What to Feed a Severely Malnourished Person? A Phased Approach to Safe Refeeding

October 15, 2025 •

4 min read

According to the World Health Organization (WHO), severe acute malnutrition is a major cause of death in children under five. Understanding what to feed a severely malnourished person is critical, as reintroducing nutrition too quickly can be fatal due to a condition called refeeding syndrome.

Quick Summary

The feeding of a severely malnourished individual must follow a cautious, phased protocol to avoid refeeding syndrome. Initial stabilization focuses on low-calorie, low-protein diets with careful electrolyte and fluid management. The second phase involves gradually increasing caloric intake for rapid weight gain and catch-up growth under close medical supervision.

Key Points

Start Slow and Cautious: The initial stabilization phase for a severely malnourished person involves frequent, small feeds of low-calorie, low-protein formula to prevent refeeding syndrome.
Monitor Electrolytes: Severe malnutrition causes dangerously low levels of crucial electrolytes like phosphate, potassium, and magnesium, which must be carefully monitored and replenished under medical supervision.
Use Specialized Formulas: World Health Organization (WHO) therapeutic foods like F-75 are used during stabilization, and higher-energy formulas like F-100 or Ready-to-Use Therapeutic Food (RUTF) are introduced in the rehabilitation phase.
Focus on Micronutrients: Deficiencies in vitamins and minerals like Vitamin A, zinc, and folate must be corrected from the start, though iron supplementation is delayed until weight gain begins.
Rehabilitate Gradually: After initial stabilization, a gradual increase in caloric intake is implemented to promote catch-up growth, with close monitoring of progress.
Consider Fortified Home Meals: For outpatient care, fortifying everyday foods with extra fats, proteins, and dairy is an effective way to boost nutrient density without increasing meal volume.
Medical Supervision is Mandatory: Due to the high risk of complications like refeeding syndrome, the entire feeding process for a severely malnourished person should be managed under the strict guidance of a healthcare professional.

The Dangers of Refeeding Syndrome

Before discussing the feeding protocol, it is vital to understand the primary danger of refeeding a severely malnourished person: refeeding syndrome. During prolonged starvation, the body's metabolism shifts to conserve energy, relying on fat and protein stores. Key minerals like phosphate, potassium, and magnesium become severely depleted within the cells.

What is Refeeding Syndrome?

Refeeding syndrome is a metabolic complication that occurs upon the rapid reintroduction of food, especially carbohydrates, after a period of starvation. The sudden influx of glucose triggers a rush of insulin, causing a rapid shift of electrolytes and fluids back into the cells. This shift can lead to dangerously low levels of phosphate (hypophosphatemia), potassium (hypokalemia), and magnesium (hypomagnesemia) in the blood. The severe electrolyte imbalances can cause a wide range of life-threatening complications, including:

Cardiac arrhythmias and heart failure
Impaired respiratory function
Neurological issues such as seizures and confusion
Fluid retention and peripheral edema

Phase 1: Initial Stabilization (The First 1-7 Days)

For a severely malnourished individual, particularly children, the first phase of treatment is inpatient, focusing on stabilizing metabolic functions and managing life-threatening complications rather than rapid weight gain. This stage is medically supervised to mitigate the risk of refeeding syndrome.

Nutritional Approach in Phase 1

The nutritional intake during this phase is characterized by being low in energy, protein, and sodium, but rich in potassium and magnesium. Specialized therapeutic foods, like F-75 (a low-lactose, milk-based formula with 75 kcal per 100ml), are commonly used. Feeding is done frequently, every two to three hours, in small oral or nasogastric feeds to prevent overwhelming the body.

Medical Management in the Initial Phase

Alongside the controlled nutritional intake, medical staff must address several issues:

Fluid Balance: Rehydration is done cautiously, not using standard IV drips except in cases of shock. Special oral rehydration solutions for malnourished individuals (like ReSoMal) are used to slowly correct dehydration and electrolyte imbalances.
Electrolyte Correction: Potassium and magnesium are replaced as necessary, often added to the feed, and monitored closely. Iron supplements are avoided initially as they can worsen infections.
Micronutrients: Vitamin A, folic acid, zinc, and copper are administered from day one to correct deficiencies. Thiamine (Vitamin B1) is particularly important and is given to prevent neurological complications.
Infection: Broad-spectrum antibiotics are given routinely, as malnourished individuals often have weakened immune systems and show few signs of infection.

Phase 2: Nutritional Rehabilitation (Catch-Up Growth)

Once the patient's appetite returns and medical complications are stable (typically after a few days to a week), the transition to Phase 2 begins. The goal is to promote rapid weight gain and catch-up growth.

Transitioning to Higher-Energy Foods

Transition Period: The transition is gradual, moving from F-75 to a higher-energy formula, such as F-100 (100 kcal per 100ml). In some settings, Ready-to-Use Therapeutic Food (RUTF), a high-energy peanut paste, is used.
Increased Intake: The volume and frequency of feeds are increased to deliver 150-220 kcal/kg/day and 4-6 g protein/kg/day.
Continued Monitoring: Regular weight measurements are crucial to track recovery. Iron supplementation is finally introduced during this phase once the patient is gaining weight.

Outpatient Care and Home-Based Feeding

When a person is well enough to be discharged from inpatient care, outpatient management becomes the focus. This involves continuing the high-energy diet at home, often with RUTF or fortified foods. Parents or caregivers are educated on how to prepare calorie-dense meals safely.

Home-Based Feeding: Fortification and Practical Tips

For those who can tolerate oral feeding, fortifying foods at home is a practical way to increase calorie and nutrient density without increasing volume.

Fortifying Everyday Foods for Malnourished Individuals

Adding fats: Mix butter, margarine, ghee, or oils into mashed potatoes, soups, and vegetables.
Adding dairy: Stir full-cream milk powder, cheese, cream, or creamy yogurts into porridge, soups, and sauces.
High-calorie drinks: Offer milky drinks, fruit juice, or smoothies enriched with extra milk powder, honey, or ice cream.
Frequent snacks: Encourage high-calorie snacks between meals, such as nuts, seeds, dried fruit, and biscuits.

Comparison of Refeeding Phases


Feature	Phase 1: Stabilization	Phase 2: Rehabilitation
Primary Goal	Treat life-threatening issues, stabilize metabolism.	Promote rapid weight gain and catch-up growth.
Typical Duration	1 to 7 days, inpatient.	Weeks to months, often outpatient.
Energy & Protein	Low energy (e.g., F-75).	High energy (e.g., F-100, RUTF).
Key Food Examples	Specialized F-75 formula.	F-100 formula, RUTF, fortified home meals.
Fluid Management	Cautious, low-sodium rehydration (ReSoMal).	Increased fluid intake to match higher energy needs.
Electrolytes	Aggressive replacement of potassium, magnesium, phosphate.	Continued correction and monitoring.
Iron Supplementation	Avoided initially.	Started once patient is gaining weight.
Risk of Refeeding Syndrome	Highest risk period.	Lower risk, but monitoring is still necessary.

Conclusion: The Path to Recovery

Feeding a severely malnourished person requires a highly cautious and structured approach to prevent the dangerous consequences of refeeding syndrome. The process is not about simply giving food but restoring the body's delicate metabolic balance over two distinct phases. Beginning with a low-calorie, fortified diet and meticulous electrolyte management, the process must transition gradually to higher energy foods for successful and sustained recovery. Always ensure medical supervision, especially during the critical initial stabilization phase, and work with healthcare professionals to monitor progress and adjust the diet as needed for a safe path back to health. This complex nutritional journey underscores that a slow, deliberate approach is the most effective and humane way to aid recovery.

World Health Organization guidelines for severe malnutrition management

Frequently Asked Questions

The very first step is to administer a specialized, low-energy formula, such as the World Health Organization (WHO) F-75 therapeutic milk, in small, frequent amounts. This is done under medical supervision to stabilize metabolic functions and correct electrolyte imbalances slowly, thereby preventing refeeding syndrome.

No, you should not give a severely malnourished person regular food immediately. Introducing a typical, high-calorie diet too quickly is extremely dangerous due to the risk of refeeding syndrome, which can cause fatal electrolyte shifts and organ failure.

Refeeding syndrome is a potentially fatal metabolic complication that can occur when nutrition is reintroduced too rapidly after a period of starvation. The sudden shift in fluids and electrolytes, particularly phosphate, potassium, and magnesium, can impair organ function and cause serious cardiac problems.

Fluid management must be cautious. For dehydrated patients, a special low-sodium oral rehydration solution (like ReSoMal) is used instead of standard solutions. IV fluids are only used in cases of shock. The goal is to correct dehydration slowly to avoid fluid overload and heart failure.

Iron supplementation is not given during the initial stabilization phase. It is introduced only after the patient has a good appetite and starts gaining weight, typically during the second week of treatment, because iron can worsen infections in the early stages.

F-75 is a low-energy, low-protein formula used during the initial stabilization phase to repair metabolism without overwhelming the body. F-100 is a high-energy, high-protein formula used in the rehabilitation phase to promote rapid weight gain and catch-up growth.

RUTF stands for Ready-to-Use Therapeutic Food, a high-energy, vitamin- and mineral-enriched paste. It is used during the rehabilitation phase and for outpatient management of severe malnutrition because it is pre-packaged, does not require preparation, and is resistant to microbes.