It will not always be easy for you to decide who should be referred to a higher level, or who you should treat yourself at your health facility. As you read above this will mainly (but not only) depend on whether the child's severe acute malnutrition is 'complicated' or 'uncomplicated'.

Certain criteria have been established to help you decide whether a child has severe complicated or severe uncomplicated malnutrition:

Age: all infants under six months of age with severe acute malnutrition (SAM) need to be treated in an in-patient facility

The presence of any medical complications, including any of the general danger signs, pneumonia/severe pneumonia, blood in the stool, fever or hypothermia mean that the severely malnourished child is classified as severe complicated malnutrition and must be treated in an in-patient facility. The table below gives you a summary of the key complications that you should look for when helping to treat children with severe acute malnutrition.

> means greater than or equal to. < means less than or equal to.

Complications and indicators for referral of children with severe acute malnutrition

Complication	Referral to in-patient care when:
General danger sign	If one of the following is present: vomiting everything, convulsion, lethargy, unconscious, or unable to feed
Pneumonia	Fast breathing For child six-12 months 50 breaths per minute and above For a child 12 months-five years 40 breaths per minute and above For a child older than five years 30 breaths per minute and above
Severe pneumonia	A child with fast breathing as indicated above and chest in-drawing
Dysentery	If blood in the stool
Fever or Low body temperature	T > 37.5 or febrile to touch T < 35°C or cold to touch

Children with poor appetite are also classified as having severe complicated malnutrition and need to be referred to in-patient care. Details on how to test for appetite will be explained briefly below.