Recognition and Management of Malnutrition

The IMCI criteria for severe acute malnutrition in children 6-59 months of age include W/H less than -3 Z score or an MUAC less than 115 or edema of both feet. Doctors Without Borders uses this same criteria for children up to 10 years of age but in adolescents from 10 to 18 years only bilateral edema of the feet or W/H percentile less than 70% is used because MUAC during this age group does not accurately reflect malnutrition. For older adults Doctors Without Borders uses bilateral edema or an MUAC <185 mm to indicate severe acute malnutrition. IMCI does not provide detailed guidance on the classification of infants 1-6 months of age. Doctors Without Borders severe malnutrition criteria indicating the need for admission to a Therapeutic Feeding Center or hospital include bilateral edema of the feet or for infants with a height less than 45 cm a confirmed weight loss of more than 10% of a prior documented weight. For infants with a height of 45-65 cm, criteria for admission is a W/H z score <-3.

Severe acute malnutrition is considered complicated when there is also an identified medical complication. Medical complications include the presence of any danger sign and or a classification requiring hospitalization for children 2 to 59 months presenting with cough, fever, ear pain, HIV, anemia, or diarrhea. Severe pneumonia that might otherwise be managed in an ambulatory setting is also considered a complication needing admission. All children and adolescents with complicated acute severe malnutrition need admission to a hospital or ITFC. Because of evidence showing that some children with severe acute malnutrition can be managed at home, IMCI recommends that uncomplicated children older than 6 months with acute severe malnutrition be given an appetite test to determine their ability to eat Ready to Use Therapeutic Food (RUTF). See the appendix for a description of how to administer the appetite test. Failure to finish their RUTF portion indicates the need for admission. Children who meet the criteria for severe acute malnutrition but have no medical complications and pass their appetite test are IMCI classified as Yellow and can be cared for in an ambulatory setting. However, Doctors Without Borders recommends that all children and adolescents with uncomplicated severe acute malnutrition be admitted to either an ITFC or ATFC.

Remember that infants under 2 months who present with signs of severe disease or local infection need inpatient care. In addition, there is consensus, that when infants younger than 6 months cannot feed because of breast feeding difficulties or inadequate formula feeding, they need admission regardless of their weight or presence of edema.