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Summary We conducted a prospective audit of 101 children aged 6 to 59 months, admitted to Kenyatta National Hospital (KNH) with severe malnutrition, from February-April 2008. Forty-seven per cent (47/101) of children were younger than one year old. Overall, 58% (59/101) of children had marasmus, 70.3% (71/101) had diarrhoea and 51.5% (52/101) had pneumonia on admission. A structured tool was prepared to capture data to allow assessment of implementation of WHO guidelines steps 1–8. The highest degree of implementation (91/101, 90%) was observed for Step 5: treatment of potentially severe infections, although only 55% (56/101) of patients had F75 prescribed even though this starter formula was available. There was modest implementation of Step 2: ensuring warmth (47/101, 46.5%), Step 3: treatment of dehydration (39/71, 54.9%) and Step 4: correction of electrolyte imbalance (46/101, 45.5%). There was least implementation of Step 8: transition to catch-up feeding (16/67, 23.8%). There was a delay in initiating feeds with a median time of 14.7 hours from the time of admission. We conclude that quality of care for children admitted with severe malnutrition at KNH, Kenya's largest tertiary level health facility, is inadequate and often does not follow WHO guidelines. Improving care will require a holistic and not simply medical approach.