions cause the hands and legs to stiffen.
  • Lethargy – Lack of alertness, drowsiness, and lack of interest in surroundings.
  • Unconsciousness – Lack of reactivity to people and other ambient stimuli.
  • Severe dehydration – Lack of fluids in the body causes fatigue, unconsciousness, poor drinking, sunken eyes, and skin pinches that return very slowly (>2 seconds).
  • Intractable vomiting – Consistent vomiting that does not respond to medical intervention and is linked to dehydration and hiatal hernia.
  • Hypoglycaemia – Low blood sugar or glucose levels (<3Mmoles per litre).
  • Hypothermia – Axillary temperatures below 35 degrees Celsius.

– A rectal temperature of less than 35.5 degrees Celsius or an underarm temperature of less than 35.5 degrees Celsius.

  • Severe anaemia – (Hb level <7 g/dl) manifests as severe palmar pallor, severe conjunctiva pallor, or severe oedema.
  • Persistent diarrhoea More than three occurrences of loose stools each day for at least 14 days without any signs of dehydration.
  • Lower respiratory tract infection – An acute infection of the trachea (windpipe), airways, and lungs.
  • A high fever – An axillary temperature of 38 degrees Celsius or higher.
  • Vitamin A deficiency in the eyes – Corneal ulcerations, conjunctivitis, bitot spots, and corneal clouding.
  • Skin lesions – Rashes, pus-filled sacks, blisters, swelling, discolourations, lumps, and hardening as well as changes in skin tone.
  • Anorexia Appetite loss.


Identifying Acute Malnutrition in Older Children, Adolescents, and Adults

There are currently no international guidelines that take into account MUAC cut-off values to distinguish between moderate and severe acute malnutrition in the group of older children and teenagers (5 to 17 years of age). Although it can be utilized, Body Mass Index (BMI)-for-Age is not appropriate in cases of growth retardation or when age is unknown.

Body Mass Index (BMI), MUAC, or bilateral pitting oedema, along with a detailed medical history, are utilized to identify acute malnutrition in adults (18 years of age and older). Dehydration and bilateral pitting oedema have an impact on BMI results and should be taken into account while conducting assessments.

While a pregnant woman’s weight should increase, MUAC does not alter significantly during pregnancy. Therefore, the only metrics that should be utilized to assess acute malnutrition in pregnant women are the MUAC and the evaluation of bilateral pitting oedema. For further details on these age groups, see our next article on Lifespan Nutrition during Childhood and Adolescence.


Indicators and Clinical Signs of SAM, MAM and At-risk categories of Acute Malnutrition 

Indicator Severe Acute Malnutrition

Moderate Acute

At Risk of Acute
Infants less than 6 months
Weight for
Length WFL
WFL < – 3 z-score
Bilateral Pitting Oedema Present
Other signs OR too weak to suckle or feed effectively (regardless of
OR IMCI danger signs; recent weight loss or failure to gain weight per WHO weight velocity standards
Children 6 to 59 months
WFH Z-Scores < -3 z-score ≥-3 z-score to < -2
z- score
≥-2 z-score to <-1
MUAC <11.5 cm ≥11.5 cm to < 12.5
≥12.5 cm to< 13.5
Bilateral Pitting Oedema Present Absent Absent
Indicator Severe Acute Malnutrition

Moderate Acute

At Risk of Acute
Older Child (5 years to 9 years)
BMI for Age < -3 z-score ≥-3 z-score to < -2
z- score
≥-2 z-score to <-1
Bilateral Pitting Oedema Present Absent Absent
Adolescent (10 years to 17 years)
BMI for Age < -3 z-score ≥-3 z-score to < -2
z- score
≥-2 z-score to <-1
Bilateral Pitting Oedema Present Absent Absent
Adults (18 years and older)
MUAC <16 cm irrespective of clinical signs N/A N/A
MUAC 16-18.4cm plus one of the following:

  • Acute Inability to stand.
  • Apparent dehydration.
18.5-21.4 N/A
BMI <16 16 to <17 17 to <18.5
Bilateral Pitting Oedema Present Absent Absent
Pregnant & lactating women with infants < 6 months
MUAC < 16cm 16 – 20.9 cm ≥21 to 23 cm
Adults living with HIV/AIDs (PLWHA)
MUAC for PLW < 19cm 19 – 20.9 cm 21 – 23.1cm
MUAC for adults with HIV/AIDS < 16cm
16 – 18.5cm with WHO stages 2 or 3 criteria.
16 – 18.4cm
BMI for adults with HIV/AIDS < 16cm 16 to 17cm 17 – 18.5cm
Bilateral Pitting Oedema Present Absent Absent

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