MODULE 2

Identification of Acute Malnutrition

Name
Designation
Office/Agency
Learning Objectives
At the end of the module, you will be able to:
• Identify children with MAM and SAM
• Measure weight and height/length correctly
• Determine the appropriate Z-score based on weight and height
• Measure the mid-upper arm circumference correctly
• Test for the presence or absence of edema
• Perform the appetite test
Measuring Malnutrition

1. Clinical signs
2. Biochemical testing
3. Dietary intake
4. Anthropometry
Determine Age and Sex

• Record age and sex

• Girls and boys grow and
develop differently
• Record Age in months
Determine Age in Months
• Date of examination minus date of birth in the following
arrangement: year/month/day
2017 03 14 2016 15 14
2013 11 08 2013 11 08
3 4 06
• Borrow 12 months from 2017
• Convert 3 years to 36 months
Therefore: Age in months = 40 months
 Measuring Malnutrition
Anthropometry
• The study and technique of
taking measurements of the
human body
• Method to assess growth
based on measures of physical
characteristics of the body
(e.g. weight, height, etc.)
• Cannot detect micronutrient
malnutrition
• Basic information and
body measurements
needed to assess an
individual’s
anthropometric status
include:
 Age
 Sex
 Weight
 Height/Length
 Left Mid-Upper Arm

Circumference
 Measuring Weight
• Measure at eye level
• Measure to the nearest 100g
• A hanging scale, a plastic basin, malong or others
may be used as long as it is secured by at least 4
ropes
• The carrier should be close to the ground
• Best if the child would not have clothes on for
weighing, ensure s/he will not be cold
• Always record immediately
 Measuring Weight
Standardize scales daily or whenever they are moved:
• Set the scale to zero
• Weigh three objects of known weight (e.g. 5, 10, and 15 kg) and
record the measured weights
• Repeat the weighing of these objects and record the weights again
• Check the scales or replace them when there is a difference of
0.01 kg or more between duplicate weighing

NOTE: A measured weight differs by 0.01 kg or more from the known standard
 Exercise:

Is this Correct
or Incorrect?
Incorrect.
• Scale not at eye level.
• Child is dressed.
 Measuring Length/Height

Measure length Measure height

• Less than 87 cm (or less than 3 feet) • 87 cm or taller
• Less than 2 years • 2 years and older
• Or those too weak to stand • Capable of standing up

NOTE: NOTE:
For children < 2 y/o For children ≥ 2 y/o or
or < 87cm who can ≥87cm who are unable
stand, the HEIGHT is to stand, the LENGTH
measured and 0.7cm is measured and 0.7cm
is added to the is deducted from the
measurement. measurement.
 Measuring Length

• Requires a partner to help position

child
• Use a length board with:
 a fixed head board and
 a movable foot plate
• Place on a level floor
• Remove the child’s socks and shoes
• Remove lower garments/diapers
• Remove any worn hair ornaments
 Measuring Length

• Child MUST look straight ahead with

his/her head parallel to the baseboard
• Legs are straight
• Feet firmly planted on the foot plate
• Read length/height to the nearest 0.1
cm
How is this position?

16
Incorrect! Incorrect Hand Position.
Hands Pressing against Ears.
Thumbs Pressing on Shoulders.

17
How is this position?

18
Incorrect!
Incorrect Child Head Position.
Chin against Chest.

19
Feet flat, heels against board

20
How is this position?

21
Correct

22
How is this position?

23
Incorrect

24
Correct or Incorrect?
Incorrect
• No partner.
• Child's neck is not
straight. Head not
facing forward
• Feet are not flat on
the foot plate.
Exercise!

Demo-Return Demo (Length Measurement)

 Measuring Height
• Requires a partner
• Use a height board with
 a vertical backboard,
 a fixed base board, and
 a movable head board
• Place on a level floor
• Remove the child’s socks and shoes
for accurate measurement
• Remove any worn hair ornaments
Exercise!

94.2 cm
What is the
height?
Is this position correct or incorrect?

29
Incorrect

30
Is this position correct or incorrect?

31
Incorrect

32
Determining the Z-score
What is the Z-score?
• It is a way to compare a child’s weight-
for-length (WFL) or weight-for- height
(WFH) to an “average”

• Use the WHO Child Growth Standards

Table
 0-23 months (boys and girls)
 24-60 months (boys and girls)
 Remember!
Normal MAM SAM

WFL/H -2 to + 2 < - 2 to -3 < -3

Z-score

WFL/H Z = Weight for Length/Height Z-

score
Steps in determining the Z-score
Do this after measuring weight and length/height
1. Take note of child’s sex
2. Determine the child’s age (in months preferably)
3. Use the correct WHO Child Growth Standards Table
4. Round off measured length or height for child's sex and age
in month to the nearest 0.5 cm
Rounding off Length/Height in centimeters (cm):

a. Subtract/Add 0.2 cm up and down from 81 cm

to get the lower and upper limits
80.8
80.9
81
81
81.1
81.2

b. Round off values between 80.8 and 81.2 to 81

Rounding off Length/Height in centimeters (cm):
 Steps in determining the Z-score
Do this after measuring weight and height/length:
Locate the length/height on the correct WHO Growth Standard Table

Example: a 25 month old boy with length 66.0 cm and weight 6.3 kg. Use the CGS form for BOYS ages 24-
60 month:

NOTE: see if it is under category

“Severely Wasted”, “Moderately
Wasted”, “Normal”,
“Overweight” or “Obese”
 Steps in determining the Z-score
Do this after measuring weight and height/length:

Example: a 25 month old boy with length 66.0 cm and weight 6.3 kg.

 Note the Z-score

 Record
 25 month old boy
 L 66.0 cm
 W 6.3 kg
 WFH Z between -3 and <-2 SD

A> MAM
Exercise!
A 32 month old girl’s height is 95.3 cm and her weight is 10.0 kg.
What is her WFH Z-score?
Do the steps:
1. Secure correct WHO Child Growth
Standards Table for age and sex.
2. Round off height to nearest 0.5 cm.
3. Round off 95.3 cm to 95.5 cm.
4. Locate 95.5 on Table.
5. Locate 10 kg along line i.e. < 10.7 kg
6. Classify nutritional status “severely
wasted” and record.
7. Record Z-score “< -3SD”
8. A> SAM
 Remember!
Normal MAM SAM

WFL/H -2 to + 2 < - 2 to -3 < -3

Z-score

WFL/H Z = Weight for Length/Height Z-

score
Measuring the Left Mid Upper Arm Circumference
(MUAC)
• Measured in children older than 6 to 60 months of age
• A simple measure of muscle wasting
• An independent measure of SAM
• Strongly predicts risk of dying from SAM
Measure the MUAC

Palpate the tip of

Always measure the the shoulder
left upper arm’s
midpoint between
shoulder and elbow
Landmarks – always measure from behind using the
left arm
1. Palpate the tip of the left shoulder
2. Palpate the tip of the bent elbow
3. Measure the distance between these two
landmarks.
4. Divide this measurement by 2.
5. This is the midpoint of the left upper arm.
6. Assistant marks the spot.
Example:
Measured distance is 15 cm.
15 cm ÷ 2 = 7.5 cm
Mark this point.
Measure the MUAC at this level.
Measuring the MUAC
Remember!

Normal MAM SAM

WFL/H -2 to + 2 < - 2 to -3 < -3
Z-score

MUAC ≥ 12.5 cm 11.5 cm to < 11.5 cm

12.4 cm
Exercise!

Demo-Return Demo
Testing for Edema
Edema – a large amount of fluid gathers so that the tissues look
swollen or puffed up

Bilateral edema is the sign of kwashiorkor, a severe form of acute

malnutrition.

These children are at high risk of dying and need to be treated in a

therapeutic feeding program urgently.
Testing for Edema
To Both Feet:
• Apply normal thumb pressure
for at least three seconds
• If a shallow print persists on
both feet, record as (+) edema

Edema on both feet (i.e. bilateral) is nutritional edema.

What is wrong here?

53
Classification of Acute Malnutrition for children over
6 to 59 months based on MUAC, WFL/H Z-score, Edema
Parameter Normal MAM SAM

MUAC ≥ 12.5 cm 11.5 to 12.4 cm < 11.5 cm

and and/or and/or
WFL or WFH -2 to +2 SD < -2 to -3 SD < -3 SD
Z-Score
and and and/or
Edema None None Present
Classification of Acute Malnutrition for Infants
less than 6 months based on WFL Z-score and Edema

Parameter Normal MAM SAM

WFL Z-Score -2 to +2 SD < -2 to -3 SD < -3 SD

and and and/or

Edema None None Present
You can now identify SAM.
Next, identify the child with SAM for OTC or ITC, or
the child with MAM for TSFP

Targeted
Supplementary
Feeding
 The Appetite Test
• Loss of appetite is the best sign of
severe metabolic malnutrition
• Appetite test is a critical part of the
assessment of the child with SAM
• It helps distinguish whether the child
with SAM needs a referral to Out-
patient Therapeutic Care (OTC) or In-
patient Therapeutic Care (ITC)
• Appetite is tested using Ready to Use
Therapeutic Food (RUTF)
Testing appetite
1. Explain to the caregiver on why the
test will be done.
2. Instruct caregiver to wash hands
properly.
3. Sit caregiver and child in a quiet space.
YOU will observe the entire process.
4. Have the caregiver offer a small
amount of RUTF on his/her finger or
directly to the child from the sachet.
Testing appetite
5. Offer water or breastfeed
after the child takes RUTF.
6. If the child is not taking it,
gently encourage intake. Do
not force feed.
7. Record amount that child has
eaten.
Testing appetite of a child with SAM
Pass Fail
The child takes 3 - 4 mouthfuls or The child takes less than 3 - 4
more of RUTF mouthfuls of RUTF. S/he is
considered to lack sufficient
appetite for OTC and should be
referred to the ITC.
Do we still need to do Appetite test
to a child with MAM?
NO, because appetite test is just
for children with SAM
Referral Form to ITC or OTC
 Exercise!

• 48 months old boy

• WFH Z is < -2 SD to – 3 SD
• MUAC 13.5 cm
• Grade 2 edema
• What is your assessment? SAM

• Next Step?
Perform appetite test.
 Summary
• Identification of MAM and SAM is an important skill for all who work in health and
nutrition, from the barangay to the hospital level.
• Acute Malnutrition is also known as Wasting with edema.
• Moderate Acute Malnutrition (MAM) is also known as Moderate Wasting; Severe
Acute Malnutrition (SAM) is also known as Severe Wasting with edema
• The classification of malnutrition to moderate or severe is dependent on
anthropometric measurements and testing for edema.
• It is important to accurately measure weight and length/height, determine the
appropriate Z-score, alternatively to measure the MUAC.
• Testing appetite is critical in deciding whether a child with SAM needs OTC or ITC
treatment.
• Correct identification of MAM and SAM can save that child’s life.
 Why do we prefer WEIGHT FOR LENGTH/HEIGHT
over Weight-for-Age in identifying children with Acute Malnutrition
B
D Weight
F
A for Age
C
Overweight to Obese
E
H G
I
J +2
K
L Normal
M (Median)
N
O P
-2
Q
Underweight

Source: Measuring Change in Nutritional Status: Guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva, World Health Organization, 1983:
P27; Calculated from the data for 18 months old boys in the NCHS reference population. Letters A to Q are children
 Why do we prefer WEIGHT FOR HEIGHT/LENGTH
over Weight-for-Age in identifying children with Acute Malnutrition
Weight B
for Height Weight
D F
Overweight A for Age
to Obese
C
+2 Overweight to Obese
E
H G
Normal
(Median) I
J +2
K
-2 L Normal
M (Median)
Wasted N
(Acutely O P
-2
Malnourished)
Q
Underweight

Source: Measuring Change in Nutritional Status: Guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva, World Health Organization, 1983:
P27; Calculated from the data for 18 months old boys in the NCHS reference population. Letters A to Q are children
How about Length/Height for Age? What does it measure?
Weight B
for Height Weight
D F
Overweight A for Age
to Obese
C
+2 Overweight to Obese
E
H G
Normal
(Median) I
J +2
K
-2 L Normal
M (Median)
Wasted N
(Acutely O P
-2
Malnourished)
Q
Underweight
-2 Normal (median)+2

Height for Age