Debate on the Management of Severe Malnutrition : A Response
By Professor Ann Ashworth, London School of Hygiene and Tropical Medicine
Many individuals and organisations, including NGOs, have contributed to the improved treatment of children with severe malnutrition, but case-management remains very poor in most hospitals in developing countries and many children die as a result. Children with severe malnutrition are usually treated at district hospitals (i.e. at the first-referral level) but medical and nursing students are usually trained in tertiary hospitals and they may go through their entire training without having managed a severely malnourished child or been taught best-practice. The WHO manual1 and the more recent WHO-IMCI guidelines2 aim to fill the knowledge gap about how to care for severely malnourished children. The Ashworth & Burgess book3 follows the WHO guidelines and is part of this endeavour. It describes in simple terms what to do and why, and is primarily for nurses, clinical officers and medical assistants working in poorly-resourced hospitals. The WHO Training Course4 teaches practical skills as well as knowledge, and hospital teams from over 20 countries have been trained in the last two years. Some national training courses have been held and more are planned.
Although the WHO manual and WHOIMCI guidelines differ only slightly, the latter reflect an international consensus of opinion as to what constitutes 'best practice' for first-referral hospitals. Ministries of Health are adopting the international guidelines, and medical and nursing schools are being encouraged and enabled to include the guidelines in their curricula. Case fatality rates are beginning to fall, but it will need the combined efforts of many people to scale-up existing efforts.
Management of infants less than six months
There are two concerns regarding the severely malnourished young infant: i) immediate welfare of the child (stabilisation with F75 and catch-up, with continued breastfeeding) ii) long-term welfare of the child at home (especially breastfeeding). Stabilisation of the child has to have priority on admission to ensure survival and return of appetite and strength. Diluted F100 is discouraged for the stabilisation phase because its potential renal solute load and sodium and lactose contents are more than twice those of F75. Thus F75 is more suited metabolically for stabilising severely malnourished infants than diluted F100. In the catch-up phase, diluted F100 may be preferable to full-strength F100 for very young infants (<4m) but this has not been tested. A randomized trial is being planned. In rapid growth, although F100 has a higher potential renal solute load than diluted F100, solutes are channeled into new tissue and do not need to be excreted by the kidney.
Although supplemental suckling has been reported as successful, this is not always the case. This technique requires considerable support and supervision and when implemented as part of routine hospital care, the results are variable. For example in Afghanistan, many infants had no weight gain for weeks with this technique. More data are needed before any conclusion can be made about the role of supplemental suckling in the care of severely malnourished infants.
In the Ashworth & Burgess book, F75 is called 'starter formula' because experience showed that a 'functional' name was more meaningful to indigenous health workers. We found mistakes were made when it was called F75 as some health workers misinterpret F75 to mean 'give 75ml'.
Management of severe oedema
In the stabilisation period, the target energy intake is 100kcal/kg body weight/day, and 'per kg body weight' is referring to metabolically- active tissue mass. The weight of severely oedematous children does not reflect their true tissue mass as their weight is elevated by oedema fluid. The WHO-IMCI Working Group took a figure of 20% as being a reasonable estimate of the proportion of weight due to oedema fluid in children with severe oedema (i.e. oedema of the feet, legs, hands, arms and face). So for severely oedematous children, the guidelines advise 100ml/kg/day of F75 instead of 130ml/kg/day (roughly a 20% reduction) which will lead to a daily energy intake of approximately 100kcal/kg oedema-free body weight/day. This achieves the target intake without risking heart failure from sodium and fluid overload. It is not 'underfeeding', as the intake /kg true weight/day is met.
Diarrhoea and dehydration
Children with profuse watery diarrhoea can become dehydrated if no action is taken to replace the lost fluid. WHO suggests 50-100ml of ReSoMal as a guide after each watery stool. This is consistent with data from the International Centre for Diarrhoeal Disease Research, Bangladesh, where the typical range for stool loss is 50-100ml/watery stool. The Centre treats many hundreds of severely malnourished children with diarrhoea each year and stool collections are made for every child. Most hospitals and TFCs have no provision for measuring stool losses and so replacement volumes will always be a matter of judgement as stool losses vary, but a guide of 50-100ml is reasonable given the large body of evidence from Bangladesh.
There is no divergence of views. Very severe anaemia may not be common but when it does occur action is required. The WHO manual and guidelines define the circumstances when a blood transfusion is needed and describe appropriate treatment. Repeat transfusions should not be given even if the haemoglobin level stays low and this is stated in the WHO-IMCI guidelines. The risk of heart failure from fluid overload is stressed in the WHO manual and guidelines, and actions to avoid fluid overload are described.
The choice of antibiotics for first-referral hospitals was guided by effectiveness, availability, and cost. The need for flexibility due to local patterns of pathogen resistance was recognised.
If there are robust new data that challenge the treatment practices advocated by WHO then these should be placed in the public domain and reported in a manner that will allow scrutiny and peer review. Divergent protocols cause confusion and distrust among health workers, and weaken the message. We should all speak with one voice. No new data have been published or presented to WHO that challenge the guidelines. There is, however, a growing body of evidence to show their effectiveness.
1Management of severe malnutrition: a manual for physicians and other senior health workers. WHO,1999.
2Management of the child with a serious infection or severe malnutrition. Guidelines for care at the firstreferral level in developing countries. WHO, 2000.
3Caring for severely malnourished children. Ashworth A, Burgess A. TALC, 2003.
4Training course on the management of severe malnutrition. WHO, 2002.
Taken from Field Exchange Issue 20, November 2003