Daily Protein Requirements for Severely Malnourished Persons
Severely malnourished individuals require 1.2-1.5 g protein/kg body weight/day to prevent body weight loss, reduce mortality and complications, and improve functional outcomes and quality of life. 1
Standard Protein Targets by Clinical Context
Hospitalized Severely Malnourished Patients
Target 1.2-1.5 g protein/kg/day as the primary recommendation, which represents a cost-effective and highly efficient measure to prevent body weight loss, reduce risk of mortality and complications, reduce hospital readmissions, and improve functional outcomes and quality of life 1
For severely malnourished older adults (≥65 years) with acute or chronic illness, the same range of 1.2-1.5 g/kg/day applies due to increased metabolic demands from inflammation, infections, or wounds 2
In cases of severe illness, injury, or profound malnutrition, protein requirements may escalate up to 2.0 g/kg/day 2
Therapeutic Feeding Programs (Severe Acute Malnutrition)
Children with severe acute malnutrition require 3 g protein/kg body weight/day along with 150 kcal/kg/day 1
This higher requirement reflects the extreme metabolic demands of catch-up growth in severely wasted children 1
Protein requirements during catch-up growth can range from 0.7 g/kg/day in the first days of treatment up to 5 g/kg/day or more when weight gain is maximum, though protein should never exceed 10-12% of total energy needs 3
Critical Implementation Considerations
Refeeding Syndrome Risk
Severely malnourished patients are at extremely high risk for refeeding syndrome and nutritional support must be initiated cautiously and slowly 1
Energy targets of 30 kcal/kg/day should be achieved gradually, not immediately 1
Some experts recommend starting at rates <10 kcal/kg/day in very undernourished patients 4
Body Weight Calculation
Use actual body weight for protein calculations, not ideal body weight, unless working with a dietitian for obese patients 2
For severely underweight patients, resting energy expenditure can be estimated at 30 kcal/kg of actual body weight/day 1
Special Populations Requiring Adjustment
Patients with severe kidney impairment (eGFR <30 ml/min/1.73m²) not on dialysis should receive only 0.8 g protein/kg/day to avoid worsening renal function 1
This represents the only major exception where protein should be restricted despite severe malnutrition 1
Metabolic Context of Severe Malnutrition
Protein Catabolism Characteristics
Severely malnourished patients exhibit markedly increased protein catabolism with negative nitrogen balance 1, 5
There is an impaired capacity for net protein synthesis and reduced sensitivity to the protein-sparing effects of glucose infusion 1
Hypercatabolic states in severe malnutrition are similar to those seen in severe sepsis or trauma 1
Achieving Positive Nitrogen Balance
A net positive nitrogen balance is difficult to achieve in severe malnutrition, making adequate protein delivery critical 1
The goal for nitrogen supply should be 0.2-0.24 g nitrogen/kg/day (equivalent to 1.2-1.5 g amino acids/kg/day) 1
Monitoring urea excretion may help tailor actual nitrogen needs 1
Common Pitfalls to Avoid
Do not use the standard 0.8 g/kg/day recommendation for severely malnourished patients, as this represents only the minimum to prevent progressive lean body mass loss in healthy individuals, not optimal repletion 2
Avoid aggressive refeeding despite the temptation to rapidly correct malnutrition, as this significantly increases mortality risk from refeeding syndrome 1
Do not rely on albumin or prealbumin levels to guide protein requirements, as these are not sensitive markers of protein intake adequacy 1
Ensure adequate energy intake is provided simultaneously, as caloric restriction increases protein requirements 2
Prioritize high-quality protein sources containing all essential amino acids 2