Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

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".)

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 'Clinical assessment'.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2017. | This topic last updated: May 27, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Management of severe malnutrition: a manual for physicians and other senior health workers, WHO, Geneva 1999. www.who.int/nutrition/publications/malnutrition/en/index.html (Accessed on November 17, 2009).
  2. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl 2006; 450:76.
  3. de Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr 2007; 137:144.
  4. World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and children, 2013. Available at: http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf (Accessed on July 17, 2017).
  5. World Health Organization (WHO) and United Nations Children's Fund (UNICEF). WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization Press; Department of Child and Adolescent Health and Development, Geneva, 2009.
  6. Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for the inpatient treatment of severely malnourished children. World Health Organization, Geneva, 2003. Available at: http://www.who.int/nutrition/publications/severemalnutrition/9241546093_eng.pdf.
  7. Saitoria, EP, Mswata, A, Sanders, D, et al. Treating severe Malnutrition. Child Health Dialogue 2000:19 www.healthlink.org.uk/PDFs/chd19.pdf (Accessed on September 13, 2007).
  8. Puoane T, Sanders D, Ashworth A, et al. Improving the hospital management of malnourished children by participatory research. Int J Qual Health Care 2004; 16:31.
  9. Ashworth A. The impact of the TMRU on the treatment of severe malnutrition. In: The Tropical 18. Metabolism Research Unit, The University of the West Indies, Jamaica, Forrester T, Picou D, Walker S (Eds), Ian Randle Publishers, Kingston 2006. p.285.
  10. Wharton B. Hypoglycaemia in children with kwashiorkor. Lancet 1970; 1:171.
  11. Reed RP, Wegerhoff FO, Rothberg AD. Bacteraemia in malnourished rural African children. Ann Trop Paediatr 1996; 16:61.
  12. Friedland IR. Bacteraemia in severely malnourished children. Ann Trop Paediatr 1992; 12:433.
  13. Management of the child with a serious infection or severe malnutrition: guidelines for care at first referral level in developing countries. Geneva, World Health Organization, 2000.
  14. The treatment of diarrhea: A manual for physicians and other senior health workers, WHO 1995.
  15. Iannotti LL, Trehan I, Clitheroe KL, Manary MJ. Diagnosis and treatment of severely malnourished children with diarrhoea. J Paediatr Child Health 2015; 51:387.
  16. Manary MJ, Hart CA, Whyte MP. Severe hypophosphatemia in children with kwashiorkor is associated with increased mortality. J Pediatr 1998; 133:789.
  17. Kimutai D, Maleche-Obimbo E, Kamenwa R, Murila F. Hypo-phosphataemia in children under five years with kwashiorkor and marasmic kwashiorkor. East Afr Med J 2009; 86:330.
  18. Yoshimatsu S, Hossain MI, Islam MM, et al. Hypophosphatemia among severely malnourished children with sepsis in Bangladesh. Pediatr Int 2013; 55:79.
  19. Golden MH. Proposed recommended nutrient densities for moderately malnourished children. Food Nutr Bull 2009; 30:S267.
  20. Ogden CL, Kuczmarski RJ, Flegal KM, et al. Centers for Disease Control and Prevention 2000 growth charts for the United States: improvements to the 1977 National Center for Health Statistics version. Pediatrics 2002; 109:45.
  21. Collins S, Myatt M, Golden B. Dietary treatment of severe malnutrition in adults. Am J Clin Nutr 1998; 68:193.
  22. English M, Snow RW. Iron and folic acid supplementation and malaria risk. Lancet 2006; 367:90.
  23. Sazawal S, Black RE, Ramsan M, et al. Effects of routine prophylactic supplementation with iron and folic acid on admission to hospital and mortality in preschool children in a high malaria transmission setting: community-based, randomised, placebo-controlled trial. Lancet 2006; 367:133.
  24. Tielsch JM, Khatry SK, Stoltzfus RJ, et al. Effect of routine prophylactic supplementation with iron and folic acid on preschool child mortality in southern Nepal: community-based, cluster-randomised, placebo-controlled trial. Lancet 2006; 367:144.
  25. Neuberger A, Okebe J, Yahav D, Paul M. Oral iron supplements for children in malaria-endemic areas. Cochrane Database Syst Rev 2016; 2:CD006589.
  26. The treatment of diarrhea; A manual for physicians and other senior health workers, WHO, Geneva 2005 http://www.who.int/child_adolescent_health/documents/9241593180/en/index.html (Accessed on November 17, 2009).
  27. Jahoor F. Effects of decreased availability of sulfur amino acids in severe childhood undernutrition. Nutr Rev 2012; 70:176.
  28. Becker K, Pons-Kühnemann J, Fechner A, et al. Effects of antioxidants on glutathione levels and clinical recovery from the malnutrition syndrome kwashiorkor--a pilot study. Redox Rep 2005; 10:215.
  29. Badaloo A, Reid M, Forrester T, et al. Cysteine supplementation improves the erythrocyte glutathione synthesis rate in children with severe edematous malnutrition. Am J Clin Nutr 2002; 76:646.
  30. Ciliberto H, Ciliberto M, Briend A, et al. Antioxidant supplementation for the prevention of kwashiorkor in Malawian children: randomised, double blind, placebo controlled trial. BMJ 2005; 330:1109.
  31. Grantham-McGregor SM, Stewart M, Desai P. A new look at the assessment of mental development in young children recovering from severe malnutrition. Dev Med Child Neurol 1978; 20:773.
  32. Grantham-McGregor SM. Assessments of the effects of nutrition on mental development and behavior in Jamaican studies. Am J Clin Nutr 1993; 57:303S.
  33. Oyedeji GA, Olamijulo SK, Osinaike AI, et al. Head circumference of rural Nigerian children--the effect of malnutrition on brain growth. Cent Afr J Med 1997; 43:264.
  34. Dale NM, Myatt M, Prudhon C, Briend A. Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children. PLoS One 2013; 8:e55404.
  35. Chang CY, Trehan I, Wang RJ, et al. Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery. J Nutr 2013; 143:215.
  36. Trehan I, Banerjee S, Murray E, et al. Extending supplementary feeding for children younger than 5 years with moderate acute malnutrition leads to lower relapse rates. J Pediatr Gastroenterol Nutr 2015; 60:544.
  37. Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Children's Fund, 2007. Available at: http://www.who.int/nutrition/publications/severemalnutrition/978-92-806-4147-9_eng.pdf (Accessed on July 17, 2017).
  38. Manary MJ, Sandige HL. Management of acute moderate and severe childhood malnutrition. BMJ 2008; 337:a2180.
  39. Trehan I, Manary MJ. Management of severe acute malnutrition in low-income and middle-income countries. Arch Dis Child 2015; 100:283.
  40. Valid International http://www.validinternational.org/demo/ctc/about.php (Accessed on February 01, 2013).
  41. Community-based therapeutic care - A field manual. Valid international, Oxford, U.K. www.validinternational.org (Accessed on September 13, 2007).
  42. Collins S. Treating severe acute malnutrition seriously. Arch Dis Child 2007; 92:453.
  43. Schofield C, Ashworth A. Why have mortality rates for severe malnutrition remained so high? Bull World Health Organ 1996; 74:223.
  44. Collins S, Dent N, Binns P, et al. Management of severe acute malnutrition in children. Lancet 2006; 368:1992.
  45. Ciliberto MA, Manary MJ, Ndekha MJ, et al. Home-based therapy for oedematous malnutrition with ready-to-use therapeutic food. Acta Paediatr 2006; 95:1012.
  46. Gatchell V, Forsythe V, Thomas PR. The sustainability of community-based therapeutic care (CTC) in nonemergency contexts. Food Nutr Bull 2006; 27:S90.
  47. Ndekha MJ, Manary MJ, Ashorn P, Briend A. Home-based therapy with ready-to-use therapeutic food is of benefit to malnourished, HIV-infected Malawian children. Acta Paediatr 2005; 94:222.
  48. Prudhon C, Prinzo ZW, Briend A, et al. Proceedings of the WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children. Food Nutr Bull 2006; 27:S99.
  49. Diop el HI, Dossou NI, Ndour MM, et al. Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial. Am J Clin Nutr 2003; 78:302.
  50. Lazzerini M, Rubert L, Pani P. Specially formulated foods for treating children with moderate acute malnutrition in low- and middle-income countries. Cochrane Database Syst Rev 2013; :CD009584.
  51. Lenters LM, Wazny K, Webb P, et al. Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health 2013; 13 Suppl 3:S23.
  52. Manary MJ. Local production and provision of ready-to-use therapeutic food (RUTF) spread for the treatment of severe childhood malnutrition. Food Nutr Bull 2006; 27:S83.
  53. Collins, S, Henry, J. Alternative RUTF formulations. Emergency Nutrition Network 2004; special supplement 2:35. www.validinternational.org/pages/sub.cfm?id=1663 (Accessed on May 24, 2007).
  54. Kerac M, Bunn J, Seal A, et al. Probiotics and prebiotics for severe acute malnutrition (PRONUT study): a double-blind efficacy randomised controlled trial in Malawi. Lancet 2009; 374:136.
  55. Oakley E, Reinking J, Sandige H, et al. A ready-to-use therapeutic food containing 10% milk is less effective than one with 25% milk in the treatment of severely malnourished children. J Nutr 2010; 140:2248.
  56. Phuka J, Thakwalakwa C, Maleta K, et al. Supplementary feeding with fortified spread among moderately underweight 6-18-month-old rural Malawian children. Matern Child Nutr 2009; 5:159.
  57. Trehan I, Goldbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med 2013; 368:425.
  58. Isanaka S, Langendorf C, Berthé F, et al. Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children. N Engl J Med 2016; 374:444.
  59. Lutter CK, Mora JO, Habicht JP, et al. Nutritional supplementation: effects on child stunting because of diarrhea. Am J Clin Nutr 1989; 50:1.
  60. Guerrant RL, Oriá RB, Moore SR, et al. Malnutrition as an enteric infectious disease with long-term effects on child development. Nutr Rev 2008; 66:487.
  61. Mbugi EV, Meijerink M, Veenemans J, et al. Effect of nutrient deficiencies on in vitro Th1 and Th2 cytokine response of peripheral blood mononuclear cells to Plasmodium falciparum infection. Malar J 2010; 9:162.
  62. Caulfield LE, Richard SA, Black RE. Undernutrition as an underlying cause of malaria morbidity and mortality in children less than five years old. Am J Trop Med Hyg 2004; 71:55.
  63. de Pee S, Semba RD. Role of nutrition in HIV infection: review of evidence for more effective programming in resource-limited settings. Food Nutr Bull 2010; 31:S313.
  64. Rah JH, Akhter N, Semba RD, et al. Low dietary diversity is a predictor of child stunting in rural Bangladesh. Eur J Clin Nutr 2010; 64:1393.
  65. Sari M, de Pee S, Bloem MW, et al. Higher household expenditure on animal-source and nongrain foods lowers the risk of stunting among children 0-59 months old in Indonesia: implications of rising food prices. J Nutr 2010; 140:195S.
  66. Golden MH. Evolution of nutritional management of acute malnutrition. Indian Pediatr 2010; 47:667.
  67. Nackers F, Broillet F, Oumarou D, et al. Effectiveness of ready-to-use therapeutic food compared to a corn/soy-blend-based pre-mix for the treatment of childhood moderate acute malnutrition in Niger. J Trop Pediatr 2010; 56:407.
  68. Bhutta ZA, Ahmed T, Black RE, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371:417.
Topic Outline