# Severe acute malnutrition in children - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls (NCBI Bookshelf NBK559224) - https://www.ncbi.nlm.nih.gov/books/NBK559224/ · Severe acute malnutrition in children - disease-level clinical article (severe-acute-malnutrition-child-full.txt) · Severe acute malnutrition in children - disease-level clinical article (severe-acute-malnutrition-child-clinical.txt) · WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ · Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) - Verified date: 2026-08 ## Verified against - Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls (NCBI Bookshelf NBK559224) - https://www.ncbi.nlm.nih.gov/books/NBK559224/ - Severe acute malnutrition in children - disease-level clinical article (severe-acute-malnutrition-child-full.txt) - Severe acute malnutrition in children - disease-level clinical article (severe-acute-malnutrition-child-clinical.txt) - WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ - Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) ## Treatment metadata - Amoxicillin — 250 mg — oral.liquid - Referral & safety-netting (no drug therapy) - Vitamin A — oral.solid ## Complete treatment card ```text SEVERE ACUTE MALNUTRITION IN CHILDREN Sources: Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls (NCBI Bookshelf NBK559224) - https://www.ncbi.nlm.nih.gov/books/NBK559224/ · Severe acute malnutrition in children - disease-level clinical article (severe-acute- malnutrition-child-full.txt) · Severe acute malnutrition in children - disease-level clinical article (severe-acute-malnutrition-child-clinical.txt) · WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ · Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Caregivers often describe faltering growth, ongoing weight loss, irritability, and past dehydration episodes in a wasted child [dehydration · failure to thrive · irritability · weight loss] - A child with kwashiorkor develops leg or facial swelling, poor appetite, tiredness, or breakdown of the skin [facial swelling · fatigue · leg swelling · poor appetite · skin ulcer] - Unlike marasmus, kwashiorkor rarely comes with a history of hunger or food-seeking behavior - A recent infection or trauma after weaning often precedes the swelling type of malnutrition SIGNS - what you find (9) - Wasted muscle bulk with almost no fat under the skin marks the emaciated form of malnutrition - Low blood pressure, low temperature, and a slow heart rate can accompany severe wasting [bradycardia · hypotension · muscle wasting] - The skin hangs loose over sunken cheeks and prominent ribs, giving an aged look in the wasted child - Sunken fontanelles from dehydration and stunted growth can hide the true weight-for-height deficit [dehydration · stunted growth] - Marasmus does not show the swelling, skin breakdown, or hair changes that mark the edematous form - Bilateral swelling that pits with pressure, starting in the legs, is the defining sign of the edematous form - Patchy areas of darkened, peeling skin over pressure points can appear in the edematous form [scaling] - Cracks at the mouth corners and thin hair that plucks out easily are seen in the edematous form - An enlarged fatty liver is a common finding in the edematous form of malnutrition TESTS (7) - A weight-for-height z-score below -3 standard deviations meets the criteria for severe wasting - A mid-upper arm circumference under 115 mm meets the criteria for severe wasting - Weight-for-age below the third percentile is not a dependable marker because it ignores stunted height - Fluid in the abdomen should prompt a check for tuberculosis, HIV, sepsis, or malaria - The WHO core panel includes a blood count, glucose, albumin and electrolytes, stool studies, HIV testing, and urine studies - Iron studies, folate, and B12 levels help characterize any accompanying anemia - Plasma protein markers such as transferrin and prealbumin help track nutritional status and treatment response IF NOT THIS - what else fits (5) - Chronic infections such as tuberculosis, HIV, and intestinal parasites can produce the same wasting pattern - Malabsorption conditions such as celiac disease and cystic fibrosis can also cause wasting - Childhood cancers such as leukemia and lymphoma belong on the differential for a wasted child - Nephrotic syndrome, liver disease with low albumin, heart failure, and severe anemia can all mimic the edematous form - Ascites appearing together with the edematous form raises suspicion for coexisting tuberculosis Source Severe acute malnutrition in children - disease-level clinical article (severe-acute- malnutrition-child-full.txt) Status traced to the source above Rx: Routine antibiotic | Main treatment | Micronutrient replacement ROUTINE ANTIBIOTIC 1. AMOXICILLIN [1st line] Adult Not applicable - the protocol is for a child (see the paediatric dose) - Not applicable Peds 20-40 mg/kg/day [child max 1500 mg] (Formulary dose, by mouth, for a child over 3 months: 20 to 40 mg/kg/day in divided doses every 8 hours, to a maximum of 500 mg per dose, or 25 to 45 mg/kg/day every 12 hours, to a maximum of 875 mg per dose. The same monograph carries a higher line for severe infection given as step-down therapy - 80 to 90 mg/kg/day in divided doses every 12 hours, still capped at 500 mg per dose - and that is the figure the trial the WHO guideline reviewed actually used in severe acute malnutrition. The guideline itself states no amount, so the calculator above shows the ordinary range and both lines are written out here rather than one being chosen silently.) 3kg -> 60-120 mg/day 4kg -> 80-160 mg/day 5kg -> 100-200 mg/day 6kg -> 120-240 mg/day 7kg -> 140-280 mg/day 8kg -> 160-320 mg/day 9kg -> 180-360 mg/day 10kg -> 200-400 mg/day 11kg -> 220-440 mg/day 12kg -> 240-480 mg/day 13kg -> 260-520 mg/day 14kg -> 280-560 mg/day 15kg -> 300-600 mg/day 16kg -> 320-640 mg/day 17kg -> 340-680 mg/day 18kg -> 360-720 mg/day 19kg -> 380-760 mg/day 20kg -> 400-800 mg/day 21kg -> 420-840 mg/day 22kg -> 440-880 mg/day 23kg -> 460-920 mg/day 24kg -> 480-960 mg/day 25kg -> 500-1000 mg/day 26kg -> 520-1040 mg/day 27kg -> 540-1080 mg/day 28kg -> 560-1120 mg/day 29kg -> 580-1160 mg/day 30kg -> 600-1200 mg/day 31kg -> 620-1240 mg/day 32kg -> 640-1280 mg/day 33kg -> 660-1320 mg/day 34kg -> 680-1360 mg/day 35kg -> 700-1400 mg/day 36kg -> 720-1440 mg/day 37kg -> 740-1480 mg/day 38kg -> 760-1500 mg/day (upper capped) 39kg -> 780-1500 mg/day (upper capped) 40kg -> 800-1500 mg/day (upper capped) 41kg -> 820-1500 mg/day (upper capped) 42kg -> 840-1500 mg/day (upper capped) 43kg -> 860-1500 mg/day (upper capped) 44kg -> 880-1500 mg/day (upper capped) 45kg -> 900-1500 mg/day (upper capped) 46kg -> 920-1500 mg/day (upper capped) 47kg -> 940-1500 mg/day (upper capped) 48kg -> 960-1500 mg/day (upper capped) 49kg -> 980-1500 mg/day (upper capped) 50kg -> 1000-1500 mg/day (upper capped) Source Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph, p338) Why WHO recommendation 3.1 states that children with uncomplicated severe acute malnutrition, not requiring admission and managed as outpatients, should be given a course of oral antibiotic such as amoxicillin. The recommendation names the drug and not an amount. The amount printed here is the Egyptian formulary's general paediatric dose for a child over 3 months with a mild to moderate infection, and the two sources are named separately because they answer different questions - WHO says give it, the formulary says how much. Caution THIS IS THE 6 TO 59 MONTH PATHWAY. The guideline behind the card sets its mid-upper-arm- circumference threshold for children of 6 to 59 months and says plainly that the evidence needed to guide treatment in infants under 6 months, and in children of 5 years and over, is not yet there. A severely malnourished infant under 6 months is a different pathway and is not dosed from here. THE FORMULARY HAS TWO LINES AND THEY ARE FAR APART. Its mild-to-moderate figure is 20 to 40 mg/kg/day and its severe-infection step-down figure is 80 to 90 mg/kg/day. The calculator shows the first. A child who is septic rather than being covered routinely is a candidate for the second, and that decision is made at the bedside and not from a dose table. USE THE SUSPENSION, NOT A CAPSULE. A 7 kg child's daily dose is roughly 140 to 280 mg, which is a fraction of a 500 mg capsule and cannot be divided accurately. The Egyptian register carries the 250 mg/5 mL and 125 mg/5 mL suspensions widely; the brands listed below are the 250 mg/5 mL. THIS IS FOR UNCOMPLICATED DISEASE MANAGED AT HOME. A child with complicated severe acute malnutrition - shock, hypoglycaemia, hypothermia, an inability to feed, or a serious infection - is admitted, and the antibiotic is then chosen for what is found and given by the ward. WHO CALLS THE ANTIBIOTIC A CONDITIONAL RECOMMENDATION ON LOW-QUALITY EVIDENCE, and its own wording is "a course of oral antibiotic such as amoxicillin" - the drug is an example, not a mandate. THE AMOUNT IS NOT WHO'S. WHO's recommendation names amoxicillin without a dose. The trial it summarises gave 80 to 90 mg/kg/day for one week, and that figure is the trial's, not a WHO instruction. The dose printed above is the Egyptian formulary's, which is what an Egyptian pharmacy dispenses against. WHO RECORDS THE ARGUMENT AGAINST IT TOO. The card's article calls routine antibiotic use controversial, because of antibiotic resistance and the effect on the gut microbiome. It is a WHO recommendation and it is contested. SCREEN FOR WHAT IS UNDERNEATH. The article asks for tuberculosis, HIV, sepsis and malaria to be considered in every child with severe acute malnutrition, especially where there is ascites. Do not give in serious hypersensitivity to amoxicillin or another beta-lactam. Egypt AMOXIL FORT 250MG/5ML SUSP. 60ML MUP > SMITHKL... 5.50 EGP AMOXICID 250MG/5ML SUSP. 60ML CID 7.00 EGP AMOXYCILLIN 250 MG/5 ML SUSP. 80 ML ARAB DRUG COMPANY (ADCO) 7.00 EGP AMOXYCILLIN 250 MG/5 ML SUSP. 100 ML ARAB DRUG COMPANY (ADCO) 7.50 EGP E-MOX 250MG/5ML SUSP. 80ML EIPICO 8.00 EGP BIOMOX 250MG/5ML SUSP. 80ML SEDICO 9.25 EGP AMOXIL FORT 250MG/5ML SUSP. 100ML MUP > SMITHKLINE BEECHAM 11.00 EGP HICONCIL 250MG/5ML SUSP. 80ML PHARCO 11.00 EGP HICILLIN 125MG/5ML SUSP. 80ML EL NASR 3.00 EGP -> ? strength differs, ? different route - not oral liquid AMOXICID 125MG/5ML SUSP. 60ML CID 6.00 EGP -> ? strength differs, ? different route - not oral liquid MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Severe Acute Malnutrition: Recognition and Management of Marasmus and Kwashiorkor - StatPearls (NCBI Bookshelf NBK559224) - https://www.ncbi.nlm.nih.gov/books/NBK559224/ Why Severe acute malnutrition is diagnosed with a tape measure and a scale, not a blood test, and the whole primary-care value is measuring the arm and spotting the child who needs an inpatient bed rather than a food parcel. Feeding a severely wasted child too fast can kill him, so the feeding regimens below are quoted for recognition and are not offered as a clinic prescription. Caution THE THREE THRESHOLDS, ANY ONE OF WHICH MAKES THE DIAGNOSIS - meet any one of these and the child has SAM: a weight-for-height z-score (WHZ) below -3 standard deviations (SD); a mid-upper arm circumference (MUAC) under 115 mm, or a MUAC-for-age z-score below -3 SD; or bilateral pitting oedema of nutritional origin. MEASURE THE ARM PROPERLY - anthropometry means measuring accurately: standing or lying length to 0.5 cm, weight to 0.1 kg, that is 100 g, and MUAC to 2 mm or better. The arm measurement applies to a child of 6 to 59 months. WEIGHT-FOR-AGE IS THE WRONG TOOL AND WILL MISS CHILDREN - it is used often, but a weight-for-age under the third percentile is not a dependable marker of SAM, because it takes no account of what stunting has done to the child's linear growth. OEDEMA HIDES THE WASTING AND FALSIFIES THE NUMBERS - a child with kwashiorkor has bilateral pitting oedema, and that oedema can push the weight and the mid-upper arm circumference up falsely. Swollen as they look, these children are usually malnourished to a profound degree. REFEEDING SYNDROME IS THE COMPLICATION OF TREATING, NOT OF THE DISEASE - bring nutrition back too fast after a stretch of severe malnutrition and the child can develop refeeding syndrome, which can kill. What happens is that electrolytes shift - the phosphate falls above all, and the potassium, the magnesium and the fluid balance are all disturbed - and from that come cardiac, neurological and respiratory complications. A wasted child sent home with a bag of food and no supervision is exposed to exactly this. WHAT DECIDES INPATIENT VERSUS COMMUNITY CARE - SAM is uncomplicated when the child still has a good appetite and shows no clinical sign - no oedema, no acute medical problem - that would raise the risk and call for admission. SAM is complicated when the child needs admitting: for rehydration, to stop infection running on to sepsis, and to keep the treatment itself from causing refeeding syndrome. Test the appetite before deciding. COMMUNITY TREATMENT IS A PROGRAMME, NOT A PRESCRIPTION - treating this in the community takes a structured programme: staff who are trained, ready-to-use therapeutic foods (RUTFs), plus follow-up at regular intervals. The quantities the article records are 2 sachets a day where the MUAC is under 115 mm or there is oedema, and 1 a day where the MUAC falls between 115 and 125 mm, aiming at 175 kcal/kg/day. Those belong to a supervised feeding programme. ORDINARY REHYDRATION FLUIDS ARE THE WRONG FLUIDS HERE - normal saline given intravenously carries sodium in excess and potassium in short supply, and will not rehydrate these children properly. ReSoMal - Rehydration Solution for Malnutrition - is the oral rehydration solution made for dehydration in a child with SAM, and it holds less sodium and more potassium than the standard WHO oral rehydration solution does. THE FIRST DAYS ARE ABOUT STABILISING, NOT GAINING WEIGHT - nutritional rehabilitation in severe acute malnutrition starts with cautious refeeding on a therapeutic milk such as F-75, which is made for the stabilisation phase - typically the first 2 to 7 days. These milks are not there to put weight on. They are there to steady the metabolism, put the electrolytes right, and make it possible to treat the infections underneath. LOOK FOR THE INFECTION THAT IS DRIVING IT - ascites should send you looking hard for what lies beneath: tuberculosis (TB), HIV, sepsis, malaria. The core WHO tests listed are haemoglobin with a blood smear; blood glucose, to catch hypoglycaemia; serum albumin and electrolytes; stool microscopy and culture; an HIV test; and urine microscopy and culture. ANTIBIOTICS AND VITAMIN A ARE PART OF THE PROTOCOL, AND THE ARTICLE STATES NO AMOUNT - children with SAM so often carry a bacterial infection below the surface that the WHO advises treating them all with a broad-spectrum antibiotic, amoxicillin for instance. The WHO also advises vitamin A, because deficiency is common and it raises the risk of infection, viral and bacterial alike, of blindness, and of death. No milligram figure for either appears in the article, so none is printed. WHAT THE EXAMINATION SHOWS, AND WHAT ELSE TO LOOK FOR - in marasmus the muscle is markedly wasted and the subcutaneous fat has all but gone, with a low blood pressure, a low temperature and a slow pulse. Look also for dry eyes and Bitot's spots, which mean vitamin A deficiency; koilonychia and pallor, which mean iron deficiency anaemia; and the signs of a low calcium - Chvostek's or Trousseau's. MEASURE THE ARM OF EVERY THIN CHILD, BECAUSE THE STAKES ARE THIS HIGH - undernutrition in all its forms - SAM, being underweight, chronic malnutrition - is reckoned to account for 35% to 45% of child deaths worldwide. MICRONUTRIENT REPLACEMENT - give alongside 3. VITAMIN A [add-on - not a substitute] Adult Not applicable - the protocol is for a child (see the paediatric dose) - Throughout the treatment period Peds About 5000 IU daily, by mouth, for as long as the treatment lasts - as part of a therapeutic food or a multi-micronutrient preparation, not as a separate high-dose capsule. No milligram-per-kilogram rule is printed because the guideline states none. Source WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children (NCBI Bookshelf NBK190317) - https://www.ncbi.nlm.nih.gov/books/NBK190317/ Why WHO recommendation 4.1 states that children with severe acute malnutrition should receive the daily recommended nutrient intake of vitamin A throughout the treatment period, and should be provided with about 5000 IU daily. The card's own article states the reason: deficiency is common in these children and carries a higher risk of viral and bacterial infection, blindness and death. It is written in international units rather than milligrams because that is how the guideline states it and how the Egyptian capsules are labelled. Caution A CHILD ALREADY ON F-75, F-100 OR PROPER RUTF NEEDS NO SEPARATE VITAMIN A. WHO recommendation 4.2 states that a child receiving therapeutic food that complies with WHO specifications does not require a high dose as a supplement - the food already carries it. Giving it on top is how a child is overdosed. THE HIGH DOSE IS CONDITIONAL, NOT ROUTINE. WHO recommendation 4.3 gives a single high dose of 50 000 IU, 100 000 IU or 200 000 IU depending on age, on admission, ONLY where the therapeutic food is not fortified to WHO specifications AND vitamin A is not part of another daily supplement. Separately, the guideline's standing recommendations give a high dose on day 1, day 2 and day 15 or discharge, whatever the food, to a child with eye signs of vitamin A deficiency, and the same to a child with recent measles. THE RECOMMENDATION DOES NOT SAY WHICH AGE GETS WHICH HIGH DOSE. It writes "depending on age" and states no cut-offs. The only age mapping anywhere in the document is a description of the trials it reviewed - 100 000 IU under 1 year, 200 000 IU at 1 year and over - which is what those studies did, not what WHO instructs. Take the bands from the programme protocol being followed. WHAT EGYPT ACTUALLY STOCKS IS A 50 000 IU CAPSULE. One registered single-ingredient vitamin A product is on the register (A-VITON, 50 000 IU); a second is cancelled, and the 10 000 IU softgel below is flagged by the register itself as an unregistered import. There is no 5 000 IU medicine, so the daily amount comes from the therapeutic food or a multi-micronutrient product, not from a vitamin A capsule. REFEEDING SYNDROME IS THE DANGER OF TREATING THIS. The article states that feeding reintroduced too quickly shifts phosphate, potassium and magnesium and can cause dysrhythmia, rhabdomyolysis, confusion and sudden death, and that thiamine deficiency may appear as glucose metabolism resumes. Egypt A-VITON 50.000 I.U. 20 CAPS. KAHIRA 5.00 EGP (0.25/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)