Debate on the Management of Severe Malnutrition
by Marie McGrath, Fiona O'Reilly and Jeremy Shoham (ENN).
Over the past six months, ENN has been a party to debate regarding technical aspects of the management of severe malnutrition. We believe that transparency and information sharing leads to clarity not confusion, and so wish to share the following key areas of debate. This article was circulated pre- publication to those involved, who were invited to respond in the form of a letter for inclusion in the same issue of Field Exchange.
In May 2003, a new publication, Caring for severely malnourished children, Ashworth and Burgess, 20031, met with some technical criticism from Professor Mike Golden in the form of a book critique submitted to ENN, and circulated to the publishers and supporting agencies (see Field Exchange 19, pp 19). In response, a review by independent experts was co-ordinated by TALC and the findings of the review are summarised in this issue of Field Exchange2. Through this process it emerged that issues raised in the original book critique primarily concerned aspects of the 1999 WHO guidelines on the management of severe malnutrition3 and consequently, subsequent publications which reflect these guidelines, e.g. Ashworth/Burgess 2003. Drawing on a number of sources, we were able to determine where there is some consensus over potential challenges to the 1999 WHO guidelines and other derivative publications. Largely based on the original critique, the following key areas of debate have emerged.
Management of severe malnutrition in infants less than six months
The 1999 WHO guidelines do not specifically extend to include malnourished infants under six months of age. Differences in field approaches to managing malnourished infants under six months have already been highlighted by the ENN - a recent study by ENN and GIFA (Geneva Infant Feeding Association) to support technical training material on infant feeding in emergencies, concluded that an urgent consultation by technical experts and field practioners was required to achieve consensus on the management of severe malnutrition in young infants4.
In the ENN/GIFA study, the most significant areas of contention were the role of breastfeeding, and the choice of therapeutic feed (if any) to use in managing young, malnourished infants.
The majority of guidelines/field protocols reviewed relied on breastfeeding (if necessary supported by supplementary suckling) to treat young infants. In contrast, WHO draft guidance available to the review advised that breastfeeding could not be relied upon, and that the first priority is therapeutic feed to ensure infant survival. This position is echoed in the recently published 'Caring for Severely Malnourished Children' (Ashworth and Burgess, 2003).
The WHO draft guidance recommend giving supplementary therapeutic milk before each breastfeed. This is contrary to the supplemental suckling technique5 and expert breastfeeding recommendations, where breastmilk is always offered first6.
The WHO draft guidance recommend the use of F75 during stablisation and full strength F100 during recovery of infants under six months. Argument against the use of full strength F100 in infants under six months revolves around water balance and renal function in young malnourished infants (see Field Exchange 19)7. Instead, the critique considers diluted F100 the formula of choice for young malnourished infants, while F75 and infant formula are considered safe to use but less pragmatic options. The Ashworth/Burgess publication recommends using a "starter formula" which is likened to F75. However the starter formulation given is of higher osmolarity than standard F75, which, it has been argued, may precipitate osmotic diarrhoea.
Management of severe oedema
The Ashworth/Burgess publication recommends energy intake of 75 kcal/kg/d in the initial treatment of children with severe oedema. The critique argues that, in practice, the degree of oedema is overestimated by clinicians, particularly the inexperienced, and nowhere warrants a reduction in intake from 100 to 75 kcal/kg/d. Overestimation of oedema will lead to underfeeding, which may not necessarily contribute to increased mortality, but delays progress and recovery. The critique also questions the evidence base for prescribing reduced energy intake in severe oedema cases.
Diarrhoea and dehydration
Management of diarrhoea and dehydration has been identified as one of the most contentious and difficult issues in the management of severe malnutrition. The 1999 WHO guidelines recommend using 50 - 100ml Resomal for each stool loss for children under 2 years, which, the critique argues, risks providing dangerous amounts of sodium and over re-hydration.
The 1999 WHO guidelines state that very severe anaemia can cause heart failure and specifies that children with very severe anaemia need a blood transfusion. The critique argues that heart failure due to anaemia (where the peripheries are warm, the pulse full and the heart overactive) is uncommon in the malnourished child. Other forms of heart failure are common and lead to breathlessness with a weak, rapid pulse, which often coincide with anaemia. Further, heart failure due to fluid overload is always associated with a fall in haemoglobin (so called dilutional anaemia). These may mislead the inexperienced clinician. Giving a blood transfusion in these circumstances is hazardous, with evidence to suggest it should only be considered in the first 24 hours of treatment. Furthermore, fluid shifts and electrolyte imbalance during treatment8, which occur more rapidly with modern therapeutic feeds, make children much more vulnerable to therapeutic errors - inappropriately transfusing to correct a dilutional fall in haemoglobin is, the critique warns, usually fatal.
The 1999 WHO guidelines recommend the use of cotrimoxazole as first line antibiotic treatment, where there are no signs of infection or complications. The critique suggests that since nearly all severely malnourished children have small bowel bacterial overgrowth (SBO)9, oral amoxicillin is preferable since (unlike cotrimoxazole) it is active against SBO. This alleviates the need to use metronidazole for SBO suppression, recommended in the Ashworth/Burgess publication (2003).
The evidence base
While these issues are derived from field experience and documentation not readily accessible, they do represent current thinking, often controversial, in addressing severe malnutrition. Gaps in evidence are also partly due to the difficulties of conducting operational research in emergencies. Certainly, individuals and agencies should bear some responsibility in sharing and writing up their experiences and findings. However there is also a sectoral responsibility to promote and support this process, and a technical responsibility to consider this informal evidence base when developing or updating guidelines.
Differing and convincing opinions on practice exist between, and are recognised by, the experts themselves. Yet alternative approaches to managing malnutrition can sometimes suggest conflicting opinions when, in reality, there are none. For example, the perspective of the clinician may present an entirely different viewpoint and set of priorities than the public health expert, more concerned with the population at large. However, conflicts and errors can arise when approaches encroach on one another, without involving the "expert other". Thus, simplifying complex clinical management, targeted at the majority of health workers but without careful clinician input, risks suggesting that such treatment is easy to administer and may be open to error. Equally, basing guidance-forall on the management of the clinical complexities of individual cases, useful for specialist and experienced practioners, risks alienating many of those working in the field who need simple, practical and pragmatic advice that will, on balance, do most good and least harm to the majority. There is room for all approaches, but a collaborative effort and consultation is required to make this work.
The way forward
The production of the 1999 WHO guidelines, has, without doubt, improved morbidity and mortality and the care of the severely malnourished, which may be substantially attributed to standardisation of care. Initiatives to improve the accessibility of standard guidance to those with few resources and limited support are long overdue and welcomed.
Although published in 1999, the current WHO guidelines were first drafted in 1992 - many of the areas of contention stem from field practices and experiences over the past 10 years. Given the everchanging face and challenges of emergency nutrition, guidelines need to be managed as working, "living" documents. The technical issues summarised here suggest the need for a formal review of the evidence base of the 1999 WHO guidelines for the management of severe malnutrition. Such a review process needs to include a mechanism to engage with field practioners, and should take into account the largely informal evidence base that is guiding current field practice. Updating and revision of guidelines takes time. Where there are identified gaps in recommendations, interim guidance - generated through expert consultation, for example - could be considered. This, in turn, could be tied in with the review process, e.g. valid for a given period. The WHO, as lead technical agency, would be well placed to initiate this process.
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1Ashworth A and Burgess A, 2003. Caring for severely malnourished children. Published by Macmillan, supported by Teaching aids At Low Cost (TALC), funded by the US Agency for International Development (USAID) through the Food and Nutrition Technical Project (FANTA) of the Academy for Educational Development (AED), 2003
2News, Caring for severely malnourished children: book review, Field Exchange 20.
3Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, 1999
4ENN/GIFA Project, summary of presentation, Field Exchange 19, p28
5Field Exchange 9, Infant feeding in a TFP, p7, Mary Corbett
6Infant Feeding in Emergencies, Module 1 for emergency relief staff. Draft material developed through collaboration of: WHO, UNICEF, LINKAGES, IBFAN, ENN and additional contributors. March 2001
7Diet and renal function in malnutrition, Summary of presentation, Field Exchange 19, p24
8Wharton BA, Howells GR, McCance RA. Cardiac failure in kwashiorkor, Lancet 1967; 2;384-387
9Unpublished data. Eva Lamm. Breath hydrogen excretion in children when malnourished and during recovery. MSc report, University of Uppsala, 1998
Taken from Field Exchange Issue 20, November 2003