<p>Severe Acute Malnutrition [SAM] is a leading cause of pediatric morbidity and mortality, particularly in low-resource settings. Electrolyte disturbances significantly influence treatment outcomes but are often underemphasized in clinical protocols. Understanding these disturbances and their impact on recovery is critical to improving management strategies and survival rates among children with SAM. To assess serum electrolyte and their association with treatment outcomes among children with SAM. A prospective cohort study was conducted among 110 under five children who were admitted with SAM in Woldia comprehensive specialized Hospital, Ethiopia. Serum electrolytes were measured at admission using standard laboratory procedures. multinomial logistic regression was employed to evaluate predictors of treatment outcomes, categorized as recovery, default, transferred out, and died. Of the 110 participants, 85.5% were transferred out after improvement, 8.2% died, and 6.4% defaulted. Hyponatremia, observed in 55.5% of study participants, was the strongest predictor of mortality with 77.8% of children who died having sodium levels below 135 mmol/L. Serum electrolyte disturbances significantly influence treatment outcomes in children with SAM, with hyponatremia being the most critical predictors of mortality. Integrating electrolyte management into SAM protocols and addressing comorbidities can enhance recovery rates and reduce mortality.</p>