Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management of uncomplicated severe acute malnutrition in children in resource-limited countries

Indi Trehan, MD, MPH, DTM&H
Mark J Manary, MD
Section Editors
Kathleen J Motil, MD, PhD
Deputy Editor
Alison G Hoppin, MD


Community-based management of acute malnutrition (CMAM) is a structured system of outpatient care for children with uncomplicated severe acute malnutrition (SAM). Key components of CMAM programs are provision of a therapeutic food that is of high nutritional quality and has minimal spoilage, known as ready-to-use therapeutic food (RUTF), and regular follow-up at home or in decentralized health centers ideally in proximity to where children live by trained community-based health workers. Using this strategy, more than 90 percent of children with SAM can be treated as outpatients, provided that the child has a good appetite and no obvious acute infection or other medical complications [1]. Children with anorexia or complications are initially treated in inpatient programs, but are transferred to outpatient care as soon as possible [2].

Over the past two decades, an increasing number of countries and relief agencies have adopted CMAM with remarkable success, leading to widespread acceptance and dissemination of this approach worldwide. Where CMAM is available, nutritional recovery rates can be expected to regularly exceed 80 percent, and case fatality rates can be expected in the 5 to 10 percent range, or even better in particularly well-functioning programs. Effective CMAM requires the presence of trained staff, reliable supply chains for RUTF and medications, and the possibility of referral for inpatient care if needed. Because of the increasing availability of RUTF, CMAM has mostly replaced the historical system of universal inpatient management, which was plagued by limited access, poor outcomes, and high costs. There certainly remains an important role for hospitalization for children with complicated SAM. However, CMAM allows most acutely malnourished children to "skip" the inpatient phase of treatment and allows for an orderly transition of care once children with complicated SAM have recovered sufficiently.  

Treatment of children with uncomplicated SAM using CMAM is described in this topic review. Treatment of complicated SAM and the evaluation of a child with malnutrition are discussed separately. (See "Management of complicated severe acute malnutrition in children in resource-limited countries" and "Malnutrition in children in resource-limited countries: Clinical assessment".)


The initial evaluation of a child at a feeding center is described in detail separately. (See "Malnutrition in children in resource-limited countries: Clinical assessment".)

Classification — In children 6 through 59 months of age, severe acute malnutrition (SAM) is defined by anthropometric criteria using mid-upper arm circumference (MUAC) <11.5 cm (115 mm), or weight-for-height Z-score <-3, or bilateral pitting edema (table 1). The malnutrition is considered uncomplicated if the child has no clinically obvious acute infections or other medical complications and has a good appetite, determined by an "appetite test" during the initial evaluation. (See 'Indications for community-based management' below.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 11, 2017.
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. Murray E, Manary M. Home-based therapy for severe acute malnutrition with ready-to-use food. Paediatr Int Child Health 2014; 34:266.
  2. Trehan I, Manary MJ. Management of severe acute malnutrition in low-income and middle-income countries. Arch Dis Child 2015; 100:283.
  3. Kerac M, Mwangome M, McGrath M, et al. Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research. Food Nutr Bull 2015; 36:S30.
  4. Angood C, McGrath M, Mehta S, et al. Research priorities to improve the management of acute malnutrition in infants aged less than six months (MAMI). PLoS Med 2015; 12:e1001812.
  5. Mwangome M, Ngari M, Fegan G, et al. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr 2017.
  6. 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).
  7. WHO. Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013 http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf (Accessed on July 10, 2017).
  8. 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).
  9. Iannotti LL, Trehan I, Clitheroe KL, Manary MJ. Diagnosis and treatment of severely malnourished children with diarrhoea. J Paediatr Child Health 2015; 51:387.
  10. Isanaka S, Kodish SR, Berthé F, et al. Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution. Am J Clin Nutr 2017; 105:1191.
  11. 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.
  12. 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).
  13. Briend A, Akomo P, Bahwere P, et al. Developing food supplements for moderately malnourished children: lessons learned from ready-to-use therapeutic foods. Food Nutr Bull 2015; 36:S53.
  14. Bahwere P, Balaluka B, Wells JC, et al. Cereals and pulse-based ready-to-use therapeutic food as an alternative to the standard milk- and peanut paste-based formulation for treating severe acute malnutrition: a noninferiority, individually randomized controlled efficacy clinical trial. Am J Clin Nutr 2016; 103:1145.
  15. Weber JM, Ryan KN, Tandon R, et al. Acceptability of locally produced ready-to-use therapeutic foods in Ethiopia, Ghana, Pakistan and India. Matern Child Nutr 2017; 13.
  16. 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.
  17. Jones KD, Hünten-Kirsch B, Laving AM, et al. Mesalazine in the initial management of severely acutely malnourished children with environmental enteric dysfunction: a pilot randomized controlled trial. BMC Med 2014; 12:133.
  18. Jones KD, Ali R, Khasira MA, et al. Ready-to-use therapeutic food with elevated n-3 polyunsaturated fatty acid content, with or without fish oil, to treat severe acute malnutrition: a randomized controlled trial. BMC Med 2015; 13:93.
  19. Hsieh JC, Liu L, Zeilani M, et al. High-Oleic Ready-to-Use Therapeutic Food Maintains Docosahexaenoic Acid Status in Severe Malnutrition. J Pediatr Gastroenterol Nutr 2015; 61:138.
  20. Brenna JT, Akomo P, Bahwere P, et al. Balancing omega-6 and omega-3 fatty acids in ready-to-use therapeutic foods (RUTF). BMC Med 2015; 13:117.
  21. Feeding malnourished children different types of fatty acids to promote neurocognitive development https://clinicaltrials.gov/ct2/show/NCT03094247 (Accessed on July 10, 2017).
  22. www.gcrieber-compact.com/product-range/malnutrition/treatment-severe/bp-100/ (Accessed on August 26, 2017).
  23. www.gcrieber-compact.com/product-range/malnutrition/treatment-severe/bp-100-paste/ (Accessed on August 26, 2017).
  24. UNICEF Position Statement: Ready-to-use therapeutic food for children with severe acute malnutrition, 2013. Available at: https://www.unicef.org/media/files/Position_Paper_Ready-to-use_therapeutic_food_for_children_with_severe_acute_malnutrition__June_2013.pdf (Accessed on August 31, 2017).
  25. 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.
  26. 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.
  27. 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.
  28. 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.
  29. 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.
  30. Isanaka S, Langendorf C, Berthé F, et al. Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children. N Engl J Med 2016; 374:444.
  31. Million M, Lagier JC, Raoult D. Meta-analysis on efficacy of amoxicillin in uncomplicated severe acute malnutrition. Microb Pathog 2017; 106:76.
  32. Kabalo MY, Seifu CN. Treatment outcomes of severe acute malnutrition in children treated within Outpatient Therapeutic Program (OTP) at Wolaita Zone, Southern Ethiopia: retrospective cross-sectional study. J Health Popul Nutr 2017; 36:7.
  33. Yebyo HG, Kendall C, Nigusse D, Lemma W. Outpatient therapeutic feeding program outcomes and determinants in treatment of severe acute malnutrition in tigray, northern ethiopia: a retrospective cohort study. PLoS One 2013; 8:e65840.
  34. 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 August 02, 2017).
  35. 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.
  36. Stobaugh HC, Bollinger LB, Adams SE, et al. Effect of a package of health and nutrition services on sustained recovery in children after moderate acute malnutrition and factors related to sustaining recovery: a cluster-randomized trial. Am J Clin Nutr 2017; 106:657.
  37. Berkley JA, Ngari M, Thitiri J, et al. Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial. Lancet Glob Health 2016; 4:e464.
  38. Blackwell N, Myatt M, Allafort-Duverger T, et al. Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Arch Public Health 2015; 73:26.
  39. Alé FG, Phelan KP, Issa H, et al. Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. Arch Public Health 2016; 74:38.
  40. Lutter CK, Mora JO, Habicht JP, et al. Nutritional supplementation: effects on child stunting because of diarrhea. Am J Clin Nutr 1989; 50:1.
  41. Trehan I, Kelly P, Shaikh N, Manary MJ. New insights into environmental enteric dysfunction. Arch Dis Child 2016; 101:741.
  42. 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.
  43. Trehan I, O'Hare BA, Phiri A, Heikens GT. Challenges in the Management of HIV-Infected Malnourished Children in Sub-Saharan Africa. AIDS Res Treat 2012; 2012:790786.
  44. 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.
  45. 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.