SAM and MAM criteria
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"severe acute malnutrition" AND "moderate acute malnutrition" AND criteria
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SAM and MAM: Diagnostic Criteria & Management
Definitions
Acute malnutrition (also called "wasting") is defined as a weight-for-height/length (WFH/L) Z-score at least 2 standard deviations below the WHO Child Growth Standards median. It is classified into two severity tiers:
SAM - Severe Acute Malnutrition
Diagnostic Criteria (any ONE of the following):
| Criterion | Threshold |
|---|---|
| Weight-for-height/length (WFH/L) Z-score | < -3 SD (below median WHO standards) |
| Mid-upper arm circumference (MUAC) | < 115 mm (in children ≥ 6 months) |
| Bilateral pitting edema of both feet | Present (nutritional/kwashiorkor-type edema) |
Children who are severely wasted are 9 times more likely to die than well-nourished children. SAM significantly increases case fatality in common illnesses like diarrhea and pneumonia.
SAM Sub-classification (IMNCI framework):
Complicated SAM (Pink - refer urgently):
- Meets SAM criteria PLUS any of:
- Any general danger sign
- Any severe classification
- Pneumonia with chest indrawing
- Unable to finish RUTF (Ready-to-Use Therapeutic Food)
- Breastfeeding problem (in infants < 6 months)
- Management: First-dose antibiotic, prevent hypoglycemia, keep warm, refer URGENTLY to hospital
Uncomplicated SAM (Yellow - outpatient):
- Meets SAM criteria AND able to finish RUTF (no medical complications)
- Management: Oral antibiotics x 5 days, RUTF for children ≥ 6 months, feeding counseling, assess for TB, follow-up in 7 days
MAM - Moderate Acute Malnutrition
Diagnostic Criteria (any ONE of the following):
| Criterion | Threshold |
|---|---|
| WFH/L Z-score | -3 to -2 SD (between -3 and -2) |
| MUAC | 115 mm to < 125 mm (in children ≥ 6 months) |
| Edema | Absent (presence of edema = SAM by definition) |
Management (Yellow category):
- Assess child's feeding, counsel mother on feeding recommendations
- Assess for possible TB infection
- If feeding problem identified: follow up in 7 days
- Routine follow-up: 30 days
- No RUTF (used only for SAM); microbiota-directed dietary supplements may improve weight gain in MAM
Normal Nutritional Status (No Acute Malnutrition)
| Criterion | Threshold |
|---|---|
| WFH/L Z-score | ≥ -2 SD |
| MUAC | ≥ 125 mm |
Quick Comparison Table
| Feature | SAM | MAM |
|---|---|---|
| WFH/L Z-score | < -3 SD | -3 to -2 SD |
| MUAC | < 115 mm | 115-124 mm |
| Bilateral edema | May be present | Absent |
| Setting | Complicated: hospital; Uncomplicated: outpatient | Outpatient/community |
| Therapeutic food | RUTF | Supplementary food / microbiota-directed supplements |
| Follow-up | 7 days | 30 days |
| Mortality risk | 9x higher than normal | Elevated but less than SAM |
Clinical Forms of SAM
- Kwashiorkor - protein-deficient; features: edema, hypoalbuminemia, fatty liver, skin and hair depigmentation, hepatomegaly
- Marasmus - protein + energy deficient; features: severe wasting, no/minimal edema, minimal subcutaneous fat, severe muscle wasting, non-normal albumin
- Marasmic kwashiorkor - combined features of both
MUAC Note (Arm Circumference Interpretation):
| MUAC | Status |
|---|---|
| ≥ 13.5 cm (135 mm) | Satisfactory nutrition |
| 12.5 - 13.5 cm (125-135 mm) | Mild-moderate malnutrition |
| < 12.5 cm (125 mm) | Severe malnutrition |
| < 11.5 cm (115 mm) | SAM threshold |
(Sources: Park's Textbook of Preventive and Social Medicine; Robbins, Cotran & Kumar Pathologic Basis of Disease)
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