WHO guideline on the prevention and

management of wasting and

nutritional oedema
(acute malnutrition) in infants and
children under 5 years
(2023)
This guideline includes recommendations and good practice statements
with regards to management of wasting and nutritional oedema in
following subsections,
• Management of infants less than 6 months of age at risk of poor
growth and development
• Management of infants and children 6-59 months with wasting
and/or nutritional oedema
• Post-exit interventions after recovery from wasting and/or nutritional
oedema
Why a new guideline?

Sustainable Development Goals which include a target to end all forms of

malnutrition by 2030.
High risk of wasting and nutritional oedema in infants and children observed in,
• contexts where health and socioeconomic indicators are at their poorest, is
heightened by ongoing crises including climate change, the COVID-19
pandemic, and conflicts.

Malnutrition can lead to poor child motor and cognitive development, along
with reduced economic productivity and elevated risk of non-communicable
disease in adulthood.
Four areas of focus in this guideline,
• Infants less than 6 months of age at risk of poor growth and development
• Moderate wasting in infants and children 6-59 months of age
• Severe wasting and nutritional oedema in infants and children 6-59
months of age
• Prevention of wasting and nutritional oedema from a child health

The 2013 WHO guideline update included a limited number of

recommendations for infants less than 6 months of age with severe wasting
and/or nutritional oedema well-recognized gap in guidance between
approximately 2 months of age to 6 months.
Also focused on providing support and interventions to
mothers/caregivers, and infants less than 6 months old who are at risk
of poor growth and development, even if they do not yet have wasting
or nutritional oedema.

Stressed on providing guidance on psychosocial elements of care for

infants at risk of poor growth and development and infants and
children with wasting and/or oedema, as well as their
mothers/caregivers.
How to identify infants with poor growth based on
sequential measures?

• No weight gain or weight loss from one measurement to the next

• Downward crossing of weight-for-age centile
• Insufficient weight gain (Approximately less than 500g/month, or if
weekly measurements: birth to 3 months, approximately less than
150-200g/week and 3 to 6months approximately less than 100-150g
per week)
Infants with poor anthropometry based on a single
measure

•Weight-for-age <-2 SD; or

•Weight-for-length <-2 SD; or
•Nutritional oedema; or
•Mid-upper arm circumference (MUAC) <110mm for infants between 6
weeks to less than 6 months of age
Infants with known risk factors for poor growth and
development
•Neurodevelopmental concerns
•Infant feeding concerns
•Maternal risk (physical or mental health problem(s) affecting caring practices)
•History of hospitalization

Infants at risk due to poor birth

outcomes
•Preterm birth
•Low birth weight
•Small for gestational age
Moderate wasting in infants and children 6-59
months of age
Weight-for-height or weight-length z-score between -2SD TO -3SD
according to the WHO child growth standards (-3 and <-2 SD) (or MUAC
=115mm to <125mm as an alternative field measure)

Severe wasting and nutritional oedema in infants

and children 6-59 months of age
Weight-for-height or weight-for-length below 3 SD according to WHO
child growth standards (or mid-upper arm circumference (MUAC)
<115mm as an alternative field measure) and/or nutritional oedema.
Term malnutrition addresses three broad groups of
conditions
•Undernutrition, which includes wasting (low weight-for-height), stunting (low
height-for-age) and underweight (low weight-for-age)
•Micronutrient-related malnutrition, (a lack of important vitamins and
minerals) or micronutrient excess
•Overweight, obesity and diet-related noncommunicable diseases (such as
heart disease, stroke, diabetes and some cancers).

Nutritional oedema is bilateral pitting oedema which starts in the feet and can
progress up to the legs and the rest of the body, including the face which is
pathognomic of severe acute malnutrition.
Severe acute malnutrition Moderate acute malnutrition
(SAM) (MAM)

 Nutritional oedema and/or  WHZ or WLZ < -2 and/or

 WHZ or WLZ < -3 and/or  MUAC = 115 and <125mm and
 MUAC <115mm.  No nutritional oedema.
 Management of infants less than 6 months of age at risk of poor
growth and development
Highlights importance of supporting mothers/caregivers and taking a family-
centred approach
Infants with any one of following characteristics should be referred and admitted
for inpatient care:
i. One or more Integrated Management of Childhood Illness (IMCI) danger signs :
not able to drink or breastfeed; vomits everything; had convulsions recently;
lethargic or unconscious; convulsing now.
ii. Acute medical problems or conditions under severe classification as per IMCI
iii. Oedema (nutritional)
iv. Recent weight loss.
Acute medical problems (as per IMCI classification) which need
referral to inpatient care include,
• Signs of possible serious bacterial infection in infants less than 2 months of age
• Shock
• Oxygen saturation <90%
• Pneumonia (with chest indrawing; and/or fast breathing; and if possible to
measure, oxygen saturation <94%)
• Dehydration (including some or severe dehydration)
• Severe persistent diarrhoea (diarrhoea for 14 days or more plus dehydration)
• Very severe febrile illness – severe malaria, meningitis
• Severe complicated measles
• Mastoiditis
Infants less than 6 months care can be transferred to outpatient
care when:
i. There have been no danger signs for at least 48 hours prior to transfer time
ii. All acute medical problems are resolved
iii. Nutritional oedema is resolving
iv. The infant has good appetite
v. Documented weight gain for at least 2-3 days is satisfactory on either exclusive
breastfeeding or replacement feeding
vi. The infant has been checked for immunizations and other routine interventions
delivered or plans made for follow-up
vii. The mothers/caregivers are linked with needed follow-up care and support
(e.g. for any health, mental health or social issues identified during
assessment).
Infants less than 6 months can have a reduced frequency of outpatient
visits when they:
i. Are breastfeeding effectively or feeding well with replacement
feeds
ii. Have sustained weight gain for at least 2 consecutive weekly visits.

Infants who are less than 6 months of age with severe wasting and/or
nutritional oedema who are admitted for inpatient care:
iii. Should be breastfed where possible. If an infant is not breastfed,
support should be given to the mother or female caregiver to re-
lactate. If this is not possible, wet nursing should be encouraged.
ii. Should also be provided a supplementary feed:

• Supplementary suckling approaches should, where feasible, be

prioritized for infants with severe wasting but no oedema
• Expressed breast milk should be given, and, where this is not
possible, commercial (generic) infant formula or F-75 or diluted F-
100 may be given for infants with oedema.
Details of feeding formulas
• F75 is the “starter” formula to use during initial management, during
stabilization phase
 F75 contains 75kcal and 0.9g protein per 100ml.
 F100 contains more calories and protein: 100kcal and 2.9g protein per 100ml.
• These are powder formulations that can be mixed with clean water.
• Once mixed with water, the mixture must be used afresh without
delay.
• One sachet of 456 g diluted in 2 litres of drinking water gives 2.4 litres
high energy milk
• F75 and F100 should be used only for inpatient care.
Feeding formulas cont.

• A cup and/or spoon should be used for feeding.

• Should be stored in a cool and dry place, protected from UV light
• Shelf life: 6 months
• Once opened, the sachet must be immediately used up.
• Once reconstituted, the milk should be consumed within 2 hours
• Destroy milk powder immediately if the color, the smell or the aspect
of the milk has changed
Should not be given full-strength F-100 if they are clinically unstable
and/or have diarrhoea or dehydration and/or nutritional oedema (due
to the renal solute load of this therapeutic milk and risk of
hyponatraemic dehydration) Updated
(Diluted F-100 refers to F-100 which is prepared using an extra 30% of
water)

Once children are stabilized, can be move into the rehabilitation phase,
from F-75 to ready-to-use therapeutic food over 2–3 days, as tolerated.
The recommended energy intake during this period is 100–135
kcal/kg/day.
 Management of infants and children 6-59
months with wasting and/or nutritional oedema

Indications for inpatient care,

I. One or more Integrated Management of Childhood Illness (IMCI)
danger signs
II. Acute medical problems
III. Severe nutritional oedema (+++)
IV. Poor appetite (failed the appetite test).
Infants and children 6-59 months old with severe wasting
who have all of the following characteristics can be
managed as outpatients

I. Good appetite
II. No danger signs or any of the acute medical problems
III. No criteria needing in-depth assessment (Diarrhoea with no
dehydration, respiratory infections with no signs of respiratory
distress, malaria with no signs of severity)
Indications to which they can be transferred to
outpatient care include,
I. They do not have any danger signs for at least 24-48 hours
II. The medical problems that prompted their admission have
resolved
III. They do not have ongoing weight loss
IV. Their nutritional oedema is no longer grade +++ and is resolving
V. Good appetite

Discharge plan should also include assessment of environmental health

aspects including water, sanitation and hygiene; food security; economic
stability; and the mental and physical health of caregivers.
Ready-to-use therapeutic food for treatment of severe
wasting and/or nutritional oedema
• RUTF includes BP 100 (a compressed dry form of food), and Plumpy nut (an oil
based-paste or spread).
• BP 100 is a compressed food product fortified with micronutrients that is used in
the rehabilitation phase of SAM
• For children < 2 years it can be used in porridge form and for the children >2
years in the dry form
• One bar (2 tablets) of BP 100 contains 300 kcal
• Once the alufoil packaging is opened, the product should be used within 2 weeks.
• Porridge made of BP 100 and water should be used within 3 hours. Use 100ml (½
cup) of boiled cooled water per tablet to make a porridge.
• It is important to give at least 200ml of safe drinking water with one bar to keep
the child hydrated.
RUTF is given as 2 regimes depending on the
nutritional assessment

• First regime: If the child is just below -3SD provide 50% of

nutrition requirement from main meals (prepared at home) and
the other 50% from RUTF as snacks
• Second regime: If the child is well below -3SD or caregivers
unable to provide nutritious meals provide 100% of nutrition
requirement from RUTF
Ready-to-use therapeutic food (RUTF) given to provide ,
• 150-185 kcal/kg/day until anthropometric recovery and resolution
of nutritional oedema
• Then the quantity can be reduced to provide 100-130 kcal/kg/day,
until anthropometric recovery

(Anthropometric recovery; weight-for-height equal to or greater than 2

standard deviations (SD) and/or MUAC equal to or greater than
125mm)
Infants and children aged 6–59 months of age with moderate wasting
(weight-for-height between -2SD and -3SD and/or a mid-upper arm
circumference between 115 mm and 125 mm, without oedema)
should have access to a nutrient-dense diet

(Nutrient-dense foods are those high in nutrients relative to their

caloric content, eg-animal source foods, beans, nuts, and many fruits
and vegetables)
In high-risk contexts all infants and children 6-59 months of age with
moderate wasting should be considered for specially formulated foods
(SFFs -fortified blended foods, commercial infant cereals, or ready-to-use
foods)
SFFs are specifically designed, manufactured, distributed, and used for
special medical purposes

High-risk contexts include;

• High rates of food insecurity
• Poor water quality and sanitation
• Low-income status / low socioeconomic status
• High incidence/prevalence of wasting and/or nutritional oedema
Among specially formulated foods (SFFs);
• Lipid-based nutrient supplements (LNS) are the preferred type.
• When these are not available, Fortified Blended Foods with added sugar, oil,
and/or milk (improved FBFs) are preferred.
• They should provide 40-60% of the total daily energy requirements needed to
achieve anthropometric recovery (100-130 kcal/kg/day)

Breast milk should be prioritized and given alongside any specially

formulated foods
Post-exit interventions after recovery from wasting and/or
nutritional oedema
I. Counselling and education on,
• Infant and young child feeding practices
• Recognition of common childhood illnesses
• Appropriate health-seeking behaviours on responsive care, safe water,
sanitation
II. Psychosocial stimulation interventions (examples include talking,
smiling, pointing, enabling, and demonstrating, with or without objects.
This also includes responsive feeding)
Identification of dehydration in infants and children
with wasting and/or nutritional oedema

Classification of hydration status in children with wasting is challenging

because,
• Clinical features (e.g. sunken eyes, slow/very slow skin pinch) may
be present in a malnourished child even without dehydration
(over-diagnosis of dehydration)
• Conversely, clinical features such as nutritional oedema may mask
signs used to diagnose dehydration or lead to a false diagnosis of
fluid overload (under-diagnosis of dehydration)
Rehydration fluids for infants and children with wasting
and/or nutritional oedema and dehydration but who are
not shocked
ReSoMal or Low-osmolarity Oral Rehydration Solution (ORS) should be
administered in accordance with existing WHO recommendations for all
children
(additional 20 mmol/L of potassium was added to WHO low-osmolarity ORS,
totaling 40 mmol/L of potassium and may reduce hyponatraemia)
ReSoMal should not be given if 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.
• Give ReSoMal/ ORS as follows, in amounts based on the child’s
weight
Use of antibiotics in severe wasting and/or
nutrition

• Children with uncomplicated severe wasting and/or nutritional

oedema, who are managed as outpatients, should be given a course
of oral antibiotic.
- Amoxicillin 15mg/kg 8 hourly
• Children who are undernourished but who do not have severe
wasting should not routinely receive antibiotics
Treatment of micronutrient deficiencies
• Children with severe wasting and/or nutritional oedema should
receive the daily recommended nutrient intake of vitamin A
throughout the treatment period.
• 5000 IU vitamin A daily, either as an integral part of therapeutic foods
or as part of a multi-micronutrient formulation
• If signs of vitamin A deficiency present below mentioned treatment
regimen is used. Immediately on diagnosis (D0), give
< 6 months 50,000 IU
6-12 months 100,000IU
>12 months 200,000IU
References

• WHO guidelines on Acute malnutrition 2023 June

• 2020 Circular & Manual SAM & MAM mangement (manual for health
workers in Sri Lanka)
THANK
YOU