Fluid management in severely malnourished children under 5 years of age without shock
In children who are under 5 years of age, severe acute malnutrition is defined by a very low weight-for-height/weight-for-length or clinical signs of bilateral pitting oedema. A very low mid-upper arm circumference also indicates severe acute malnutrition in children who are 6–59 months of age. Severe acute malnutrition affects an estimated 19 million children under 5 years of age worldwide and is estimated to account for approximately 400,000 child deaths each year.
Children with severe acute malnutrition may have difficulty keeping themselves properly hydrated, however it can be difficult to assess the hydration status of severely malnourished children. As a result, fluid management is complex in children with severe acute malnutrition, particularly in those who have diarrhoea.
Where dehydration in severe acute malnutrition is caused by other diarrhoeal diseases, WHO recommends treatment with an altered version of oral rehydration salts called ReSoMal, which is higher in potassium and lower in sodium.
WHO recommends that children who are under 5 years of age with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, with either
- ReSoMal, or
- half-strength standard WHO low-osmolarity oral rehydration solution with added potassium and glucose* at a rate of 5–10 mL/kg/h, for up to a maximum of 12 hours, unless the child has cholera or profuse watery diarrhoea. Children suspected of having cholera or have profuse watery diarrhoea should be given standard WHO low-osmolarity oral rehydration solution that is normally made, i.e. not further diluted.
The full set of recommendations are provided within the guidance documents referenced below.
* standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not be used
Other guidance documents
Pocket book of hospital care for children: second edition. Guidelines for the management of common illnesses with limited resources
Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers
The treatment of diarrhoea. A manual for physicians and other senior health workers
Training course on the management of severe malnutrition
Management of severe malnutrition: a manual for physicians and other senior health workers
Systematic reviews used to develop the guidelines
Systematic review of the care of children with diarrhoea in the community-based management of severe acute malnutrition
The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review
Related Cochrane reviews
- Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children