Fluid management in severely malnourished children under 5 years of age without shock

Intervention | Last updated: 15 May 2023

In children who are under 5 years of age, severe acute malnutrition is defined by a very low weight-for-height/weight-for-length or clinical signs of bilateral pitting oedema. A very low mid-upper arm circumference also indicates severe acute malnutrition in children who are 6–59 months of age. Severe acute malnutrition affects an estimated 19 million children under 5 years of age worldwide and is estimated to account for approximately 400,000 child deaths each year.

Children with severe acute malnutrition may have difficulty keeping themselves properly hydrated, however it can be difficult to assess the hydration status of severely malnourished children. As a result, fluid management is complex in children with severe acute malnutrition, particularly in those who have diarrhoea.

WHO Recommendations

Children who are under 5 years of age 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, with either

ReSoMal, or
half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and glucose* at a rate of 5–10 mL/kg/h, for up to a maximum of 12 hours, unless the child has cholera or profuse watery diarrhoea. Children suspected of having cholera or have profuse watery diarrhoea should be given standard WHO low-osmolarity oral rehydration solution that is normally made, i.e. not further diluted.

* standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not be used

Guidelines and guidance documents Learn More

GRC-approved guidelines

Guideline: updates on the management of severe acute malnutrition in infants and children

Pocket book of hospital care for children: Second edition

The treatment of diarrhoea

Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers

Training course on the management of severe malnutrition

Management of severe malnutrition: a manual for physicians and other senior health workers

Evidence

Systematic reviews used to develop the guidelines

Systematic review of the care of children with diarrhoea in the community-based management of severe acute malnutritionpdf

pdf, 298kb Manary M, Iannotti L, Trehan I, Weisz A. Geneva: World Health Organization; 2012.

The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review

Picot J, Hartwell D , Harris P, Mendes D, Clegg AJ, and Takeda A. Health Technology Assessment. 2012; Vol.16:No.19(for Guideline: Updates on the management of severe acute malnutrition in infants and children).

Cost-effectiveness Learn More

Cost-effectiveness analyses

The analyses listed below were conducted to assess the overall cost-effectiveness of inpatient and/or outpatient management of SAM, of which the intervention listed on this webpage is a component. The analyses do not assess the cost-effectiveness of this specific intervention alone.

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Goudet S, Jayaraman A, Chanani S, Osrin D, Devleesschauwer B, Bogin B, et al. PLoS One. 2018; 13(11):e0205688.

Economic Cost of Community-Based Management of Severe Acute Malnutrition in a Rural District in Ghana

Abdul-Latif A-M C, Nonvignon J. Health. 2014; 6: 886-899.

Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia

Tekeste A, Wondafrash M, Azene G, Deribe K. Cost Eff Resour Alloc. 2012; 10:4.

Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model

Bachmann MO. Cost Eff Resour Alloc. 2009 Jan; 7:2.

Costs, cost-effectiveness and financial sustainability of community-based management of acute malnutrition in northern Nigeria

Frankel S, Roland M, Makinen M. Washington DC: Results for Development Institute; 2015.

Cost-effectiveness of community-based management of acute malnutrition in Malawi

Wilford R, Golden K, Walker DG. Health Policy Plan. 2012; 27(2):127-37.

The cost-effectiveness of forty health interventions in Guinea

Jha P, Bangoura O, Ranson K. Health Policy Plan. 1998; 13(3):249-62.

Cost-effectiveness of the community-based management of severe acute malnutrition by community health workers in southern Bangladesh

Puett C, Sadler K, Alderman H, Coates J, Fiedler JL, Myatt M. Health Policy Plan. 2013; 28(4):386-99.

e-Library of Evidence for Nutrition Actions (eLENA)