Research Article: How Can We Improve the Care of Severely Malnourished Children in Africa?

Date Published: February 30, 2007

Publisher: Public Library of Science

Author(s): Geert Tom Heikens

Abstract: Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines.

Partial Text: More than 10 million children under the age of five die each year, of whom 1.5 million are severely malnourished [1]. Pelletier and colleagues showed that 53%–60% of global child deaths are attributed to malnutrition (determined by weight-for-height z-scores of less than minus 1) [2], representing 5.7–6.4 million malnutrition-related deaths each year associated with pneumonia, diarrhoea, measles, and malaria [3].

The WHO therapeutic guidelines [8,9] are based on a large body of accumulated experience of over 30 years, from nutrition units in Uganda [10], South Africa [11], and the Caribbean [12,13]. And yet despite this extensive clinical experience and physiological reasoning, there have been very few clinical trials.

In sub-Saharan African countries with the highest case fatality of malnutrition, AIDS and tuberculosis (TB) have led to an epidemic of secondary severe malnutrition related to these co-morbidities [28]. Severely sick malnourished children with AIDS and TB appear to differ in their pathophysiological and clinical response to the accepted WHO therapeutic guidelines, compared with children with primary severe malnutrition due to food shortage and non-HIV/TB related infection [29].

The question arises: is it the therapeutic approaches that are at fault, or is it that the population being treated differs from those on which the WHO treatment guidelines were based? A new study published in PLoS Medicine, by Kathryn Maitland and colleagues, helps to answer this crucial question [36]. The study is timely and relevant for reconsidering the applicability of the WHO treatment guidelines.

Maitland et al. identify three risk groups for triage: a very high risk group, a moderate risk group, and a low risk group (Box 1), which corresponded to fatality rates of 34%, 23%, and 7%, respectively. The low risk group had no specific acute clinical signs or symptoms and needed only “limited requirements for close supervision”.

I would like to suggest that five aggregated determinants characterise the unresolved problem in the case management of sick severely malnourished children in sub-Saharan Africa.

Duke et al. recently suggested that the process of WHO consultations be expanded through testing and piloting of the proposed guidelines in a variety of settings [52]. Multi-centre studies are crucial, and they must incorporate new approaches to critical care pathways in the early phase of treatment for severe acute malnutrition. This work should include appraisal of emerging bacterial resistance and its impact on mortality, and it must consider critical care pathways for resource-poor district hospitals. Only then will we be able to deliver adequate care to millions of young children whose problems have hitherto not been addressed by the child survival agenda [53].



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