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Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 1.6
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| Children with severe wasting and/or nutritional oedema who are discharged from treatment programmes should be periodically monitored to avoid a relapse (10). |
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Conditional recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 3.1
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| Children with uncomplicated severe wasting and/or nutritional oedema, not requiring to be admitted and who are managed as outpatients, should be given a course of oral antibiotic such as amoxicillin (10). |
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Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 3.2
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| Children who are undernourished but who do not have severe wasting and/or nutritional oedema should not routinely receive antibiotics unless they show signs of clinical infection (10). |
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Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 4.1
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| Children with severe wasting and/or nutritional oedema should receive the daily recommended nutrient intake of vitamin A throughout the treatment period. Children with severe wasting and/or nutritional oedema should be provided with about 5000 IU vitamin A daily, either as an integral part of therapeutic foods or as part of a multi-micronutrient formulation (10). |
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Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 4.2
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| Children with severe wasting and/or nutritional oedema do not require a high dose of vitamin A as a supplement if they are receiving F-75, F-100 or RUTF that complies with WHO specifications (and therefore already contains sufficient vitamin A), or vitamin A is part of other daily supplements (10). |
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4.3 Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 4.3
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| Children with severe wasting and/or nutritional oedema should be given a high dose of vitamin A (50 000 IU, 100 000 IU or 200 000 IU, depending on age) on admission, only if they are given therapeutic foods that are not fortified as recommended in WHO specifications and vitamin A is not part of other daily supplements (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 5.1
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| Children with severe wasting and/or nutritional oedema who present with either acute or persistent diarrhoea, can be given RUTF in the same way as children without diarrhoea, whether they are being managed as inpatients or outpatients (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 5.2
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| In inpatient settings, where RUTF is provided as the therapeutic food in the rehabilitation phase (following F-75 in the stabilization phase) |
| Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into the rehabilitation phase, they should transition from F-75 to RUTF over 2–3 days, as tolerated. The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend on the number and skills of staff available to supervize feeding and monitor the children during rehabilitation. |
| Two options for transitioning children from F-75 to ready-to-use therapeutic food are suggested: |
| a) start feeding by giving RUTF as prescribed for the transition phase. Let the child drink water freely. If the child does not take the prescribed amount of RUTF, then top up the feed with F-75. Increase the amount of RUTF over 2–3 days until the child takes the full requirement of RUTF, or |
| b) give the child the prescribed amount of RUTF for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of RUTF in the first 12 h, then stop giving the RUTF and give F-75 again. Retry the same approach after another 1–2 days until the child takes the appropriate amount of RUTF to meet energy needs (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 5.3
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| In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation phase Children who have been admitted with complicated severe wasting and/or nutritional oedema and are achieving rapid weight gain on F-100 should be changed to RUTF and observed to ensure that they accept the diet before being transferred to an outpatient programme (10). |
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Strong recommendation, Low certainty evidence
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Standing from 2013
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Recommendation 6.3
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| ReSoMal (or locally prepared ReSoMal using standard WHO low-osmolarity oral rehydration solution) should not be given if children are suspected of having cholera or have profuse watery diarrhoea. Such children should be given standard WHO low-osmolarity oral rehydration solution that is normally made, i.e. not further diluted (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 7.1
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| Children with severe wasting and/or nutritional oedema who are HIV infected and who qualify for lifelong antiretroviral therapy should be started on antiretroviral drug treatment as soon as possible after stabilization of metabolic complications and sepsis. This would be indicated by return of appetite and resolution of severe oedema. HIV-infected children with severe wasting and/or nutritional oedema should be given the same antiretroviral drug treatment regimens, in the same doses, as children with HIV who do not have severe wasting and/or nutritional oedema. HIV infected children with severe wasting and/or nutritional oedema who are started on antiretroviral drug treatment should be monitored closely (inpatient and outpatient) in the first 6–8 weeks following initiation of antiretroviral therapy, to identify early metabolic complications and opportunistic infections (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 7.2
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| Children with severe wasting and/or nutritional oedema who are HIV infected should be managed with the same therapeutic feeding approaches as children with severe wasting and/or nutritional oedema who are not HIV infected (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 7.3
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| HIV-infected children with severe wasting and/or nutritional oedema should receive a high dose of vitamin A on admission (50 000 IU to 200 000 IU depending on age) and zinc for management of diarrhoea, as indicated for other children with severe wasting and/or nutritional oedema, unless they are already receiving F-75, F-100 or RUTF, which contain adequate vitamin A and zinc if they are fortified following the WHO specifications (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 7.4
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| HIV-infected children with severe wasting and/or nutritional oedema in whom persistent diarrhoea does not resolve with standard management should be investigated to exclude carbohydrate intolerance and infective causes, which may require different management, such as modification of fluid and feed intake, or antibiotics (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 8.2
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| Infants who are less than 6 months of age with severe wasting and/or nutritional oedema should receive the same general medical care as infants with severe wasting and/or nutritional oedema who are 6 months of age or older: |
| a) infants with severe wasting and/or nutritional oedema who are admitted for inpatient care should be given parenteral antibiotics to treat possible sepsis and appropriate treatment for other medical complications such as tuberculosis, HIV, surgical conditions or disability; |
| b) infants with severe wasting and/or nutritional oedema who are not admitted should receive a course of broad-spectrum oral antibiotic, such as amoxicillin, in an appropriately weight-adjusted dose (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 8.3
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| Feeding approaches for infants who are less than 6 months of age with severe wasting and/or nutritional oedema should prioritize establishing, or re-establishing, effective exclusive breastfeeding by the mother or other caregiver (10). |
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Strong recommendation, Very low certainty evidence
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Standing from 2013
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Recommendation 8.7
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| For infants who are less than 6 months of age with severe wasting and/or nutritional oedema and who do not require inpatient care, or whose caregivers decline admission for assessment and treatment: |
| a) counselling and support for optimal infant and young child feeding should be provided, based on general recommendations for feeding infants and young children, including for low-birth-weight infants; |
| b) weight gain of the infant should be monitored weekly to observe changes; |
| c) if the infant does not gain weight, or loses weight while the mother or caregiver is receiving support for breastfeeding, then he or she should be referred to inpatient care; |
| d) assessment of the physical and mental health status of mothers or caregivers should be promoted and relevant treatment or support provided (10). |
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Best practice statement
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Standing from 2017
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Best practice statement 1
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| All infants and children aged less than 5 years presenting to primary health-care facilities should have both weight and length/height measured, in order to determine weight-for-length/height and to classify nutritional status according to WHO child growth standards (189). |
| Note: The measurement of mid-upper arm circumference both at health facilities and in the community can be used to identify children with moderate wasting or severe wasting and/or nutritional oedema. However, mid-upper arm circumference cannot be used to determine overweight or obesity, as there are no validated cut-off values as yet. The best practice statement therefore only makes reference to weight and length/height. |
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Best practice statement
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Standing from 2017
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Best practice statement 2
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| Caregivers and families of infants and children aged less than 5 years presenting to primary health-care facilities should receive general nutrition counselling, including promotion and support for exclusive breastfeeding in the first 6 months and continued breastfeeding until 24 months or beyond (189). |
| Note: Against the background of best practice that caregivers of all infants and children aged less than 5 years should receive general nutrition counselling, no recommendation is made regarding providing nutrition counselling that is specific to children with stunting only. |
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Conditional recommendation, Moderate certainty evidence
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Standing from 2021
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Recommendation
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| Standard ready-to-use therapeutic food (RUTF) (with at least 50% of protein coming from dairy products) is recommended for outpatient treatment of children with severe wasting and nutritional oedema. Use of RUTF formulations with less than 50% of protein from dairy products for outpatient treatment of children with severe wasting and nutritional oedema is encouraged within research and evaluation settings (190). |
