Understanding the WHO guidelines for treatment of malnutrition in clinical practice

October 18, 2025 •

3 min read

Malnutrition affects nearly 20 million children under five worldwide, making them extremely vulnerable to severe illness and death. The World Health Organization (WHO) provides critical guidelines for treatment of malnutrition, emphasizing a systematic approach to dietary and medical management based on the severity of the condition.

Quick Summary

This article details the World Health Organization's phased approach for treating acute malnutrition, distinguishing between inpatient and outpatient care, and highlighting key dietary and nutritional interventions.

Key Points

Phased Treatment: The WHO protocol divides treatment into initial stabilization, rehabilitation, and follow-up phases to address different needs as the patient recovers.
Inpatient vs. Outpatient: Management is determined by the severity and presence of complications, with uncomplicated cases treated at home using Ready-to-Use Therapeutic Food (RUTF).
Nutritional Therapy: Specialized diets are used, including F-75 for stabilization and F-100 or RUTF for rehabilitation and catch-up growth.
Infection Control: All severely malnourished children receive a broad-spectrum antibiotic upon admission, as their immune systems are compromised.
Micronutrient Supplementation: Vitamins and minerals are crucial for recovery, though iron is delayed until the rehabilitation phase to prevent exacerbating infections.
Breastfeeding Support: For infants under six months with SAM, exclusive breastfeeding is prioritized and mothers are given special support.
Integrated Community Care: The Community-Based Management of Acute Malnutrition (CMAM) model effectively links health facilities and community health workers to increase treatment coverage.

An Overview of WHO's Approach to Acute Malnutrition

The World Health Organization's strategy for addressing acute malnutrition is grounded in a comprehensive 10-step plan designed to stabilize and rehabilitate patients. This approach was developed to combat the previously high fatality rates in health facilities. A core principle is the need for specialized management of malnourished individuals, who have altered metabolic states, making rapid refeeding dangerous.

Diagnosis and Triage: SAM vs. MAM

Identifying the type of acute malnutrition is the initial step, guiding treatment towards inpatient or outpatient care. Diagnosis relies on anthropometric measurements and clinical signs for children aged 6–59 months.

Severe Acute Malnutrition (SAM): Characterized by a mid-upper arm circumference (MUAC) below 115mm, a weight-for-height/length z-score less than -3, or bilateral pitting oedema. These cases typically require specialized care.
Moderate Acute Malnutrition (MAM): Defined by a MUAC between 115mm and 125mm or a weight-for-height/length z-score between -2 and -3. Targeted supplementary feeding is crucial to prevent progression to SAM.

The 10-Step Treatment Protocol

The WHO's 10-step protocol for complicated SAM in an inpatient setting is structured into stabilization, rehabilitation, and follow-up phases.

Phase 1: Initial Stabilization

This phase (1 to 7 days) focuses on treating life-threatening issues before intensive feeding. Key actions include managing low blood sugar and body temperature, correcting dehydration and electrolyte imbalances cautiously with special solutions like ReSoMal, treating infections with broad-spectrum antibiotics, and providing essential micronutrients, withholding iron initially. Feeding begins with small, frequent amounts of F-75 formula to allow for stabilization.

Phase 2: Rehabilitation

This phase starts when medical complications are stable and appetite returns, focusing on catch-up growth. The diet transitions to higher-energy foods like F-100 formula or Ready-to-Use Therapeutic Food (RUTF). Emotional support, sensory stimulation, and caregiver education are also vital.

Phase 3: Follow-Up

After discharge, regular follow-up is necessary to monitor recovery and provide ongoing caregiver support.

Inpatient vs. Outpatient Management

WHO guidelines distinguish between inpatient and outpatient care based on the child's condition.


Feature	Inpatient Treatment	Outpatient Treatment
Patient Profile	Complicated SAM. Infants under 6 months with SAM.	Uncomplicated SAM. Children with MAM.
Therapeutic Foods	F-75 (stabilization), F-100 (rehabilitation).	RUTFs.
Feeding Logistics	Supervised feeds in clinic.	Caregiver administers RUTF at home with monitoring.
Medications	Routine antibiotics (IV/IM), vitamins, minerals. Iron withheld initially.	Oral antibiotics, vitamins, minerals. Iron added later.
Environment	Controlled clinical setting.	Home-based care.

A note on MAM and Special Populations

Treatment for MAM typically involves Ready-to-Use Supplementary Foods (RUSFs) or local nutrient-rich foods in an outpatient setting. Infants under six months with SAM require inpatient care with a focus on supporting exclusive breastfeeding or using appropriate alternatives.

The Importance of an Integrated Approach

The Integrated Management of Acute Malnutrition (IMAM) framework, combining facility and community care, is key to the success of the WHO guidelines. This allows uncomplicated SAM to be treated at home with RUTFs, improving coverage and outcomes while reducing costs and infection risks. Community health workers are essential in identifying, referring, and following up on cases.

For more detailed information, the WHO's technical guidelines on the management of severe acute malnutrition are a valuable resource(https://www.who.int/news/item/27-11-2013-who-issues-new-guidance-for-treating-children-with-severe-acute-malnutrition).

Conclusion

The WHO guidelines provide a critical, evidence-based approach to treating malnutrition, significantly improving recovery and survival rates, particularly in children. The phased protocol, differentiated care based on severity, specialized therapeutic foods, and integrated community management are all vital components for successful outcomes globally.

Frequently Asked Questions

The key difference is the setting of care. Children with uncomplicated Severe Acute Malnutrition (SAM) can be treated as outpatients, while those with complications, or all infants under 6 months, require inpatient care. Treatment for Moderate Acute Malnutrition (MAM) is primarily outpatient, using supplementary feeding.

The three phases are: 1) Initial Stabilization, focusing on treating life-threatening complications; 2) Rehabilitation, where intensive feeding promotes catch-up growth; and 3) Follow-up, which focuses on preventing relapse after discharge.

Severely malnourished children have altered electrolyte balance. A special rehydration solution called ReSoMal, which is lower in sodium and higher in potassium, is used instead of standard ORS.

Iron supplementation should not be given during the initial stabilization phase, as it can worsen infections. It should be started only once the child's appetite has returned and catch-up feeding has begun, typically in the rehabilitation phase.

RUTF stands for Ready-to-Use Therapeutic Food. It is a nutrient-dense paste used for the outpatient treatment of uncomplicated Severe Acute Malnutrition (SAM) because it is ready-to-eat and safe for home use.

Infants under 6 months with SAM should be referred for inpatient care, prioritizing effective exclusive breastfeeding with support for the mother. If breastfeeding is not possible, alternative breast milk or specially prepared formula is used.

Discharge criteria generally include a stable medical condition, absence of oedema for at least two weeks, a weight-for-height z-score of at least -2, and a MUAC of at least 125mm for at least two weeks.