Undernutrition contributes to nearly half of all deaths in children under five, according to WHO and UNICEF. Children with severe acute malnutrition (SAM) are at very high risk of dying from common illnesses, and their bodies respond to treatment differently from healthy children. In northern Nigeria, the Sahel, the Horn of Africa and conflict areas, nurses often run outpatient and inpatient nutrition programmes. Getting the details right saves lives.
Identifying SAM (children 6–59 months)
- Mid-upper arm circumference (MUAC) below 11.5 cm (the red zone on a MUAC tape); or
- Weight-for-height/length below −3 Z-score; or
- Bilateral pitting oedema (press both feet for 3 seconds; a dent remains) — called kwashiorkor.
Outpatient or inpatient?
Children with SAM who have a good appetite (pass the appetite test with ready-to-use therapeutic food, RUTF) and no medical complications can usually be treated at home through community-based programmes, with weekly or fortnightly visits. Children who fail the appetite test, have severe oedema, or have medical complications (danger signs, severe pneumonia, severe dehydration, hypothermia, hypoglycaemia, high fever, severe anaemia) need inpatient care.
The WHO 10 steps of inpatient care
- Treat and prevent hypoglycaemia: feed immediately and every 2–3 hours, day and night.
- Treat and prevent hypothermia: keep warm, cover with blankets, skin-to-skin with the mother, keep away from draughts.
- Treat and prevent dehydration: carefully, with ReSoMal (rehydration solution for malnutrition), not standard ORS or rapid IV fluids, except in shock.
- Correct electrolyte imbalance (potassium, magnesium): included in therapeutic feeds and mineral mixes.
- Treat and prevent infection: give antibiotics routinely, as per protocol, even without obvious signs, because malnourished children may not show the usual signs of infection.
- Correct micronutrient deficiencies: vitamin A, folic acid, zinc; iron only once the child is gaining weight.
- Start cautious feeding with F-75 (stabilisation phase).
- Achieve catch-up growth with F-100 or RUTF (rehabilitation phase).
- Provide sensory stimulation and emotional support: play, care and affection.
- Prepare for follow-up after recovery.
Why caution matters
- Fluids: a malnourished child’s heart is weak, and standard rehydration can cause heart failure. Follow the SAM rehydration protocol and monitor breathing and pulse closely.
- Feeding: giving too much too soon can cause refeeding syndrome. F-75 is designed to be gentle.
- Danger signs during treatment: rising pulse and breathing rate, increasing oedema, or new crackles may indicate fluid overload. Stop fluids or feeds and escalate.
Daily nursing care
- Feed on schedule, including at night, and record intake.
- Temperature, pulse and respiratory rate at least every 4 hours.
- Weigh daily, at the same time, on the same scale, and plot.
- Check oedema daily.
- Skin care (children with kwashiorkor often have broken, peeling skin), eye care, and hygiene.
- Involve and teach the mother or carer, who will continue care at home.
Preventing malnutrition
- Exclusive breastfeeding for 6 months; good complementary feeding from 6 months. See our breastfeeding guide.
- Growth monitoring and MUAC screening in the community.
- Immunisation, malaria prevention, safe water and sanitation, and treating diarrhoea promptly.
- Maternal nutrition in pregnancy.
Related: IMCI danger signs · Hypoglycaemia
Based on WHO guidelines on the management of severe acute malnutrition in infants and children, and the WHO guideline on the prevention and management of wasting and nutritional oedema (2023). Educational content: follow your national CMAM/IMAM protocol.