e-Library of Evidence for Nutrition Actions (eLENA)

Fluid management in severely malnourished children under 5 years of age with 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 and may be unable to tolerate the rapid changes in blood volume associated with changes in hydration status. This can lead to shock, a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. Adequately managing fluids is critical for treating shock in children with severe acute malnutrition.

WHO recommendations

Children under 5 years of age with severe acute malnutrition and signs of shock or severe dehydration and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either

  • half-strength Darrow’s solution with 5% dextrose, or
  • Ringer’s lactate solution with 5% dextrose

If neither is available, 0.45% saline + 5% dextrose should be used.


This is a summary of one of several WHO recommendations on the management of SAM in infants and children. The full set of recommendations can be found in 'Full set of recommendations' and in the guidelines and guidance documents under ‘WHO documents’ below.

WHO documents

WHO documents

GRC-approved guidelines
Other guidance documents


Systematic reviews used to develop the guidelines
Clinical trials

Last update:

10 January 2017 11:29 CET

Category 1 intervention

Guidelines have been recently approved by the WHO Guidelines Review Committee

Essential Nutrition Actions

This intervention is a component of managing children with SAM, which is an Essential Nutrition Action targeting the first 1000 days of life.

Global targets

Implementation of this intervention may contribute to the achievement of the following targets:

Global nutrition targets

Target 6: Reduce and maintain childhood wasting to less than 5%