21Background: Malnourished children are more prone to infectious diseases including severe 22 diarrhea compared to non-malnourished children. Understanding of the differences in the 23 presentation of severe diarrhea such as cholera in children with varying nutritional status may 24 help in the early identification and management these children. However, data are scarce on 25 differences in the presentation in such children. Thus, we aimed to identify the clinical 26 differentials among children with cholera with or without malnutrition. 27 Methods: Data were extracted from diarrheal disease surveillance system (DDSS) of the Dhaka 28 Hospital of icddr,b for the period, January 2008 to December 2017. Among under-five children, 29 cholera positive (culture confirmed) and malnourished children (weight-for-age, weight-for-30length or height-for-age Z score (WAZ, WHZ or HAZ) ˂-2) were considered as the cases 31 (n=305) and children with cholera but non-malnourished (WAZ, HAZ, and WHZ ≥-2.00 to 32 ≤+2.00) were the controls (n=276). 33 Results: A total of 14,403 under-five children were enrolled in the surveillance system during 34 the study period. After adjusting for potential covariates such as maternal illiteracy and slum 35 dwelling, it was revealed that under-five malnourished children with cholera significantly more 36 often presented to the hospital during evening hours (6 pm to 12 mid-night) (OR=1.64, 95% 37 CI=1.16-2.31, P<0.05), had fathers who were illiterate (OR=1.70, 95% CI=1.11-2.62, P<0.05), 38 presented with history of cough within last 7 days (OR=1.64, 95% CI=1.10-2.43, P<0.05), 39 dehydrating diarrhea (OR=1.70, 95% CI=1.15-2.53, P<0.05), and had longer hospitalization 40 (OR=1.50, 95% CI=1.05-2.14, P<0.05).3 41 Conclusions: The study results underscore the importance of understanding of the basic 42 differences in the presentation of severe cholera in malnourished children for prompt 43 identification and the subsequent management of these children. These observations may help 44 policy makers in formulating better case management strategy. 45 Author Summary: 48 Malnourished children are more vulnerable to infectious diseases including cholera in 49 comparison to the non-malnourished children. They often have suboptimal immune function, 50 though there is no precise information on whether there is any difference in associated factor(s) 51 or clinical course of cholera in under-five children with varying nutritional status. Therefore, this 52 study was conducted to elucidate these insights by using the surveillance data of the Dhaka 53 hospital of icddr,b. Among all the under-five children with cholera, 305 malnourished (WAZ or 54 WLZ or HAZ ˂-2) children constituted as the cases (malnourished), and another 276 non-55 malnourished (WAZ, HAZ, and WHZ ≥-2.00 to ≤+2.00) cholera children formed the comparison 56 group. 57In this study we revealed that care seeking at evening time was more common in the 58 malnourished children with cholera compared to those without malnutrition. Dehydrating 59 diarrhea was...