Diagnosis of SAM

1. Definition and Diagnostic Criteria (Children 6–59 Months)

SAM is defined by the presence of any one of the following three criteria in a child aged 6 to 59 months:

• Severe Wasting (Weight-for-Height/Length):
  • Weight-for-Height (or Length) Z-score < -3 Standard Deviations (SD) of the WHO Child Growth Standards,,,.
  • This indicates that the child is very thin for their height due to acute nutrient loss.
• Mid-Upper Arm Circumference (MUAC):
  • MUAC < 115 mm (< 11.5 cm),,,.
  • Measurement is done on the left upper arm using a standard color-coded tape.
  • Red Zone: Indicates SAM,.
• Nutritional Oedema:
  • Presence of bilateral pitting oedema of the feet,,,.
  • Method of Assessment: Apply gentle thumb pressure on the dorsum of both feet for at least 3 seconds (count 1001, 1002, 1003). If a pit (dent) remains after releasing the thumb, oedema is present,.
  • Significance: The presence of bilateral oedema and low albumin is diagnostic for Kwashiorkor, which is classified as severe malnutrition regardless of other anthropometric indicators.

2. Diagnostic Criteria for Infants (< 6 Months)

The criteria for infants less than 6 months differ because MUAC is not a validated indicator for this age group. Diagnosis is based on:

• Weight-for-Length: < -3 Z-score (using WHO standards),.
• Visible Severe Wasting:
  • Used when length is < 49 cm or weight-for-length charts are unavailable.
  • Look for severe loss of muscle and fat on the shoulders, arms, buttocks, and thighs. The skin may appear loose, often described as a "baggy pants" appearance on the buttocks,,.
• Bilateral Pitting Oedema: Presence of oedema in both feet (after excluding medical causes like nephrotic syndrome),.

3. Classification Based on Complications (Triage)

Once SAM is diagnosed, the child must be further assessed to determine the treatment setting (Inpatient vs. Outpatient).

A. Complicated SAM (Requires Inpatient Care/Facility-Based Management)

A child with SAM is classified as "Complicated" if they have any of the following,,:

• Poor Appetite: Fails the Appetite Test (unable to consume a specific amount of Ready-to-Use Therapeutic Food/RUTF),.
• Medical Complications:
  • Severe oedema (+++, generalized).
  • Hypothermia, hypoglycemia, severe dehydration, or shock.
  • Severe anemia (severe palmar pallor).
  • Infections: Pneumonia, severe skin infection, tuberculosis, etc.
  • IMNCI Danger Signs: Lethargy, unconsciousness, convulsions.
• Age < 6 months: All infants under 6 months with SAM are typically managed as inpatients.

B. Uncomplicated SAM (Community/Home-Based Management)

A child is classified as "Uncomplicated" if they meet all the following criteria,,:

• Good Appetite: Passes the appetite test.
• Clinically Well: Alert and no medical complications.
• Mild Oedema: Oedema is absent or mild (+ or ++).

4. Summary Table of Diagnostic Cut-offs