Protocol · WHO wasting guideline
Acute malnutrition in a child
A child with severe wasting or nutritional oedema can die of an infection that would not trouble a well-fed child. Find them by measuring MUAC and pressing both feet in every child, decide quickly between inpatient and outpatient care, and keep them in treatment until they have fully recovered.
- Based on WHO wasting guideline
- For health workers, nutrition staff and community health workers
- Reviewed October 2026
1Who / when
- Every child aged 6 to 59 months at every sick or well visit: MUAC and both feet.
- Infants under 6 months who are underweight, wasted, not gaining weight or feeding poorly: see the infant box under Treat.
- Community health workers can screen, classify and manage or refer with training and supervision.
2Red flags: refer now
Admit (refer urgently) a child with severe wasting or oedema who has any of:
- Any IMCI general danger sign (not able to drink, vomits everything, convulsions, lethargic or unconscious).
- An acute medical problem or severe classification (for example pneumonia with chest indrawing, severe dehydration).
- Severe oedema (+++): feet, legs, hands and face.
- Poor appetite: fails the RUTF appetite test.
Complicated severe acute malnutritionBefore transfer: first dose of an appropriate antibiotic, prevent low blood sugar (breastfeed, or milk or sugar water), keep the child warm, refer urgently.
3Assess
- MUAC with a MUAC tape in every child 6 months and over.
- Oedema: press the tops of both feet with your thumbs; pitting on both feet is nutritional oedema.
- Weight-for-height/length z-score (WHZ) if you have scales, a height board and WHO charts.
- Danger signs and a full IMCI assessment; HIV status; TB contact.
- Appetite test (6 months and over, no complication): in a quiet corner offer RUTF for up to 30 minutes. Passes if the child eats at least one-third of a 92 g packet (or 3 teaspoons from a pot).
4Classify
| Findings (6 to 59 months) | Classify as | Care |
|---|---|---|
| Oedema of both feet, or WHZ below -3, or MUAC below 115 mm, and a danger sign, medical complication, oedema +++ or failed appetite test | Complicated severe acute malnutrition | Inpatient care; refer urgently |
| Oedema (+ or ++), or WHZ below -3, or MUAC below 115 mm; passes appetite test; no complication | Uncomplicated severe acute malnutrition | Outpatient: RUTF, amoxicillin, review in 7 days |
| WHZ -3 to below -2, or MUAC 115 to under 125 mm, no oedema | Moderate acute malnutrition | Feeding counselling, treat illness; supplementary food if at high risk; review in 30 days |
| WHZ -2 or more, or MUAC 125 mm or more, no oedema | No acute malnutrition | Feeding advice if under 2 years |
5Treat
Uncomplicated severe acute malnutrition (outpatient)
- RUTF to give 150 to 185 kcal/kg a day (one 92 g packet is 500 kcal). Example (IMCI 2014): 4 to 4.9 kg, 2 packets a day; 5 to 6.9 kg, 2.5 packets a day; 7 to 8.4 kg, 3; 8.5 to 9.4 kg, 3.5; 9.5 to 10.4 kg, 4; 10.5 to 11.9 kg, 4.5; 12 kg and over, 5. Use your national RUTF table.
- Oral antibiotic such as amoxicillin (dose per national formulary).
- Do not give iron or high-dose vitamin A to a child on RUTF: RUTF contains them.
- Malaria test in malaria areas; treat other illness. Dehydration: ReSoMal (or low-osmolarity ORS if none) given slowly; refer if you are not sure.
- Breastfeed first, then RUTF; offer plenty of clean water. Assess for TB.
Moderate acute malnutrition
Nutrient-dense diet and counselling for all. Add a specially formulated food (lipid-based supplement preferred) if MUAC 115 to 119 mm, under 24 months, past severe wasting, relapse, illness such as HIV or TB, or in a humanitarian crisis. No routine antibiotics unless there is infection.
Infants under 6 months at risk
Admit if a danger sign, severe illness, oedema or recent weight loss. Otherwise support effective breastfeeding (or safe replacement feeds) and the mother's own health, and review regularly. Do not give RUTF.
6Follow-up
- Uncomplicated severe: first review in 7 days, then every 14 days. Measure MUAC and weight the same way, check oedema and appetite. New complication, oedema appears, or fails appetite test: refer urgently.
- Moderate: review after 30 days, then monthly; refer if losing weight or MUAC falling.
- Exit treatment only when WHZ is -2 or more and MUAC is 125 mm or more on 2 consecutive visits, with no oedema for 2 visits. Weight-gain percentages are not exit criteria.
- After exit: periodic checks to prevent relapse.
7Counsel
- RUTF is a medicine for this child only: do not share it. Give small meals often through the day.
- Wash hands before feeding; keep RUTF covered.
- Play with and talk to the child: stimulation helps recovery.
- Return at once if the child stops eating, has swelling, vomiting, diarrhoea, fever, or fast breathing.
This food is medicine for your child. Give it in small amounts many times a day, after breastfeeding, with clean water to drink. Do not share it. Come back in one week, or at once if she stops eating or gets sick.
8When to refer
- Urgently: any danger sign, medical complication, oedema +++, or failed appetite test.
- Uncomplicated severe that is not improving, losing weight, or has had previous episodes.
- Infant under 6 months with severe wasting, oedema or recent weight loss.
- HIV, TB, disability or heart disease needing long-term care, or severe social problems: link to services.
9Sources
- World Health Organization. WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. 2023. Definitions, admission and exit criteria, RUTF energy, moderate wasting, infants under 6 months, standing 2013 recommendations on antibiotics and vitamin A.
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Classification table, appetite test, RUTF packets by weight, pre-referral steps, follow-up intervals.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.