Intended for healthcare professionals

Clinical Review

Management of acute moderate and severe childhood malnutrition

BMJ 2008; 337 doi: (Published 13 November 2008) Cite this as: BMJ 2008;337:a2180
  1. Mark J Manary, professor,
  2. Heidi L Sandige, instructor
  1. 1Department of Pediatrics, Washington University School of Medicine, St Louis, MO 63110, USA
  1. Correspondence to: M J Manary manary{at}

    Acute childhood malnutrition affects about a tenth of the world’s children under 5 years of age, particularly those living in circumstances of extreme poverty in the developing world.1 2 Malnutrition is typically the result of an inadequate diet and is one of the most common diagnoses in children in health facilities in sub-Saharan Africa and south Asia. Acute childhood malnutrition leads to greater risk of death or disability from common paediatric illnesses such as pneumonia and diarrhoeal disease, and it shapes long term health by compromising physical and intellectual development.3 The condition carries a case fatality rate of 5-60%.4 5 This review describes how best to manage cases of acute childhood malnutrition in light of recent changes in standard recommendations.

    Sources and selection criteria

    We searched Medline for the terms “moderate malnutrition”, “severe malnutrition”, “supplementary feeding”, and “therapeutic feeding”, limiting the search to children. We utilised a personal archive of references, specifically concerning recent recommendations or changes in the standards of care. This article relies on evidence we have drawn from involvement in the international community that generates the latest research in care for malnourished children.

    What is acute malnutrition?

    In acute malnutrition, the amount of one or more macronutrients available to body tissues is inadequate to sustain optimal function. Macronutrient deficiency may result from inadequate diet, poor absorption of ingested nutrients, or the presence of a chronic inflammatory condition that increases requirements for nutrients while promoting a nutrient wasting, catabolic state.

    How is acute malnutrition diagnosed and categorised?


    Nutritional status is assessed with the weight for height z score, which compares a child’s weight to that of a healthy reference population of children of the same height or length and is expressed in units of standard deviations from the mean of the reference population. Recently the World Health Organization redefined normal child anthropometry, considering a diversity of ethnicities and recognising that …

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