e-Library of Evidence for Nutrition Actions (eLENA)

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.

WHO recommendations

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.

* standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not 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%