Menu ENN Search

Review of WHO guidelines for the inpatient management of severe acute malnutrition

Summary of research1

Location: Global

What we know: Optimising SAM management is an important strategy for reducing malnutrition-related mortality.

What this article adds: A recent review examined the evolution and evidence supporting existing guidelines on the inpatient management of SAM. Gaps persist and extend across the entire spectrum of guidance on the management of complicated SAM. Absence of relevant published data has forced a reliance on expert opinion (the basis of half the recommendations). Supporting evidence is often of very low quality and not specific to the recommended treatment. Recommendations based on expert opinion (clinical experience and basic science) or weak evidence are not necessarily incorrect but clinical context has changed; changes include an emerging younger infant caseload and outpatient treatment changing inpatient profile. There are significant gaps in evidence-based clinical guidance, which include HIV case management, management post-discharge mortality, antimicrobial therapy and fluid management. WHO guidance has failed to keep pace with developments and experience; more trials are needed to strengthen the evidence base.

Each year, severe acute malnutrition (SAM) is the direct cause of an estimated 540,000 child deaths and contributes to many other child deaths (Black et al, 2013). SAM without medical complications can be effectively managed in the community; however complicated cases still warrant inpatient management. Case fatality rates should be less than 10% if adhering to World Health Organization (WHO) inpatient management guidelines. However, despite reported compliance, mortality rates of 10 to 40% are documented among hospitalised SAM children in sub-Saharan Africa (Kerac et al, 2014; Fergusson and Tomkins, 2009). Optimising SAM management is an important strategy for reducing malnutrition-related mortality.

WHO’s first guidelines on the management of malnutrition (1981) were replaced in 1999 by guidelines on the management of SAM. Both summarised decades of clinical experience and described the achievement of low malnutrition-related case fatality rates in specific settings. Further guideline revisions were made in 2003 and 2013. Relevant joint statements from WHO and other United Nations (UN) agencies were issued in 2007 and 2009. The combination of these documents constitutes the current WHO SAM guidelines. A recent review identified evidence gaps within the guidelines which, if filled, may help reduce mortality further.

The evolution of each recommendation’s development was traced using Google scholar and the WHO website, including documents predating current guidance, and any modifications and references cited in support of the recommendation noted. Each recommendation was evaluated using the GRADE system. To determine the aims and extent of any recently completed, ongoing or pending trials relevant to the management of complicated SAM, the authors searched the WHO International Clinical Trials Registry Platform, and the Controlled Trials metaRegister until 10 August 2015.

Eight documents containing 33 current recommendations met the inclusion criteria.

Results show that gaps persist and extend across the entire spectrum of guidance on the management of complicated SAM. The absence of relevant published data has forced a reliance on expert opinion. Supporting evidence was often of very low quality and was not specific to the recommended treatment. Guideline reforms have been driven by an overwhelming clinical need rather than by compelling evidence.

Recommendations supported by weak evidence or expert opinion are not necessarily incorrect; many are grounded in basic science research and careful clinical observations. However, the population of paediatric inpatients with SAM has dramatically changed in the last ten to 20 years: human immunodeficiency virus (HIV) has emerged as an important contributing problem; younger infants now represent an increasing proportion of malnourished children; and outpatient care for uncomplicated cases has eclipsed hospital management. Data from previous eras may therefore not be generalisable to the modern child with complicated SAM.

In some areas the absence of clinical data is particularly concerning, such as in the management SAM in HIV-infected children and infants. Post-discharge mortality in SAM cases is high but poorly understood. Empiric antibiotics have been recommended since at least 1969 and the currently endorsed regimen has remained unchanged since standardised in 1996. Antimicrobial therapy and fluid management are both conspicuous knowledge gaps.

In conclusion, WHO’s guidelines on the inpatient management of SAM have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with SAM is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.


1Tickella KD and Dennob DM. (2016). Inpatient management of children with severe acute malnutrition: A review of WHO guidelines. Bull World Health Organ 2016;94:642–651. doi10.2471/BLT.15.162867

2The Grading of Recommendations Assessment, Development and Evaluation.


Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al. Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013 Aug 3;382(9890):427–51. doi: PMID: 23746772 2.

Kerac M, Bunn J, Chagaluka G, Bahwere P, Tomkins A, Collins S, et al. Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): A prospective cohort study. PLoS ONE. 2014;9(6):e96030.

Fergusson P and Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg. 2009 Jun;103(6):541–8.

More like this

FEX: Thiamine content of F-75 for complicated severe acute malnutrition: time for a change?

Summary of research1 Location: Global What we know: Complicated cases of severe acute malnutrition (SAM) are usually severely ill with comorbidities. What this article adds:...

en-net: CMAM and routine medicine

Based on WHO guideline, all severe acute malnourished children admitted to therapeutic programme are supposed to receive antibiotic whether or not they show any sign and...

FEX: Research Snapshots

The following provides a short summary of each of these important research studies. A fuller summary of each can be found online at Inpatient management...

FEX: The MAMI Project – Key findings and recommendations

Summary of report1 Child malnutrition is a major global public health issue. The burden of acute malnutrition in children 6 months to 5 years is well recognised, and the...

FEX: Antibiotics as part of the management of severe acute malnutrition

Summary of published research1 Mothers receive instruction on how to adminster antibiotics Location: Malawi What we know already: There is a high prevalence of clinically...

FEX: Community management of uncomplicated malnourished infants under six months old: barriers to national policy change

By Sonja Read and Marie McGrath View this article as a pdf Sonja Read is a public health nutritionist and was lead researcher (ENN consultant) on the project. Marie McGrath...

FEX: Auditing the identification and inpatient management of acute malnutrition in infants under six months in Malawi

Summary of MSc thesis By Laura White Laura White is a Canadian-trained registered dietitian who recently completed an MSc in Nutrition for Global Health at the London School...

FEX: Integration of management of children with severe acute malnutrition in paediatric inpatient facilities in India

View this article as a pdf By Praveen Kumar, Virendra Kumar, Sila Deb, Arpita Pal, Keya Chatterjee, Rajesh Kumar Sinha and Sanjay Prabhu Praveen Kumar is a paediatrician...

FEX: Therapeutic challenges and treatment of hypovolaemic shock in severe malnutrition

Summary of proceedings1 A severely malnourished child attending the Kilifi programme A recent article by Maitland on therapeutic challenges in the treatment of severe...

FEX: A consultation of operational agencies and academic specialists on MUAC and WHZ as indicators of SAM

Summary of meeting report1 The treatment of severe acute malnutrition (SAM) is a costeffective, evidence-based ‘direct’ nutrition intervention, according to the 2008 Lancet...

FEX: Management of At risk Mothers and Infants (MAMI) meeting

A one-day meeting of the Management of At risk Mothers and Infants (MAMI)1 Special Interest Group (SIG) took place in London on 17 January 2018. The meeting was hosted by ENN...

FEX: Letter on inadequate coverage of SAM in Lancet Undernutrition Series, by Susan Shepherd

SAM inadequately addressed in the Lancet Undernutrition Series Dear Editor, In 2003, The Lancet captured and focused attention on saving children’s lives with the publication...

FEX: En-net update

By Tamsin Walters, en-net moderator Over the past four months1, 32 questions have been posted on en-net, generating 69 responses. Two upcoming trainings have been advertised...

FEX: WHO emergency nutrition response in South Sudan

By Marina Adrianopoli and Allan Mpairwe Marina Adrianopoli has been supporting WHO in South Sudan as Emergency Nutrition Focal Point since 2014. She has over 10 years'...

FEX: WHO guideline updates on the management of SAM in infants and children

The WHO has released guidance on updated evidence and practice for key interventions in the management of severe acute malnutrition (SAM) in infants and young children. The...

FEX: Building health service capacity to manage severe acute malnutrition in Mali

By Dr Malam Kanta Issa View this article as a pdf Lisez cet article en français ici Dr Malam Kanta Issa has worked as the Head of Mission for ALIMA Mali since 2015....

FEX: OptiMA study in Burkina Faso: Emerging findings and additional insights

View this article as a pdf Lisez cet article en français ici By Kevin PQ Phelan Kevin PQ Phelan is Nutrition Advisor at ALIMA, the Alliance for International Medical...

FEX: Admission profile and discharge outcomes for infants aged less than six months admitted to inpatient therapeutic care in ten countries

Summary of research* Location: Global (Burundi, DRC, Kenya, Liberia, Myanmar, Niger, Somalia, Sudan, Tajikistan, Uganda) What we know: The burden of acute malnutrition in...

FEX: Mortality and causes of mortality in children 6-59 months of age admitted to inpatient therapeutic feeding centres in Niger

By Florence Tapié de Céleyran, Kerstin Hanson, Cecilia Ferreyra, Nuria Salse, Didier Tshialala, Cristian Casademont, Rebecca Grais and Helena Huerga View this...

FEX: WHO consultation on management of moderate malnutrition in U5s

The WHO, in collaboration with UNICEF, WFP and UNHCR, hosted a second consultation to discuss the programmatic aspects of the management of moderate malnutrition in children...


Reference this page

Review of WHO guidelines for the inpatient management of severe acute malnutrition. Field Exchange 55, July 2017. p48.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.