Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

uncomplicated

1st line – community-based therapy with ready-to-use therapeutic food (RUTF)

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ACUTE
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uncomplicated
1st line – 

community-based therapy with ready-to-use therapeutic food (RUTF)

Once a provisional diagnosis of kwashiorkor is made, the condition should be categorised as uncomplicated (amenable to outpatient therapy) or complicated (requiring facility-based care). A child's clinical presentation is the primary determinant of the decision, but available resources must also be considered. The decision to offer hospital care is based on clinical judgement and expert opinion. Complications and electrolyte status in kwashiorkor are difficult to identify either clinically or via laboratory investigation, so treatment should be based on a standardised protocol.

Kwashiorkor can be classified as uncomplicated if the child passes an 'appetite test'. The child is asked to consume approximately 30 grams of RUTF under direct observation. If the child is able to eat this in a reasonable amount of time (≤15 minutes) and does not have any other obvious complications, the illness is most likely to be uncomplicated and can be treated at home.[46][47][48] Children with any complications, such as abnormal mental status, marked lethargy, decreased consciousness, a significant concomitant infection, or underlying illness, or those who fail the appetite test, should have complications urgently addressed and be referred for inpatient care as a case of complicated kwashiorkor.

RUTF is a paste-like therapeutic food that is nutritionally equivalent to traditional milk-based diets and contains ample micro-nutrients for catch-up growth and replenishment of body stores, when given at 175 kcal/kg/day. The child receives a supply of RUTF upon enrolment, and returns for follow-up at regular intervals (every 1-2 weeks) for progress to be assessed and for subsequent supplies of therapeutic food.

If resources are limited or the child lives far from the health centre, it is reasonable to schedule follow-up every 4 weeks.[50]

Dietary therapy ceases when oedema has resolved for at least 1 week, and anthropometry and clinical assessment indicate a recovery to >-2 standard deviations below the mean weight for height and/or mid-upper arm circumference (MUAC) is ≥ 125 mm (depending on whether either or both were low at the time of admission). This is typically between 4 and 8 weeks after diagnosis.

Plus – oral antibiotics

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ACUTE
|
uncomplicated
Plus – 

oral antibiotics

Treatment recommended for ALL patients in selected patient group

All children with uncomplicated severe acute malnutrition should be treated with a broad-spectrum oral antibiotic, as sepsis, probably from bacterial translocation, is underappreciated. This recommendation is based on two large randomised, double-blind clinical trials conducted in rural Africa. Amoxicillin or cefdinir have been shown to be effective, and it is likely other agents may also be effective.[52][53]

Treatment course: 7 days.

Primary options

amoxicillin: 80-90 mg/kg/day orally given in 2 divided doses

OR

cefdinir: children ≥6 months of age: 14 mg/kg/day orally given as a single dose or in 2 divided doses

complicated

1st line – facility-based care with regular milk-based liquid food

Back
ACUTE
|
complicated
1st line – 

facility-based care with regular milk-based liquid food

Once a provisional diagnosis of kwashiorkor is made, the condition should be categorised as uncomplicated (amenable to outpatient therapy) or complicated (requiring facility-based care). A child's clinical presentation is the primary determinant of the decision, but available resources must also be considered. The decision to offer hospital care is based on clinical judgement and expert opinion. Complications and electrolyte status in kwashiorkor are difficult to identify either clinically or via laboratory investigation, so treatment should be based on a standardised protocol.

Kwashiorkor can be classified as uncomplicated if the child passes an 'appetite test'. The child is asked to consume approximately 30 grams of ready to use therapeutic food under direct observation. If the child is able to eat this in a reasonable amount of time (≤15 minutes) and does not have any other obvious complications, the illness is most likely to be uncomplicated and can be treated at home.[46][47][48]​ Children with any complications, such as abnormal mental status, marked lethargy, decreased consciousness, a significant concomitant infection, or underlying illness, or those who fail the appetite test, should have complications urgently addressed and be referred for inpatient care as a case of complicated kwashiorkor.

Hospital care involves feeding small amounts of a milk-based liquid food every 2-3 hours, with an initial recommended daily intake of 100 kcal/kg/day, increasing each day as tolerated.[1] Once the child's condition has stabilised and appetite has returned, the child is best managed in the same way as a child with uncomplicated malnutrition, at home, with dietary therapy. As appetite typically returns slowly, regulation of a child's dietary intake as the appetite returns at home is not necessary as long as the child consumes a minimum 100 kcal/kg/day.

Plus – empirical antibiotic therapy

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ACUTE
|
complicated
Plus – 

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Sepsis occurs in 15% to 60% of children with complicated severe malnutrition, and it is standard practice to administer broad-spectrum parenteral antibiotics.[54]

Ampicillin or benzylpenicillin plus gentamicin is recommended for 7 days.

If the child remains febrile or fails to improve within 48 hours, or looks particularly septic/toxic on presentation, ceftriaxone can be given parenterally for 7 days and adjusted depending on culture results. If the child improves significantly and is to be discharged from inpatient care before the 7 full days have been completed, they can be changed to oral antibiotics as above to complete the 7 day course.

Primary options

gentamicin: 7.5 mg/kg intramuscularly/intravenously once daily

-- AND --

ampicillin: 200 mg/kg/day intramuscularly/intravenously given in divided doses every 6 hours maximum 12 g/day

or

benzylpenicillin sodium: 25-50 mg/kg intramuscularly/intravenously every 4–6 hours, maximum 2.4 g/dose

Secondary options

ceftriaxone: 50-75 mg/kg intramuscularly/intravenously every 24 hours, maximum 2 g/day

Consider – vitamin A supplementation

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ACUTE
|
complicated
Consider – 

vitamin A supplementation

Additional treatment recommended for SOME patients in selected patient group

Children aged 6-59 months with severe acute malnutrition should receive vitamin A supplementation throughout the treatment period, either within the therapeutic ready-to-use foods that comply with World Health Organization specifications or as part of a multi-micronutrient formulation.​​[55][56]

Vitamin A is given orally in higher doses if there are any signs of xerophthalmia.[57]

Primary options

vitamin A: xerophthalmia: children <6 months of age: 50,000 units/day orally as a single dose on day 1, repeat on days 2 and 14; children 6-12 months of age: 100,000 units/day orally as a single dose on day 1, repeat on days 2 and 14; children >12 months of age: 200,000 units/day orally as a single dose on day 1, repeat on days 2 and 14

Plus – oxygen ± fluid resuscitation

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ACUTE
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complicated
|
with shock
Plus – 

oxygen ± fluid resuscitation

Treatment recommended for ALL patients in selected patient group

Severely malnourished children should be monitored carefully for shock. It may result from cardiac failure, compromised capillary integrity, or, less commonly, fluid losses. Determining shock aetiology will guide treatment and influence outcome. Supplemental oxygen is given when possible. Hypovolaemic shock is more likely if there are 6 stools a day or large volumes of watery stool.

In the case of confirmed shock, resuscitation with intravenous fluids should be done cautiously (10-15 mL/kg/hour), assessing for response (reduced heat rate, reduced respiratory rate, improved capillary refill) or over-hydration (increasing heart rate, enlarging liver, increasing respiratory rate). After 2 hours the child should be re-assessed, and if there is an improvement, oral rehydration should be continued in addition to F-75 therapeutic milk in quantities estimated to replace losses.

The child should be considered for volume replacement with colloid solution or blood if not responding and not over-hydrated, as non-response may represent septic shock.

Plus – Rehydration Solution for Malnutrition (ReSoMal)

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ACUTE
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complicated
|
with dehydration
Plus – 

Rehydration Solution for Malnutrition (ReSoMal)

Treatment recommended for ALL patients in selected patient group

Dehydration is overestimated and over-diagnosed in malnourished children.

For children with continual diarrhoea, management of diarrhoea using a standardised oral rehydration protocol has been associated with a reduction in mortality.[59]

ReSoMal is used for malnourished children with dehydration, both to achieve euvolaemia and to replace further ongoing gastrointestinal losses. It can be given either orally or via a nasogastric tube.[54] Standard World Health Organization oral rehydration salts are too high in sodium (70 mmol/L of sodium) and too low in potassium to be given; these increase the risk of heart failure (sodium retention due to inability of the kidneys to adequately excrete the high sodium load in the setting of a heart muscle that is thin and atrophied in severely malnourished children).[29][30]

Between 70 and 100 mL of ReSoMal per kg of body weight is usually enough to rehydrate. It should be given orally or by nasogastric tube over 12 hours, starting with 5 mL/kg every 30 minutes for the first 2 hours, and then 5-10 mL/kg per hour (slower than for children who are not severely malnourished). The child should be reassessed at least every hour. The exact amount to give should be guided by how much the child will drink, the amount of ongoing losses from diarrhoea or vomiting, or any signs of overhydration, especially signs of heart failure. Overhydration is indicated by an elevated pulse rate (increase of ≥25 beats/minute) and respiratory rate (increase of ≥5 breaths/minute), engorged jugular veins, or increasing oedema (e.g., puffy eyelids).[1]

Rehydration therapy can be stopped when ≥3 of the following signs occur: the child is no longer thirsty, is passing urine, is less lethargic, the respiratory or pulse rates slow, skin pinch returns more quickly, and tears, moist eyes, moist mouth are present. However, many severely malnourished children will not show these signs even when hydrated.

Fluids given to maintain hydration should be based on the child's willingness to drink and, if possible, the amount of ongoing diarrhoea. In general, children under 2 years should receive 50-100 mL (between one-quarter and one-half of a large cup) of ReSoMal after each loose stool, while older children should have 100-200 mL, continued until diarrhoea stops.[1]

Plus – supplemental glucose or sucrose

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ACUTE
|
complicated
|
with hypoglycaemia
Plus – 

supplemental glucose or sucrose

Treatment recommended for ALL patients in selected patient group

Hypoglycaemia is defined as a blood glucose <3 mmol/L (<54 mg/dL).

To treat hypoglycaemia, in a conscious child, a bolus feed of 50 mL of 10% glucose or sucrose solution can be given.

For an unconscious or convulsing child, 5 mL/kg of 10% glucose dextrose or sucrose solution can be given intravenously or 50 mL via a nasogastric tube. This is followed by a quarter amount of the 2-hourly feed every 30 minutes for the first 2 hours, continued until the blood glucose reaches 3 mmol/L.

Repeat blood glucose testing with finger/heel prick of blood is advised after 2 hours. Most children stabilise in 30 minutes, when 2-hourly feeds can be commenced. If unsuccessful, or if rectal temperature falls to <35.5°C (96°F) or level of consciousness deteriorates, treatment can be repeated.

Plus – dietary adjustment

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ACUTE
|
complicated
|
with electrolyte imbalance
Plus – 

dietary adjustment

Treatment recommended for ALL patients in selected patient group

Food should be prepared without salt, and additional F-75 rehydration fluid is recommended initially and ReSoMal if necessary. Phosphate- and potassium-rich diets are recommended.

Plus – gentle warming

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ACUTE
|
complicated
|
with hypothermia
Plus – 

gentle warming

Treatment recommended for ALL patients in selected patient group

The child is kept dry, wrapped in blankets, and close to the mother's body. If the rectal temperature is <35.5°C (96°F), immediate feeding is advised while maintaining warmth and keeping the child close to the mother.

Plus – potassium permanganate wash and topical ointment/dressing

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ACUTE
|
complicated
|
with dermatosis
Plus – 

potassium permanganate wash and topical ointment/dressing

Treatment recommended for ALL patients in selected patient group

If the nappy area is affected by dermatosis, it is best left uncovered. If it affects other areas, zinc ointment or paraffin gauze dressings can help with analgesia and prevent infection.

Affected areas should be bathed in 0.01% potassium permanganate for 10 minutes on a daily basis to help prevent infection, although antibiotics are also given.

Primary options

zinc oxide topical: apply to the affected area(s) when required

Plus – blood transfusions

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ACUTE
|
complicated
|
with severe anaemia (<40 g/L [4 g/dL])
Plus – 

blood transfusions

Treatment recommended for ALL patients in selected patient group

Typically, the anaemia does not compromise oxygen delivery to the tissues, and blood transfusions have been identified as a risk factor for heart failure. The World Health Organization recommends giving blood transfusions only if haemoglobin is <40 g/L (4 g/dL) or there is cardiac failure secondary to anaemia. Oral iron is associated with poorer outcome, and should not be administered in the initial phase of treatment. It is not indicated until after 10 days, and the child has an appetite and the oedema has resolved. It is most safely given via therapeutic feed.

Plus – metronidazole

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ACUTE
|
complicated
|
with giardiasis
Plus – 

metronidazole

Treatment recommended for ALL patients in selected patient group

If oedema fails to respond within 5-7 days, the World Health Organization recommends the addition of metronidazole in the case of persistent diarrhoea or if Giardia is identified in the stool.[1] Duration of therapy will be guided by response but is typically 5-7 days.

Primary options

metronidazole: 30 mg/kg/day orally given in divided doses every 8 hours, maximum 4 g/day

Plus – antituberculous therapy

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ACUTE
|
complicated
|
with TB
Plus – 

antituberculous therapy

Treatment recommended for ALL patients in selected patient group

Tuberculosis (TB) should be considered in patients not responding to treatment. Family history, chest x-ray, and TB skin testing are helpful although not always positive even in the presence of TB, particularly if there is also HIV infection. Choice of drug therapy would depend on local protocols, resources, and resistance patterns.

Plus – trimethoprim/sulfamethoxazole

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ACUTE
|
complicated
|
with HIV exposure or infection
Plus – 

trimethoprim/sulfamethoxazole

Treatment recommended for ALL patients in selected patient group

Immunosuppressed children are at increased risk of opportunistic infections and are susceptible to atypical pathogens. Prophylactic trimethoprim/sulfamethoxazole is recommended if HIV infection is known or if exposure is suspected, particularly in an endemic area. Treatment should be given for 3 weeks. Additionally, antiretroviral therapy should be considered if not already established but is also dependent on the availability of medication.

Primary options

trimethoprim/sulfamethoxazole: 5-10 mg/kg/day orally given in divided doses every 12 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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