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Severe malnutrition in children in developing countries: TreatmentAuthors

William J Klish, MDBuford L Nichols, MDSection EditorKathleen J Motil, MD, PhD

Deputy EditorAlison G Hoppin, MDDisclosures

All topics are updated as new evidence becomes available and our peer review process iscomplete.Literature review current through: Jul 2013. | This topic last updated: mar 21, 2013.

INTRODUCTION Severe malnutrition is primarily a problem in 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 developing 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 developing countries with severe malnutrition are

reviewed here. Causes and clinical manifestations associated with this disorder are discussed

separately. (See "Malnutrition in developing countries: Clinical assessment"and"Micronutrient

deficiencies associated with malnutrition in children".)

The treatment of malnourished children from developed countries is discussed elsewhere.

Although the principles of treatment of malnourished children from developed countries are similar

to those from developing countries, the specific details may vary based on local customs and

resources. (See"Management of failure to thrive (undernutrition) in children younger than two

years".)

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.)

CLASSIFICATION 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
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Charts The degree of malnutrition can be determined by plotting the height and weight on Z-

score charts. Charts based on recumbent length are used for children up to two years of age

(figure 1A-D) and charts based on standing height are used for those between two and five years

(figure 2A-D) [1]. Wasting and stunting are defined by the following (these diagnoses are not

mutually exclusive):

Length-for-age boys: birth to 2 years (z-scores)
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Length-for-age girls: birth to 2 years (z-scores)

Weight-for-length boys: birth to 2 years (z-scores)


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Weight-for-length girls: birth to 2 years (z-scores)

Wasting (indicates acute malnutrition):

Moderate wasting weight/height z-score


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Calculators Z-scores and percentiles may be calculated using the following calculators,

which are based on the WHO child growth standards.

Infants zero to two years:

Boys (calculator 1)

Girls (calculator 2)

Children two to five years:

Boys (calculator 3)

Girls (calculator 4)

WHO MANAGEMENT GUIDELINES The protocol for management of severely malnourished

children developed by WHO consists of three phases: initial stabilization, rehabilitation, and

follow-up. The approach is based upon the altered nutritional physiology of the edematousmalnourished child (table 2A-C)[1], and has been validated in the field [5-8]. The ten steps in

the process are outlined in the figure (figure 3)[5].
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The initial phase is a critical time with an emphasis on treatment of hypoglycemia,

hypothermia, and dehydration, and the detection and treatment of infection. Feedings are

begun in this period and advanced after the first week as the rehabilitation phase begins.

Deficiencies of electrolytes and vitamins are treated throughout initial and rehabilitation

phases, except that iron supplementation is delayed until the beginning of rehabilitation.

The rehabilitation phase lasts approximately two to six weeks. During this phase, themother is trained to continue care at home, and any social problems are addressed.

Emotional stimulation and sensory development of the child extends throughout the initial

and rehabilitation phases.

In the follow-up phase, the physical, mental, and emotional development of the child are

monitored after discharge.

INITIAL PHASE The initial phase is a critical time that emphasizes treatment of disorders that

may be life-threatening, including hypoglycemia, hypothermia, infection, and dehydration.

Prolonged fasting that may be required for diagnostic procedures should be delayed until the end

of this phase. The composition of the initial diet and the electrolyte solution are outlined below [6].

Hypoglycemia and hypothermia occur with fasting of four to six hours duration or can be

precipitated by a serious systemic infection. These conditions may be associated with apnea.

These disorders usually respond to early and frequent feedings and temperature control. Blood

glucose should be monitored if hypothermia or apnea occurs [9].

Treatment priorities are temperature control (warming), antibiotics for infection, and rehydration.

Feedings are begun in this period. They are advanced as the ch ilds appetite returns during or

after the first week, as the rehabilitation phase begins.

Warming If the rectal temperature is


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Sulfamethoxazole trimethoprimsuspension, 5 mL orally twice daily for five days if

weight >4 kg; or 2.5 mL twice daily for five days if weight


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contains glucose (125 mmol/L), sodium (45 mmol/L), potassium (40mmol/L), magnesium

(3 mmol/L), zinc (0.3 mmol/L), and copper (0.045 mmol/L). ReSoMal is available commercially.

This solution also can be made as follows:

Dilute one packet of the standard WHO-recommended ORS into two liters of water

(instead of one liter of water used for the standard ORS dilution).

Add 50 g of sucrose (25 g/L); 50 g of sucrose is approximately 4 tablespoons.

Add 40 mL (20 ml/L) of mineral mix solution (table 5)

Rehydration methods If the child is able to drink, the solution is given by mouth. The required

amount can be given as sips or by spoon every few minutes. However, malnourished children are

weak and quickly become exhausted, so they may not take enough fluid voluntarily. If this occurs,

the solution should be given by nasogastric tube.

If adequate rehydration cannot be achieved through oral or nasogastric administration of

ReSoMal alone, intravenous fluids may be given. Half-strength Darrow's solution with 5 percent

glucose is preferred [1]; the half-strength solution is created by diluting full-strength Darrowssolution (table 6) with an equal amount of 5 percent dextrose in water (D5W). It is also acceptable

to use Lactated Ringer's solution with 5 percent glucose or half normal saline, but these solutions

should be supplemented with sterile potassium chloride, 20 mmol/L. As mentioned above,

hydration via the intravenous route should be approached cautiously, since children with

malnutrition are at risk for overhydration and heart failure. The initial bolus should be no more

than 15 mL/kg over one hour. If there are signs of improvement (decrease in pulse and respiration

rates), then a second bolus of 15 mL/kg may be given if the child is still unable to take this volume

by mouth. If the child does not improve after the first bolus, he or she may be suffering from shock

rather than dehydration. (See"Malnutrition in developing countries: Clinical assessment", section

on 'Distinguishing sepsis from dehydration'.)
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Volume replacement A volume of 70 to 100 mL/kg body weight of ReSoMal usually is enough

to restore normal hydration. This amount should be given over the course of 12 hours, starting

with 5 mL/kg every 30 minutes for the first two hours, and then 5 to 10 mL/kg per hour. This rate

is slower than the rate of rehydration for children without severe malnutrition.

The child should be assessed at least hourly. The volume administered depends upon the amount

the child will drink, the volume of ongoing losses in stooland/or emesis, and any signs of

overhydration, especially heart failure. Oral rehydration should be stopped if an increase inrespiratory and/or pulse rates, engorgement of the jugular veins, or increasing edema (eg, puffy

eyelids) occurs.

Rehydration is complete when the child no longer is thirsty and produces urine, and signs of

dehydration have resolved. Fluids given to maintain hydration should be based upon the child's

willingness to drink and the amount of ongoing losses in the stool. As a guide, children younger

than two years of age should be given 50 to 100 mL (between one-fourth and one-half of a large

cup) of ReSoMal after each loose stool; older children should receive 100 to 200 mL. This

treatment is continued until the diarrhea stops.

Refeeding Feedings should be reinitiated using a formula containing 75 kcal/100 mL (known

as F-75 formula) (table 7). Standard commercial infant formulas can be used if available but mayneed potassium supplementation, since they only contain 20 mEq/liter of potassium, rather than

the 40 mEq/literfound in F-75. The energy intake should equal approximately 80 kcal/kg per day

and not exceed 100 kcal/kg. The formula is fed in small amounts and at frequent intervals because

intestinal motility and gastric acid production are decreased in severe malnutrition (table 2A-C).

Infants can be fed orally using a cup and spoon; a dropper or syringe can be used in weaker

infants. Feeding also should be given by nasogastric tube if the child has impaired consciousness

or has vomiting, tachypnea, or painful stomatitis.
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REHABILITATION PHASE The rehabilitation phase begins as the appetite improves. At this

time, the formula is gradually changed to F-100, which contains 100 kcal/100 mL (table 7). Again,

the standard commercial tube feeding formulas (30 kcal/oz) can be used if available, but

potassium will need to be supplemented since they only contain about 35 mEq/liter rather than

the 63 mEq/liter found in F-100. The volume of oral intake is increased slowly to provide 150 to

220 kcal/kg per day. This treatment is continued until the child's weight-for-height Z-score is >1.Children older than two years of age can be successfully rehabilitated using the same formulas

that are given to infants. However, in these patients, locally available solid foods supplemented

with vitamin and mineral mixes should be introduced. A modified rehabilitation feed, which can

be formulated from whole milk, can be seen in the table (table 8).

The child should be fed at least five times daily during the rehabilitation phase. Feeding frequency

can be decreased to three times daily when the child attains -1 SD of the median WHO reference

values (available at www.cdc.gov/growthcharts) [2,14]. The adjustment of feeding frequency

should take place under supervision before discharge. It is done by gradually reducing and thenstopping the supplementary feeds of F-100 while adding or increasing the mixed diet until the

child is eating a diet similar to what will be eaten at home

Dietary supplements Dietary supplements of vitamins and minerals that are begun during

initial management are continued in the rehabilitation phase using the WHO vitamin mix (table 9).

Providing supplementation with vitamin A, iron, and folate is especially important [1,15].

Multivitamins are provided at approximately 1.5 times the dose given to a normal child
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Vitamin A Severely malnourished children have vitamin A deficiency that can result in

blindness if vitamin A is not supplemented during nutritional rehabilitation. Thus, a large dose of

Vitamin A should be given on the day of hospital admission [1]. Vitamin A is given orally in a dose

according to age: younger than 6 months, 50,000 IU; 6 to 12 months, 100,000 IU; older than 12

months, 200,000 IU.

Iron and folate Nearly all severely malnourished infants have anemia. Supplementation

withfolic acidshould begin on the day of admission (initial dose 5 mg, followed by 1 mg daily), in

addition to the standard amount in the WHO vitamin mix. Elemental iron (3 mg/kg per day in three

divided oral doses) is begun as the rehabilitation phase starts and is continued for three months.

Iron should not be given during the initial phase because of the effect of free iron on oxidative

stress. (See"Micronutrient deficiencies associated with malnutrition in children".)

When making decisions regarding routine prophylactic iron and folic acid supplementation of

children in developing countries, the local disease patterns and the availability and use of

treatment services for common infectious diseases must be considered [16-19]. A controlled trial

of routine supplementation of children with iron and folic acid with or without zinc supplementation

in Pemba, Zanzibar (a region with a high rate of malaria transmission) was stopped prematurelybecause of increased morbidity and mortality in the groups receiving iron and folic acid [17]. A

similar study in southern Nepal (a region with a low rate of malaria transmission) found no effect

of iron and folic acid supplementation on risk of death [18]. For developing areas with high rates

of malaria transmission, we suggest that supplementation of iron and folic acid be targeted to

children with anemia, and that such children be monitored for the development of malaria and

other infections. (See "Iron deficiency in infants and young children: Screening, prevention,

clinical manifestations, and diagnosis", section on 'Immunity and infection'.)

Zinc Supplemental zinc is included in the WHO rehydration solution and formulas used for

refeeding. In addition, children with diarrhea should be treated with supplemental zinc, using

doses of 10 to 20 mg daily for 10 to 14 days [20]. (See"Zinc deficiency and supplementation in

children and adolescents".)

FAILURE TO RESPOND When the WHO treatment guidelines are followed, a severely

malnourished child without complications should show definite signs of improvement within a few

days, followed by continued progress [1]. Children who fail to respond to treatment may not

achieve the initial anticipated rate of improvement (primary failure) or may deteriorate after an

initial satisfactory response (secondary failure). When a patient fails to respond to treatment, care

practices should be reviewed, and the child should be reevaluated [1]. The objective is to identify

a specific cause and to correct the problem.

Failure to respond may be due to the treatment environment or the individual patient. The hospital

may provide a poor environment for malnourished children. As examples, staff may be insufficient

or inadequately trained, scales may be inaccurate, and feedings may be incorrectly prepared.

Children may fail to respond to treatment because they have a serious underlying condition.

Malnutrition may result from a variety of conditions including unrecognized congenital

abnormalities, inborn errors of metabolism, malignancies, immunological diseases, and other

diseases of the major organs.

Patients may fail to respond because they are fed insufficient food or have a vitamin or mineral

deficiency [15]. Malabsorption of nutrients or rumination may contribute to lack of improvement.

Children who fail to respond to nutritional treatment should be investigated for infection [1].

Malnutrition leads to increased susceptibility to infection because nutritional deficiency results in

immunosuppression and often occurs in the setting of a home environment with poor sanitation.

The most frequent infections include diarrhea, dysentery, pneumonia, urinary tract infection, otitis
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media, skin infections, and tuberculosis. Other infections include intestinal worms, malaria, and

human immunodeficiency virus (HIV) infection. (See"Persistent diarrhea in children in developing

countries".)

Review of rehabilitation failure Accurate records should be kept of all children who fail to

respond to treatment and of all deaths. Data should include the child's age, sex, date of admission,

weight-for-height (or length) on admission, principal diagnoses, and treatment. If the child died,

the date and time of death and apparent cause should be noted. These records should be

reviewed periodically to identify areas for improvement. The timing of treatment failure or death

can be helpful. As an example, deaths that occur within the first two days often are caused by

hypoglycemia, unrecognized or mismanaged septic shock, or serious infection, whereas deaths

that occur later often are caused by heart failure related to improper fluid management. Optimum

practices should result in a case-fatality rate of less than 5 percent [1].

COGNITIVE AND FAMILY REHABILITATION Severe malnutrition can result in delayed

mental and behavioral development [21,22]. This delay likely is caused by significantly reduced

brain growth, as assessed by measurement of head circumference, in malnourished compared

with well nourished children [23]. The effect on cognition and behavior is the most serious long-term result of malnutrition.

Play programs that provide emotional and physical stimulation should start during rehabilitation

and continue after discharge. These programs may reduce the risk of the child having some

permanent intellectual disability and emotional impairment [21,22].

Sensory deprivation should be avoided [1]. The child should be able to see and hear what is

happening around him or her. He or she should never be restrained, and the face should not be

covered. The mother or an alternate caregiver should stay with the child in the hospital and during

rehabilitation. She should be encouraged to feed, hold, comfort, and play with her child as much

as possible.

Children undergoing treatment for malnutrition should receive care in a cheerful environment.

Toys should be available that are appropriate for the child's age and level of development. Play

with other children is an important component of rehabilitation. Mothers should be encouraged to

participate and can be trained to supervise play sessions.

Physical activity should be encouraged to promote the development of essential motor skills and

enhance growth. Patients who are unable to move may benefit from passive motion of the limbs.

As the child's nutritional status and general condition improve, the duration and intensity of

physical activities should increase.

Parent education Parents should receive education regarding the causes of malnutrition and

its prevention. Breast feeding is a particularly important and practical measure to preventmalnutrition, so all mothers should be educated to breast feed future infants whenever possible.

Parents should also be given education about an appropriate diet and sanitary feeding

techniques, strategies to stimulate the child's mental and emotional development, and other

parenting skills. Teaching should begin well before discharge. The mother should spend as much

time as possible at the nutrition rehabilitation center with her child, and should provide care,

including food preparation, for her child under supervision. She should be taught how to treat, or

obtain treatment for, diarrhea and other infections, and to understand the importance of regular

treatment for intestinal parasites.

DISCHARGE PHASE During rehabilitation, preparations should be made to ensure that the

child is fully reintegrated into the family and community after discharge. The family must be

prepared to prevent recurrence of severe malnutrition. If possible, the home should be evaluated
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by a social worker or nurse before discharge to ensure an adequate environment. If the child is

abandoned or conditions at the home are unsuitable, a foster home should be sought [1]

Discharge criteria A child is considered ready for discharge when his or her weight-for-height

has reached -1 SD (90 percent) of the median WHO reference values (table 10), corresponding

to approximately 15 to 20 percent weight gain [2,4]. Others have suggested use of mid-arm

muscle circumference of >12.5 cm as a discharge criteria, which typically represents a larger

weight gain [24]. To achieve one or all of these thresholds for discharge, the child should eat four

to six meals daily. Some children may be discharged before the target weight-for-height has been

reached. In these cases, continued outpatient care is needed through full recovery.

Other discharge criteria include completed treatment of all nutritional deficiencies and infections,

and initiation or continuation of the standard immunization schedule (table 10). The mother or

caregiver should be willing to care for the child. She should be able to provide food, appropriate

toys, and initial treatment for diarrhea and infections. A health worker should be available to

provide follow-up of the child and support for the mother[1]. (See"Standard immunizations for

children and adolescents", section on 'Overview'.

COMMUNITY-BASED THERAPEUTIC CARE International consensus guidelines now

recommend community-based care for children with uncomplicatedsevere acute malnutrition

[25]. Uncomplicated severe acute malnutrition is characterized by good appetite at enrollment

and no clinical signs of sepsis, and represents the vast majority of children with malnutrition who

present for care [26]. Details of the approach, a field manual, current programs, and outcomes

are available throughValid Internationaland theWorld Health Organization(WHO) [25,27,28].

Rationale The WHO approach to treatment of severe acute malnutrition in an inpatient feedingcenter, as described above, is often limited by cost, inadequate supply of trained medical

personnel, and poor access to health care facilities for many populations. As a result, many of the

13 million children with malnutrition are not treated [29,30].

Community-based therapeutic care (CTC) provides a different approach to treatment for

malnutrition, emphasizing a decentralized and low-cost model of care. CTC is not limited by

adequacy of local health care services. Key components of the CTC approach are:

Decentralized design and community involvement, to minimize geographic barriers and

encourage early presentation and compliance.

Early intervention for moderate acute malnutrition, to prevent progression. Use of simple protocols and supplies, including Ready to Use Therapeutic Food (RUTF),

which often can be produced locally.
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Integrated approach allowing for smooth transitions between inpatient care for children

with complicated severe acute malnutrition, and outpatient care for children without

complications.

Between 2001 and 2005, an increasing number of countries and relief agencies adopted this

approach with remarkable success. Children with severe malnutrition, with or without edema butwith a good appetite, were effectively treated as outpatients; children with anorexia or

complications were initially treated in inpatient programs [29]. Recovery rates were nearly 80

percent, case fatality rates were 4.1 percent and, thus, equivalent to the rates on the WHO

protocol, but "coverage" rates (ability to reach the population in need) were increased to 72

percent [29,31,32]. As a result, CTC has become the preferred approach for emergency relief

programs. The approach is also increasingly adopted for larger nonemergency programs, such

as those in Malawi and Ethiopia [33,34], and is now recommended by the WHO for uncomplicated

cases of severe acute malnutrition [25,35].

Key strategies Key CTC strategies are outpatient treatment with RUTF and a brief empiric

course of antibiotics.

Ready to Use Therapeutic Food (RUTF) The CTC approach requires food supplements that

are of high nutritional quality, inexpensive, easily transportable, and have minimal spoilage.

During the 1990s, an effective RUTF was developed from a mixture of peanuts, sugar, oil, and

powdered milk, supplemented with a vitamin and mineral mixture. The nutrient profile is similar to

that of the F100 diet, but the energy density of RUTF is fourfold higher(table 11). Because of low

water content, RUTF can be kept unrefrigerated for several months and is thus ideal for outpatient

use. In a randomized trial in severely malnourished children in Senegal, children treated with

RUTF recovered more quickly than children treated with F100 [36].
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The RUTF mixture is available commercially in the form of bars, under the brand name

Plumpy'nut. It also can be prepared as a paste made from locally available foods with the

addition of powdered milk and a commercially available vitamin and mineral mixture [37]. Newer

formulations substitute locally available sources of protein (eg, sesame paste) and grain (rice,

maize, sorghum, or barley) [38]. In a randomized trial, addition of probiotic bacteria and prebiotic

fiber to RUTF did not alter the frequency or speed of nutritional cure, frequency of diarrhea orother clinical symptoms, or cumulative mortality [39]. RUTF is provided at doses of approximately

175 kcal (733 J)/kg/day. Children who display a good appetite by consuming RUTF in the

ambulatory care facility are good candidates for outpatient treatment.

Antibiotics We recommend a brief empiric course of oral antibiotics

(eg,amoxicillinorcefdinir for seven days) for children treated for uncomplicated severe acute

malnutrition in an outpatient setting [25]. This practice was initially suggested by the WHO based

primarily on expert opinion and observations of the high rates of clinically significant infections

among hospitalized children with severe acute malnutrition [40,41], but the evidence base was

weak and somewhat contradictory [42,43]. The practice is now supported by a prospective

randomized trial in 2767 children in Malawi, who were treated with a seven-day course of

amoxicillin, cefdinir, or placebo in addition to nutritional rehabilitation with RUTF [44]. Either

amoxicillin or cefdinir improved recovery rates, time to recovery, and weight gain as compared to

placebo. Moreover, treatment with antibiotics reduced mortality, from 7.4 percent among children

treated with placebo, to 4.8 percent among those treated with amoxicillin or 4.1 percent among

those treated with cefdinir.

COMMUNITY-BASED PREVENTIVE CARE Effective preventive care requires recognition of

children at risk for severe malnutrition and implementation of interventions to arrest progression

to the severely malnourished state. The following review of strategies and recommendations for

preventing malnutrition may be beneficial to the local practitioner in countries with substandard

child growth and development.

Recognition of at risk populations In developed countries, severe malnutrition is usually

caused by an underlying chronic illness. By contrast, in resource-limited settings, both food

insecurity and an acute treatable illness contribute to malnutrition. In many cases, malnutrition

can be prevented by treating the underlying illness.

Diarrheal illness Chronic or prolonged diarrhea is a common risk factor for the development

of severe malnutrition. Isolated diarrheal illnesses (duration


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patients with HIV infection, treatment with appropriate anti-retroviral (ARV) drugs and treatment

or prevention of associated infections are essential steps to prevent or treat malnutrition [49]. In

addition, children with HIV infection require adequate nutritional supplementation to meet their

increased metabolic needs. (See"Natural history and classification of pediatric HIV infection".)

Supplementation strategies for prevention of malnutrition Throughout the 20th century,

food distribution measures were implemented in a variety of contexts to combat food insecurity

and malnutrition.

Generalized food distribution The usual approach to food crises has been to organize a

generalized food distribution (GFD), in which daily food rations (typically an allotment of a cereal

item) are distributed to all members of a population. Although helpful as a first line strategy during

a crisis, GFD schemes usually fail to prevent malnutrition because they do not target risk groups

within a population who would benefit most from nutrition support [50-52].

Targeted supplementation strategies Because of the poor efficacy of GFD schemes, the

WHO now endorses supplementation strategies that target at-risk subgroups as the best strategy

for preventing malnutrition within a population experiencing food insecurity.

Targeted childhood supplemental feeding programs directly supplement those populations and

age groups at the greatest risk for malnutrition, usually nursing mothers and children younger

than 60 months. Current recommendations emphasize protein and lipid rich food items, such as

Ready to Use Therapeutic Food (RUTF) [25,35], in contrast to previous strategies which relied

on grain-based foods.

RUTF supplements provide a supplement that is readily transportable and sanitary, with a

relatively long shelf life without refrigeration. Multiple studies have established the efficacy of

RUTFs as a therapeutic strategy for children with moderate to severe malnutrition, as outlined

above (see'Ready to Use Therapeutic Food (RUTF)'above). Additional interest has been focused

on whether use of RUTF in children who are already exhibiting stunting may prevent progression

to more severe forms of malnutrition. A single study in Niger evaluated the use of RUTF for

children with moderate acute malnutrition and suggested modest benefit as compared with

treatment with a more traditional supplementation strategy [53]. Additional questions of

composition and cost also come into consideration when considering the use of RUTFs within a

resource limited setting [50-52].

OTHER STRATEGIES Strategies to promote breastfeeding substantially improve infant

survival but have little effect on preventing stunting. In populations with insufficient food, provision

of complimentary weaning supplements increased the height-for-age by 41 percent [54].

Theoretical models using this data suggest that a combination of several interventions designed

to improve nutrition and prevent related disease could reduce stunting at three years of age by

36 percent.

Until adequate community research has been conducted and meaningful and successful ways of

ensuring nutrient security for families are achieved, we will need to rely on fortified food

supplements that have been such a success for preventing all forms of malnutrition [52]. From a

global perspective, elimination of stunting must be complimented by improvements of the

underlying structural determinants of malnutrition: poverty, poor education, disease burden, and

lack of women's empowerment [54].

SUMMARY AND RECOMMENDATIONS

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.
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Malnutrition is categorized based upon the degree of wasting or stunting and the

presence of edema (table 1). The child's weight for height, and the height for age are

expressed as Z-scores (also known as the standard deviation [SD] score). The degree of

malnutrition can be determined by plotting the height and weight on Z-score charts.

Charts based on recumbent length are used for children up to two years of age (figure

1A-D), and charts based on standing height are used for those between two and fiveyears (figure 2A-D). (See'Classification'above.)

Treatment of a malnourished child begins with a stabilization phase, emphasizing

treatment of hypoglycemia, hypothermia, and dehydration, and the detection and

treatment of infection. Feedings are begun in this period, and electrolytes and vitamins

are replaced, except for iron. The rehabilitation phase lasts two to six weeks and consists

of advancing nutrition, ongoing vitamin supplementation with the addition of iron, and

training of the parent for follow-up care (figure 3). (See 'WHO management

guidelines'above.)

For the initial treatment of children with severe malnutrition, we recommend empiric

treatment with broad-spectrum antibiotics rather than no treatment (Grade 1B), because

many children with severe malnutrition have systemic infections. Blood cultures shouldbe obtained, but treatment should be initiated while awaiting results. Typical treatment

regimens for children with no apparent complications are trimethoprim-

sulfamethoxazole orally for five days. For children with symptoms suggesting

complications such as hypoglycemia, hypothermia, or lethargy, we recommend

intravenous antibiotics such as the combination ofampicillinandgentamicinrather than

oral antibiotics (Grade 1B). (See'Antibiotics'above.)

Dehydration in the malnourished child should be differentiated from septic shock and

treated with oral rather than intravenous rehydration when possible to reduce the risk of

overhydration and heart failure. The optimal solution for initial rehydration is ReSoMal,

which is based on the standard WHO rehydration oral solution that has been modified by

decreasing sodium and increasing potassium concentrations (table 4). A total of about70 to 100 mL/kg body weight should be given during the first 12 hours of treatment.

(See'Rehydration'above and'ReSoMal'above.)

After rehydration is complete, feedings should be initiated using a formula containing

75 kcal/100 mL (F-75) (table 7). Standard commercial infant formulas can be used if

available but may need potassium supplementation. The energy intake should be

approximately 80 kcal/kg per day and should not exceed

100 kcal/kg. (See'Refeeding'above.)

After the child's appetite improves (usually after about one week), the child enters the

rehabilitation phase, and feedings are advanced to a formula containing 100 kcal/100 mL

(F-100). The child should be fed at least five times daily, and goals for intake are 150 to

220 kcal/kg body weight daily. Children older than two years of age can be successfullyrehabilitated using the same formulas that are given to infants, with the addition of locally

available solid foods supplemented with vitamin and mineral mixes. (See'Rehabilitation

phase'above.)

Dietary supplements of vitamins and minerals that are begun during initial management

are continued in the rehabilitation phase using the WHO vitamin mix (table 9).

Multivitamins are provided at approximately 1.5 times the dose given to a normal child.

Supplementation withfolic acidand other vitamins except iron are begun on admission;

iron supplements are added as the rehabilitation phase begins. (See 'Dietary

supplements'above.)

For children with uncomplicated severe acute malnutrition, which is characterized by

good appetite at enrollment and no clinical signs of sepsis, international consensusguidelines support community-based outpatient care. Community-based therapeutic care
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