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Severe malnutrition in children in resource-limited countries: Treatment

William J Klish, MD
Buford L Nichols, MD
Section Editor
Kathleen J Motil, MD, PhD
Deputy Editor
Alison G Hoppin, MD


Severe malnutrition is primarily a problem in resource-limited ("developing") countries. Severely malnourished children typically are brought to medical attention when a health crisis, such as an infection, precipitates the transition between marasmus (a state of nutritional adaptation) and kwashiorkor, in which adaptation is no longer adequate. In some cases malnutrition is precipitated by political disruptions like war or natural disasters like drought, which interfere with the food supply. (See "Malnutrition in children in resource-limited countries: Clinical assessment", section on 'Protein-energy malnutrition'.)

An intensive and comprehensive approach is required to reduce the mortality rate associated with this condition and improve outcome. The initial nutritional and medical management, rehabilitation, and follow-up of children from resource-limited countries with severe malnutrition are reviewed here. Causes and clinical manifestations associated with this disorder are discussed separately. (See "Malnutrition in children in resource-limited countries: Clinical assessment" and "Micronutrient deficiencies associated with malnutrition in children".)

The treatment of malnourished children from resource-rich countries is discussed elsewhere. Although the principles of treatment of malnourished children from resource-rich countries are similar to those from resource-limited countries, the specific details may vary based on local customs and resources. (See "Failure to thrive (undernutrition) in children younger than two years: Management".)

The approach to treating children with severe malnutrition as inpatients in hospitals or feeding centers, as promoted by the World Health Organization (WHO) protocol, is described below. A different approach to management of malnutrition, known as community-based therapeutic care (CTC) is also discussed briefly. This approach appears to produce equal recovery and case fatality rates, and to increase population coverage, and has been successfully implemented by relief organizations. (See 'Community-based therapeutic care' below.)


The World Health Organization (WHO) developed criteria for the classification of severe malnutrition in children [1]. These criteria are based upon the degree of wasting or stunting and the presence of edema (table 1). The child's weight for his or her height and the height for his or her age are expressed as Z-scores (also known as the standard deviation [SD] score), calculated as the observed value minus the median value of the reference population divided by the standard deviation of the reference population. (See "Malnutrition in children in resource-limited countries: Clinical assessment", section on 'Assessment of severity'.)


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