ReviewManagement of severe acute malnutrition in children
Introduction
Severe acute malnutrition (SAM), is defined as a weight-for-height measurement of 70% or more below the median, or three SD or more below the mean National Centre for Health Statistics reference values (that will likely be replaced by new WHO growth curves1), which is called “wasted”; the presence of bilateral pitting oedema of nutritional origin, which is called “oedematous malnutrition”;2 or a mid-upper-arm circumference of less than 110 mm in children age 1–5 years.3, 4 Many advanced cases of SAM are complicated by concurrent infective illness, particularly acute respiratory infection, diarrhoea, and gram-negative septicaemia. By contrast, chronic malnutrition (termed “stunted”) is defined by a height-for-age indicator. In addition, a composite form of malnutrition including elements of both stunting and wasting is defined with a weight-for-age indicator. As these different forms of malnutrition have different causes and require substantially different treatments, clear nomenclature to differentiate them is needed.
Case-fatality rates in hospitals treating SAM in developing countries average 20–30% and have remained unchanged since the 1950s5 despite the fact that clinical management protocols capable of reducing case-fatality rates to 1–5% have been in existence for 30 years. In 1992, this failure to translate scientific knowledge of what is needed to treat malnutrition into effective large-scale interventions, was criticised as “nutrition malpractice”;6 13 years and numerous studies and clinical manuals later, there is an even greater discrepancy between actual practice in most institutions treating SAM and our knowledge of what works.
The treatment of severe acute malnutrition occupies a unique position between clinical medicine and public health. The causes are essentially poverty, social exclusion, poor public health, and loss of entitlement,7 and most cases can be prevented by economic development and public-health measures designed to increase dietary quantity and quality alone, with no need for clinical input. However, as acute malnutrition becomes more severe, normal physiological mechanisms that adapt the organism to low food intake become more pronounced.8, 9, 10, 11, 12 These “reductive adaptations” affect every physiological function in the body,13, 14, 15 mobilising energy and nutrient reserves and decreasing energy and nutrient demands; they are initially beneficial and allow the organism to maintain homoeostasis. However, as the severity of nutritional insult increases, these adaptations progressively limit the body's ability to respond to stresses such as infection.15, 16, 17 In practice, inpatient units treating SAM are commonly confronted by extremely ill patients who need intensive medical and nursing care. Most of these units are in the poorest parts of the poorest countries and have severe capacity constraints, in particular, very few skilled staff. In addition, most carers of malnourished patients come from the poorest families and have great demands on their time. To achieve an impact at a population level, management protocols must take these socioeconomic realities into account, balancing the potentially conflicting demands and ethics of clinical medicine with those of public health.
Section snippets
Worldwide public-health significance of malnutrition
Malnutrition is a major public-health problem throughout the developing world and is an underlying factor in over 50% of the 10–11 million children under 5 years of age who die each year of preventable causes.18, 19, 20, 21 However, while the child-survival movement commonly acknowledges the importance of undernutrition, defined as low weight for age,22 the importance of acute malnutrition is seldom mentioned. For example, none of the five papers of the recent child survival series in The Lancet
High case-fatality rates for SAM
Over the past 50 years, in most resource-poor settings, case-fatality rates for severe malnutrition treated in health facilities have remained at 20–30% for marasmus (wasting malnutrition) and up to 50–60% for kwashiorkor.5, 31 By contrast, since the 1970s there have been management protocols capable of achieving case-fatality rates of 1–5%,15, 32, 33 and well-resourced humanitarian agencies using these protocols frequently achieve mortality rates under the 10% level stipulated in the
Current management protocols
At present, an exclusive inpatient approach to the clinical care of SAM is recommended. The core of accepted WHO management protocols is ten steps in two phases (stabilisation and rehabilitation).2, 36, 37, 38, 39 The approach requires many trained staff and substantial inpatient bed capacity. Where these are available and sufficient attention is paid to the quality of care, there is good evidence that these protocols can substantially decrease case-fatality rates in both stable environments33,
Effect of HIV and tuberculosis
HIV and tuberculosis are increasing the workloads of hospital units treating SAM through both the direct effects of infection and the indirect negative effects on livelihoods and food security. HIV and tuberculosis infection decrease skilled human resource capacity in health services, raise the prevalence of SAM, and increase case-fatality rates.43, 44, 57, 58 In sub-Saharan Africa, a high proportion of severely malnourished children admitted to nutritional rehabilitation units are now also HIV
Treatment at home and in the community
Concerns over the limited capacity of hospital units to treat SAM are not new. Since the 1960s, the high cost and poor success rates of inpatient treatment have prompted debate over whether hospitals were the best places to treat SAM.65, 66 There are several well-known weaknesses of a centre-based approach: limited inpatient capacity and lack of enough skilled staff in hospitals to treat the large numbers needing care;67, 68 the centralised nature of hospitals promotes late presentation and
Ready-to-use therapeutic food
The Ashworth review indicates that the recent development of ready-to-use therapeutic food has greatly eased the difficulties associated with providing a suitable high-energy, nutrient-dense food that is safe for use in outpatient programmes. Ready-to-use therapeutic food is an energy-dense food enriched with minerals and vitamins, with a similar nutrient profile but greater energy and nutrient density than F100, the diet recommended by WHO in the recovery phase of the treatment of SAM.86 In
Community-based management of acute malnutrition
During the past 5 years, a growing number of countries and international relief agencies have adopted a community-based model for the management of acute malnutrition, called community-based therapeutic care.94, 95, 96, 97 This model provides a framework for an integrated public-health response to acute malnutrition, treating most patients with SAM solely as outpatients and reserving inpatient care for the few with SAM and complications.73 The model also aims to integrate treatment with various
Conclusion
Where sufficient resources are available, the WHO inpatient treatment model for SAM can achieve low case-fatality rates. However, exclusive inpatient treatment strategies are resource-intensive and require many skilled staff. Because the prevalence of SAM is highest in resource-poor environments, there is usually a substantial mismatch between the many patients requiring treatment and few skilled staff and scarce resources available to treat them. The HIV/AIDS pandemic is further lowering
The way forward
Community-based therapeutic care should now be scaled up in both emergency and non-emergency settings and appropriate training included in medical, nursing, and primary health-care curricula. To start this process, WHO, UNICEF, and the UN Standing Committee on Nutrition recently convened an informal consultation on the community-based management of severe malnutrition in children. The meeting began the process of incorporating these techniques into the WHO guidelines.103 This is an essential
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