Paeds · gastroenterology-hepatology-and-nutrition
Malnutrition: nutritional rehabilitation and monitoring
Also known as Severe acute malnutrition · SAM · Moderate acute malnutrition · MAM · Marasmus · Kwashiorkor · Oedematous malnutrition · Refeeding syndrome · Nutritional rehabilitation · Ready-to-use therapeutic food · F-75 · F-100 · Community-based management of acute malnutrition
Fellowship guide to acute malnutrition and its nutritional rehabilitation in children. The page covers the recognition of severe and moderate acute malnutrition by weight-for-height z-score, mid-upper arm circumference and bilateral pitting oedema; the split between complicated and uncomplicated SAM that sends a child to inpatient stabilisation or outpatient ready-to-use therapeutic food; the World Health Organization phased rehabilitation from F-75 stabilisation through transition to F-100 catch-up feeding; the mechanism and prevention of refeeding syndrome through phosphate, potassium and magnesium monitoring and thiamine; the use of ReSoMal rather than standard oral rehydration solution; the rational use of antibiotics; and a discharge and follow-up plan that prevents relapse.
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- A child with severe acute malnutrition who loses appetite, becomes febrile or lethargic, or develops severe oedema has complicated SAM and needs urgent inpatient stabilisation with F-75, not outpatient ready-to-use therapeutic food
- Refeeding syndrome: as feeding restarts, serum phosphate, potassium and magnesium can fall precipitously within hours to days, causing arrhythmia, heart failure, seizures and death, so electrolytes and phosphate must be monitored before and during refeeding
- The malnourished heart tolerates sodium and fluid poorly, so never give standard oral rehydration solution or a rapid intravenous bolus to a malnourished child without a clear indication, and prefer ReSoMal for dehydration
- Bilateral pitting oedema in a wasted child is kwashiorkor and marks severe acute malnutrition regardless of the weight or MUAC, and must not be dismissed as simple fluid retention or nephrotic syndrome
- Hypoglycaemia and hypothermia are common, rapid and lethal in SAM; a drowsy, cold, wasted child needs an immediate glucose check, warmth and urgent feeding
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- Recognition and classification of acute malnutrition in children
- Anthropometric assessment: weight-for-height z-score and MUAC
- Principles of nutritional rehabilitation
- WHO phased management of severe acute malnutrition: F-75 to F-100
- Refeeding syndrome: pathophysiology, prevention and monitoring
- Community-based management of acute malnutrition and RUTF
- The malnourished child: assessment and inpatient rehabilitation
- Refeeding syndrome and electrolyte monitoring
- Complicated versus uncomplicated SAM and disposition
- Long case: a child with severe acute malnutrition and its social context
- Short case: anthropometry and assessment of the malnourished child
- Nutrition: acute malnutrition, F-75 and F-100, and refeeding
- Growth and anthropometric assessment including MUAC
- Severe acute malnutrition: criteria and WHO management
- Refeeding syndrome and micronutrient correction
- Assessment and management of the malnourished child
- Acute malnutrition: SAM and MAM classification
- Nutritional rehabilitation and refeeding syndrome
- Medical Knowledge: malnutrition, nutritional rehabilitation and refeeding
- Medical Expert: malnutrition, nutritional rehabilitation and monitoring
Overview & Definition
A wasted toddler sits listless in his mother's lap, his arms thin as sticks and his mid-upper arm too small for the red zone of the measuring tape. The danger in front of you is not only the starvation that brought him here, but the harm that feeding him too quickly can do. This is the paradox at the heart of acute malnutrition: the treatment is food, yet food given wrongly can kill. [1] [3]
Acute malnutrition is a recent, rapid loss of nutritional status, marked by wasting (low weight for height) or by bilateral pitting oedema. It is "acute" because it reflects what has happened over weeks to a few months, in contrast to stunting, the chronic short stature of long-term undernutrition. The severe form, severe acute malnutrition (SAM), carries a high mortality when untreated, and most of the craft of managing it lies in refeeding the child safely. [1] [11]
The examiner's framework rests on four ideas. First, recognise and grade the malnutrition with anthropometry. Second, decide whether the child is sick enough to need a hospital bed. Third, refeed in the WHO's phased way, stabilising before you rehabilitate. Fourth, guard against refeeding syndrome at every step and watch for relapse after discharge. [1] [8]
References12ShowHide
- [1]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.PMID 24564235
- [2]Sachdev HS; Kurpad AV The recent WHO guideline on acute malnutrition overestimates therapeutic energy requirement. Lancet Reg Health Southeast Asia, 2024.PMID 38807646
- [3]Mogase T; Van Onselen A; Rodriguez-Sanchez N; et al The Identification and Management of Refeeding Syndrome in Inpatient Severely Acutely Malnourished Children Aged 6 to 59 Months in Sub-Saharan African Countries: A Systematic Review and Meta-Analysis. Children (Basel), 2025.PMID 41007088
- [4]Corsello A; Trovato CM; Dipasquale V; et al Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review. J Pediatr Gastroenterol Nutr, 2023.PMID 37705405
- [5]da Silva JSV; Seres DS; Sabino K; et al ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract, 2020.PMID 32115791
- [6]Namusoke H; Hother AL; Rytter MJ; et al Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda. Am J Clin Nutr, 2016.PMID 26739034
- [7]Hother AL; Girma T; Rytter MJ; et al Serum phosphate and magnesium in children recovering from severe acute undernutrition in Ethiopia: an observational study. BMC Pediatr, 2016.PMID 27814707
- [8]Muzeyi W; Ochieng Andra T; Oriokot L; et al High Incidence of Refeeding Syndrome during the Transition from F75 to Ready-to-Use Therapeutic Feeds among Children 6 to 59 Months with Severe Acute Malnutrition at the Pediatric Nutritional Unit of Mulago Hospital. J Nutr Metab, 2024.PMID 39372094
- [9]O'Brien KS; Sie A; Dah C; et al Comparing Azithromycin to Amoxicillin in the Management of Uncomplicated Severe Acute Malnutrition in Burkina Faso: A Pilot Randomized Trial. Am J Trop Med Hyg, 2022.PMID 35008055
- [10]Hiffler L; Adamolekun B; Fischer PR; et al Thiamine content of F-75 therapeutic milk for complicated severe acute malnutrition: time for a change? Ann N Y Acad Sci, 2017.PMID 28905406
- [11]Rytter MJ; Babirekere-Iriso E; Namusoke H; et al Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study. Am J Clin Nutr, 2017.PMID 28031190
- [12]Lamsal KP; Parajuli KR; Pun BK; et al Accuracy of Using Mid-Upper Arm Circumference to Detect Wasting Among Children Aged 6-59 Months in Nepal. Glob Health Sci Pract, 2021.PMID 34933983