Severe Acute Malnutrition in Infants and Children
Publication Date: August 9, 2013
Last Updated: March 14, 2022
Recommendations
1. Admission and discharge criteria for children who are 6–59 months of age with severe acute
malnutrition
Criteria for identifying children with severe acute malnutrition for treatment
1.1 In order to achieve early identification of children with severe acute
malnutrition in the community, trained community health workers and community members
should measure the mid-upper arm circumference of infants and children who are 6–59 months of age
and examine them for bilateral pitting oedema. Infants and children who are 6–59 months of age and
have a mid-upper arm circumference <115 mm, or have any degree of bilateral oedema, should be
immediately referred for full assessment at a treatment centre for the management of severe acute
malnutrition (strong recommendation, low quality evidence).
1.2 In primary health-care facilities and hospitals, health-care workers should assess
the mid-upper arm circumference or the weight-for-height/weight-for-length status of
infants and children who are 6–59 months of age and also examine them for bilateral oedema. Infants
and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a
weight-for-height/length <–3 Z-score1 of the WHO growth standards (4), or have bilateral
oedema, should be immediately admitted to a programme for the management of severe acute
malnutrition (strong recommendation, low quality evidence).
Criteria for inpatient or outpatient care
1.3 Children who are identified as having severe acute malnutrition should first be assessed
with a full clinical examination to confirm whether they have medical complications and whether
they have an appetite. Children who have appetite (pass the appetite test) and are clinically well
and alert should be treated as outpatients. Children who have medical complications, severe oedema
(+++), or poor appetite (fail the appetite test), or present with one or more Integrated Management
of Childhood Illness (IMCI) danger signs should be treated as inpatients (strong recommendation,
low quality evidence).
Criteria for transferring children from inpatient to outpatient care
1.4 Children with severe acute malnutrition who are admitted to hospital can be transferred to
outpatient care when their medical complications, including oedema, are resolving and they have a
good appetite, and are clinically well and alert. The decision to transfer children from inpatient
to outpatient care should be determined by their clinical condition and not on the basis of
specific anthropometric outcomes such as a specific mid-upper arm circumference or
weight-for-height/length (strong recommendation, low quality evidence).
Criteria for discharging children from treatment
1.5. a. Children with severe acute malnutrition should only be discharged from treatment when
their:
— weight-for-height/length is ≥–2 Z-score and they have had no oedema for at least 2 weeks, or
— mid-upper-arm circumference is ≥125 mm and they have had no oedema for at least 2 weeks.
b. The anthropometric indicator that is used to confirm severe acute malnutrition should also be
used to assess whether a child has reached nutritional recovery, i.e. if mid- upper arm
circumference is used to identify that a child has severe acute malnutrition, then mid-upper arm
circumference should be used to assess and confirm nutritional recovery. Similarly, if
weight-for-height is used to identify that a child has severe acute malnutrition, then
weight-for-height should be used to assess and confirm nutritional recovery.
c. Children admitted with only bilateral pitting oedema should be discharged from
treatment based on whichever anthropometricindicator, mid-upper arm circumference or
weight-for-height is routinely used in programs.
d. Percentage weight gain should not be used as a discharge criterion (strong recommendation, low
quality evidence).
Follow-up of infants and children after discharge from treatment for severe acute malnutrition
1.6. Children with severe acute malnutrition who are discharged from treatment programs should
be periodically monitored to avoid a relapse (strong recommendation, low quality
evidence).
2. Where to manage children with severe acute malnutrition who have oedema
2.1 Children with severe acute malnutrition who have severe bilateral oedema (+++),1 even if
they present with no medical complications and have appetite, should be admitted for inpatient care
(strong recommendation, very low quality evidence).
3. Use of antibiotics in the management of children with severe acute malnutrition in
outpatient care
3.1 Children with uncomplicated severe acute malnutrition, not requiring to be
admitted and who are managed as outpatients, should be given a course of oral antibiotic such as
amoxicillin (conditional recommendation, low quality evidence).
3.2 Children who are undernourished but who do not have severe acute malnutrition should not
routinely receive antibiotics unless they show signs of clinical infection (strong
recommendation, low quality evidence).
4. Vitamin A supplementation in the treatment of children with severe acute malnutrition
4.1 Children with severe acute malnutrition should receive the daily recommended nutrient
intake of vitamin A throughout the treatment period. Children with severe acute mal-
nutrition should be provided with about 5000 IU vitamin A daily, either as an integral part of
therapeutic foods or as part of a multi-micronutrient formulation (strong recommendation, low
quality evidence).
4.2 Children with severe acute malnutrition do not require a high dose of vitamin
A as a supplement if they are receiving F-75, F-1002 or ready-to-use therapeutic food
that complies with WHO specifications (and therefore already contains sufficient vitamin A), or
vitamin A is part of other daily supplements (strong recommendation, low quality evidence).
4.3. Children with severe acute malnutrition should be given a high dose of vitamin A (50 000
IU, 100 000 IU or 200 000 IU, depending on age) on admission, only if they are given therapeutic
foods that are not fortified as recommended in WHO specifications and vitamin A is not part of
other daily supplements (strong recommendation, low quality evidence).
5. Therapeutic feeding approaches in the management of severe acute malnutrition in
children who are 6–59 months of age
5.1 Children with severe acute malnutrition who present with either acute or
persistent diarrhoea, can be given ready-to-use therapeutic food in the same way as
children without diarrhoea, whether they are being managed as inpatients or outpatients (strong
recommendation, very low quality evidence).
5.2 In inpatient settings, where ready-to-use therapeutic food is provided as the therapeutic
food in the rehabilitation phase (following F-75 in the stabilization phase)
Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into
the rehabilitation phase, they should transition from F-75 to ready-to-use therapeutic food over
2–3 days, as tolerated. The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend
on the number and skills of staff available to supervise feeding and monitor the children during
rehabilitation (strong recommendation, very low quality evidence). Two options for transitioning
children from F-75 to ready-to use therapeutic food are suggested:
a. start feeding by giving ready-to-use therapeutic food as prescribed for the transition phase.
Let the child drink water freely. If the child does not take the prescribed amount of ready-to-use
therapeutic food, then top up the feed with F-75. Increase the amount of ready-to-use therapeutic
food over 2–3 days until the child takes the full requirement of ready-to-use therapeutic food, or
b. give the child the prescribed amount of ready-to-use therapeutic food for the
transition phase. Let the child drink water freely. If the child does not take at least half the
prescribed amount of ready-to-use therapeutic food in the first 12 h, then stop giving the
ready-to-use therapeutic food and give F-75 again. Retry the same approach after another 1–2 days
until the child takes the appropriate amount of ready-to-use therapeutic food to meet energy needs.
5.3 In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation
Phase
Children who have been admitted with complicated severe acute malnutrition and are achieving rapid
weight gain on F-100 should be changed to ready-to-use therapeutic food and observed to ensure that
they accept the diet before being transferred to an outpatient program (strong recommendation,
very low quality evidence).
6. Fluid management of children with severe acute malnutrition
6.1 Children with severe acute malnutrition who present with some dehydration or severe
dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric
tube, using oral rehydration solution for malnourished children (5–10 mL/kg/h up to a maximum of 12
h) (strong recommendation, low quality evidence).
6.2 Full-strength, standard WHO low-osmolarity oral rehydration solution (75 mmol/L of
sodium) should not be used for oral or nasogastric rehydration in children with severe acute
malnutrition who present with some dehydration or severe dehydration. Give either ReSoMal or
half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and
glucose, unless the child has cholera or profuse watery diarrhoea (strong recommendation, low
quality evidence).
Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2 L water (instead
of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 ml
of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are
available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration
solution. In this situation, dilution can be revised to add 1 L.
6.3 ReSoMal2 (or locally prepared ReSoMal using standard WHO low-osmolarity
oral rehydration solution) should not be given if children are suspected of having
cholera or have profuse watery diarrhoea.1 Such children should be given standard WHO low- osmolarity oral rehydration solution that is normally made, i.e. not further diluted (strong recommendation, low quality evidence).
6.4 Children with severe acute malnutrition and signs of shock or severe dehydration and who
cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids,
either:
a. half-strength Darrow’s solution with 5% dextrose, or
b. Ringer’s lactate solution with 5% dextrose.
If neither is available, 0.45% saline + 5% dextrose should be used (conditional recommendation,
very low quality evidence).
7. Management of HIV-infected children with severe acute malnutrition
7.1 Children with severe acute malnutrition who are HIV infected and who qualify for lifelong
antiretroviral therapy should be started on antiretroviral drug treatment as soon as
possible after stabilization of metabolic complications and sepsis. This would be indicated by
return of appetite and resolution of severe oedema. HIV-infected children with severe acute
malnutrition should be given the same antiretroviral drug treatment regimens, in the same doses, as
children with HIV who do not have severe acute malnutrition. HIV- infected children with severe
acute malnutrition who are started on antiretroviral drug treatment should be monitored closely
(inpatient and outpatient) in the first 6–8 weeks following initiation of antiretroviral therapy,
to identify early metabolic complications and opportunistic infections (strong recommendation, very
low quality evidence).
7.2 Children with severe acute malnutrition who are HIV infected should be managed with the
same therapeutic feeding approaches as children with severe acute malnutrition who are not HIV
infected (strong recommendation, very low quality evidence).
7.3 HIV-infected children with severe acute malnutrition should receive a high dose of vitamin
A on admission (50 000 IU to 200 000 IU depending on age) and zinc for management of diarrhoea, as
indicated for other children with severe acute malnutrition, unless they are already receiving
F-75, F-100 or ready-to-use therapeutic food, which contain adequate vitamin A and zinc if they are
fortified following the WHO specifications (strong recommendation, very low quality evidence).
7.4 HIV-infected children with severe acute malnutrition in whom persistent diarrhoea does not
resolve with standard management should be investigated to exclude carbohydrate intolerance and
infective causes, which may require different management, such as modification of fluid and
feed intake, or antibiotics (strong recommendation, very low quality evidence).
8. Identifying and managing infants who are less than 6 months of age with severe acute
malnutrition
8.1 Infants who are less than 6 months of age with severe acute malnutrition and any of the
following complicating factors should be admitted for inpatient care:
a. any serious clinical condition or medical complication as outlined for infants who are 6
months of age or older with severe acute malnutrition;
b. recent weight loss or failure to gain weight;
c. ineffective feeding (attachment, positioning and suckling) directly observed for 15–20
min, ideally in a supervised separated area;
d. any pitting oedema;
e. any medical or social issue needing more detailed assessment or intensive support (e.g.
disability, depression of the caregiver, or other adverse social circumstances)
(strong recommendation, very low quality evidence).
8.2 Infants who are less than 6 months of age with severe acute malnutrition should receive the
same general medical care as infants with severe acute malnutrition who are 6 months of age or
older:
a. infants with severe acute malnutrition who are admitted for inpatient care should be given
parenteral antibiotics to treat possible sepsis and appropriate treatment for other
medical complications such as tuberculosis, HIV, surgical conditions or disability;
b. infants with severe acute malnutrition who are not admitted should receive a course of
broad-spectrum oral antibiotic, such as amoxicillin, in an appropriately weight- adjusted
dose
(strong recommendation, very low quality evidence).
8.3 Feeding approaches for infants who are less than 6 months of age with severe
acute malnutrition should prioritize establishing, or re-establishing, effective exclusive breast-
feeding by the mother or other caregiver (strong recommendation, very low quality
evidence).
8.4 Infants who are less than 6 months of age with severe acute malnutrition and who are admitted:
a. should be breastfed where possible and the mothers or female caregivers should be supported to
breastfeed the infants. If an infant is not breastfed, support should be given to the mother or
female caregiver to re-lactate. If this is not possible, wet nursing2 should be encouraged;
b. should also be provided a supplementary feed:
— supplementary suckling approaches should, where feasible, be prioritized;
— for infants with severe acute malnutrition but no oedema, expressed breast milk should be
given, and, where this is not possible, commercial (generic) infant formula or F-75 or diluted
F-1003 may be given, either alone or as the supplementary feed together with breast milk;
— for infants with severe acute malnutrition and oedema, infant formula or F-75 should
be given as a supplement to breast milk;
c. should not be given undiluted F-100 at any time (owing to the high renal solute load and risk
of hypernatraemic dehydration);
d. if there is no realistic prospect of being breastfed, should be given appropriate and adequate
replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe
preparation and use, including at home when discharged.
malnutrition
Criteria for identifying children with severe acute malnutrition for treatment
1.1 In order to achieve early identification of children with severe acute
malnutrition in the community, trained community health workers and community members
should measure the mid-upper arm circumference of infants and children who are 6–59 months of age
and examine them for bilateral pitting oedema. Infants and children who are 6–59 months of age and
have a mid-upper arm circumference <115 mm, or have any degree of bilateral oedema, should be
immediately referred for full assessment at a treatment centre for the management of severe acute
malnutrition (strong recommendation, low quality evidence).
1.2 In primary health-care facilities and hospitals, health-care workers should assess
the mid-upper arm circumference or the weight-for-height/weight-for-length status of
infants and children who are 6–59 months of age and also examine them for bilateral oedema. Infants
and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a
weight-for-height/length <–3 Z-score1 of the WHO growth standards (4), or have bilateral
oedema, should be immediately admitted to a programme for the management of severe acute
malnutrition (strong recommendation, low quality evidence).
Criteria for inpatient or outpatient care
1.3 Children who are identified as having severe acute malnutrition should first be assessed
with a full clinical examination to confirm whether they have medical complications and whether
they have an appetite. Children who have appetite (pass the appetite test) and are clinically well
and alert should be treated as outpatients. Children who have medical complications, severe oedema
(+++), or poor appetite (fail the appetite test), or present with one or more Integrated Management
of Childhood Illness (IMCI) danger signs should be treated as inpatients (strong recommendation,
low quality evidence).
Criteria for transferring children from inpatient to outpatient care
1.4 Children with severe acute malnutrition who are admitted to hospital can be transferred to
outpatient care when their medical complications, including oedema, are resolving and they have a
good appetite, and are clinically well and alert. The decision to transfer children from inpatient
to outpatient care should be determined by their clinical condition and not on the basis of
specific anthropometric outcomes such as a specific mid-upper arm circumference or
weight-for-height/length (strong recommendation, low quality evidence).
Criteria for discharging children from treatment
1.5. a. Children with severe acute malnutrition should only be discharged from treatment when
their:
— weight-for-height/length is ≥–2 Z-score and they have had no oedema for at least 2 weeks, or
— mid-upper-arm circumference is ≥125 mm and they have had no oedema for at least 2 weeks.
b. The anthropometric indicator that is used to confirm severe acute malnutrition should also be
used to assess whether a child has reached nutritional recovery, i.e. if mid- upper arm
circumference is used to identify that a child has severe acute malnutrition, then mid-upper arm
circumference should be used to assess and confirm nutritional recovery. Similarly, if
weight-for-height is used to identify that a child has severe acute malnutrition, then
weight-for-height should be used to assess and confirm nutritional recovery.
c. Children admitted with only bilateral pitting oedema should be discharged from
treatment based on whichever anthropometricindicator, mid-upper arm circumference or
weight-for-height is routinely used in programs.
d. Percentage weight gain should not be used as a discharge criterion (strong recommendation, low
quality evidence).
Follow-up of infants and children after discharge from treatment for severe acute malnutrition
1.6. Children with severe acute malnutrition who are discharged from treatment programs should
be periodically monitored to avoid a relapse (strong recommendation, low quality
evidence).
2. Where to manage children with severe acute malnutrition who have oedema
2.1 Children with severe acute malnutrition who have severe bilateral oedema (+++),1 even if
they present with no medical complications and have appetite, should be admitted for inpatient care
(strong recommendation, very low quality evidence).
3. Use of antibiotics in the management of children with severe acute malnutrition in
outpatient care
3.1 Children with uncomplicated severe acute malnutrition, not requiring to be
admitted and who are managed as outpatients, should be given a course of oral antibiotic such as
amoxicillin (conditional recommendation, low quality evidence).
3.2 Children who are undernourished but who do not have severe acute malnutrition should not
routinely receive antibiotics unless they show signs of clinical infection (strong
recommendation, low quality evidence).
4. Vitamin A supplementation in the treatment of children with severe acute malnutrition
4.1 Children with severe acute malnutrition should receive the daily recommended nutrient
intake of vitamin A throughout the treatment period. Children with severe acute mal-
nutrition should be provided with about 5000 IU vitamin A daily, either as an integral part of
therapeutic foods or as part of a multi-micronutrient formulation (strong recommendation, low
quality evidence).
4.2 Children with severe acute malnutrition do not require a high dose of vitamin
A as a supplement if they are receiving F-75, F-1002 or ready-to-use therapeutic food
that complies with WHO specifications (and therefore already contains sufficient vitamin A), or
vitamin A is part of other daily supplements (strong recommendation, low quality evidence).
4.3. Children with severe acute malnutrition should be given a high dose of vitamin A (50 000
IU, 100 000 IU or 200 000 IU, depending on age) on admission, only if they are given therapeutic
foods that are not fortified as recommended in WHO specifications and vitamin A is not part of
other daily supplements (strong recommendation, low quality evidence).
5. Therapeutic feeding approaches in the management of severe acute malnutrition in
children who are 6–59 months of age
5.1 Children with severe acute malnutrition who present with either acute or
persistent diarrhoea, can be given ready-to-use therapeutic food in the same way as
children without diarrhoea, whether they are being managed as inpatients or outpatients (strong
recommendation, very low quality evidence).
5.2 In inpatient settings, where ready-to-use therapeutic food is provided as the therapeutic
food in the rehabilitation phase (following F-75 in the stabilization phase)
Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into
the rehabilitation phase, they should transition from F-75 to ready-to-use therapeutic food over
2–3 days, as tolerated. The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend
on the number and skills of staff available to supervise feeding and monitor the children during
rehabilitation (strong recommendation, very low quality evidence). Two options for transitioning
children from F-75 to ready-to use therapeutic food are suggested:
a. start feeding by giving ready-to-use therapeutic food as prescribed for the transition phase.
Let the child drink water freely. If the child does not take the prescribed amount of ready-to-use
therapeutic food, then top up the feed with F-75. Increase the amount of ready-to-use therapeutic
food over 2–3 days until the child takes the full requirement of ready-to-use therapeutic food, or
b. give the child the prescribed amount of ready-to-use therapeutic food for the
transition phase. Let the child drink water freely. If the child does not take at least half the
prescribed amount of ready-to-use therapeutic food in the first 12 h, then stop giving the
ready-to-use therapeutic food and give F-75 again. Retry the same approach after another 1–2 days
until the child takes the appropriate amount of ready-to-use therapeutic food to meet energy needs.
5.3 In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation
Phase
Children who have been admitted with complicated severe acute malnutrition and are achieving rapid
weight gain on F-100 should be changed to ready-to-use therapeutic food and observed to ensure that
they accept the diet before being transferred to an outpatient program (strong recommendation,
very low quality evidence).
6. Fluid management of children with severe acute malnutrition
6.1 Children with severe acute malnutrition who present with some dehydration or severe
dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric
tube, using oral rehydration solution for malnourished children (5–10 mL/kg/h up to a maximum of 12
h) (strong recommendation, low quality evidence).
6.2 Full-strength, standard WHO low-osmolarity oral rehydration solution (75 mmol/L of
sodium) should not be used for oral or nasogastric rehydration in children with severe acute
malnutrition who present with some dehydration or severe dehydration. Give either ReSoMal or
half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and
glucose, unless the child has cholera or profuse watery diarrhoea (strong recommendation, low
quality evidence).
Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2 L water (instead
of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 ml
of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are
available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration
solution. In this situation, dilution can be revised to add 1 L.
6.3 ReSoMal2 (or locally prepared ReSoMal using standard WHO low-osmolarity
oral rehydration solution) should not be given if children are suspected of having
cholera or have profuse watery diarrhoea.1 Such children should be given standard WHO low- osmolarity oral rehydration solution that is normally made, i.e. not further diluted (strong recommendation, low quality evidence).
6.4 Children with severe acute malnutrition and signs of shock or severe dehydration and who
cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids,
either:
a. half-strength Darrow’s solution with 5% dextrose, or
b. Ringer’s lactate solution with 5% dextrose.
If neither is available, 0.45% saline + 5% dextrose should be used (conditional recommendation,
very low quality evidence).
7. Management of HIV-infected children with severe acute malnutrition
7.1 Children with severe acute malnutrition who are HIV infected and who qualify for lifelong
antiretroviral therapy should be started on antiretroviral drug treatment as soon as
possible after stabilization of metabolic complications and sepsis. This would be indicated by
return of appetite and resolution of severe oedema. HIV-infected children with severe acute
malnutrition should be given the same antiretroviral drug treatment regimens, in the same doses, as
children with HIV who do not have severe acute malnutrition. HIV- infected children with severe
acute malnutrition who are started on antiretroviral drug treatment should be monitored closely
(inpatient and outpatient) in the first 6–8 weeks following initiation of antiretroviral therapy,
to identify early metabolic complications and opportunistic infections (strong recommendation, very
low quality evidence).
7.2 Children with severe acute malnutrition who are HIV infected should be managed with the
same therapeutic feeding approaches as children with severe acute malnutrition who are not HIV
infected (strong recommendation, very low quality evidence).
7.3 HIV-infected children with severe acute malnutrition should receive a high dose of vitamin
A on admission (50 000 IU to 200 000 IU depending on age) and zinc for management of diarrhoea, as
indicated for other children with severe acute malnutrition, unless they are already receiving
F-75, F-100 or ready-to-use therapeutic food, which contain adequate vitamin A and zinc if they are
fortified following the WHO specifications (strong recommendation, very low quality evidence).
7.4 HIV-infected children with severe acute malnutrition in whom persistent diarrhoea does not
resolve with standard management should be investigated to exclude carbohydrate intolerance and
infective causes, which may require different management, such as modification of fluid and
feed intake, or antibiotics (strong recommendation, very low quality evidence).
8. Identifying and managing infants who are less than 6 months of age with severe acute
malnutrition
8.1 Infants who are less than 6 months of age with severe acute malnutrition and any of the
following complicating factors should be admitted for inpatient care:
a. any serious clinical condition or medical complication as outlined for infants who are 6
months of age or older with severe acute malnutrition;
b. recent weight loss or failure to gain weight;
c. ineffective feeding (attachment, positioning and suckling) directly observed for 15–20
min, ideally in a supervised separated area;
d. any pitting oedema;
e. any medical or social issue needing more detailed assessment or intensive support (e.g.
disability, depression of the caregiver, or other adverse social circumstances)
(strong recommendation, very low quality evidence).
8.2 Infants who are less than 6 months of age with severe acute malnutrition should receive the
same general medical care as infants with severe acute malnutrition who are 6 months of age or
older:
a. infants with severe acute malnutrition who are admitted for inpatient care should be given
parenteral antibiotics to treat possible sepsis and appropriate treatment for other
medical complications such as tuberculosis, HIV, surgical conditions or disability;
b. infants with severe acute malnutrition who are not admitted should receive a course of
broad-spectrum oral antibiotic, such as amoxicillin, in an appropriately weight- adjusted
dose
(strong recommendation, very low quality evidence).
8.3 Feeding approaches for infants who are less than 6 months of age with severe
acute malnutrition should prioritize establishing, or re-establishing, effective exclusive breast-
feeding by the mother or other caregiver (strong recommendation, very low quality
evidence).
8.4 Infants who are less than 6 months of age with severe acute malnutrition and who are admitted:
a. should be breastfed where possible and the mothers or female caregivers should be supported to
breastfeed the infants. If an infant is not breastfed, support should be given to the mother or
female caregiver to re-lactate. If this is not possible, wet nursing2 should be encouraged;
b. should also be provided a supplementary feed:
— supplementary suckling approaches should, where feasible, be prioritized;
— for infants with severe acute malnutrition but no oedema, expressed breast milk should be
given, and, where this is not possible, commercial (generic) infant formula or F-75 or diluted
F-1003 may be given, either alone or as the supplementary feed together with breast milk;
— for infants with severe acute malnutrition and oedema, infant formula or F-75 should
be given as a supplement to breast milk;
c. should not be given undiluted F-100 at any time (owing to the high renal solute load and risk
of hypernatraemic dehydration);
d. if there is no realistic prospect of being breastfed, should be given appropriate and adequate
replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe
preparation and use, including at home when discharged.
Recommendation Grading
Overview
Title
Management of Severe Acute Malnutrition in Infants and Children
Authoring Organization
World Health Organization
Publication Month/Year
August 9, 2013
Last Updated Month/Year
June 26, 2023
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Inclusion Criteria
Male, Female, Child, Infant
Health Care Settings
Ambulatory, Childcare center, Emergency care, Hospital
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Prevention
Diseases/Conditions (MeSH)
D044342 - Malnutrition, D000067011 - Severe Acute Malnutrition
Keywords
infants, malnutrition, acute malnutrition
Supplemental Methodology Resources
Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document, Systematic Review Document