Infants presenting with severe malnutrition (especially kwashiorkor) are very sick and a number will die within a week of starting treatment. They must all be hospitalised immediately. This phase of treatment usually lasts about a week:

1. Correct and avoid hypoglycaemia, hypothermia or dehydration. Check the blood glucose 6 hourly for the first few days and whenever the child’s temperature falls below 35.5 °C. A feed of 50 ml of 10% glucose orally should correct hypoglycaemia. Correct any dehydration slowly with oral fluids. Avoid intravenous fluids if possible. Do not use diuretics to reduce the oedema.
2. Give broad spectrum antibiotics (ampicillin and gentamicin if clinically septic or co-trimoxazole if there is no obvious site of infection) to all children for a week. Assume that all children with severe malnutrition have a bacterial infection.
3. Start with oral or nasogastric feeds every 3 hours, both day and night, as soon as possible. Usually a starter formula or, if diarrhoea is present, a lactose-free formula 100 ml/kg/24 hours is used for the first week. High volume feeds may cause heart failure.
4. Give oral potassium chloride 0.5 g/kg/day (4 to 6 mmol/kg/day) as these children are severely potassium depleted, especially children with kwashiorkor. Also give extra magnesium, 0.4 to 0.6 mmol/kg/day, as well as zinc 2 mg/kg/day, folic acid 5 mg per day, multivitamin syrup 10 ml per day and vitamin A 50 000 to 100 000 units on day 1.
5. Do not give oral iron yet. Iron can be very dangerous as these children do not have enough protein to carry iron safely in the blood stream.