With careful training and an efficient referral system, domiciliary care preceded by one week of day care is the most cost-effective treatment option for severe malnutrition in this setting.

Over 1300 severely malnourished children (< 60% of US National Center for Health Statistics weight-forheight, with edema, or both) are admitted each year to the Children's Nutrition Unit in Dhaka. Fatality during treatment is low and recovery is rapid. Our aim was to determine whether this initial success is sustained when children return home. A previous attempt to address this question was frustrated by the difficulty in tracing children after discharge because most are from slum settlements and families move frequently. This prospective study with fortnightly monitoring was therefore undertaken. The main outcomes of interest were anthropometric status, relapse, morbidity, and mortality. Children (n = 437) who had been treated for severe malnutrition when aged 12-59 mo and had reached the discharge criterion of 80% of weight-for-height, were followed for the next 12 mo. During follow-up, 7.5% were lost without trace, 0.6% relapsed, and 2.3% died. Morbidity was high, with a mean of seven episodes of diarrhea during the year. Outpatient visits for diarrhea occurred for 67% of children, and 58% had pneumonia (10% had pneumonia three times). After 12 mo, mean weight-for-height was 91% (Ϫ0.92 z score) but mean height-for-age remained at 84% (Ϫ4.14 z score). Weight gain, but not height gain, tended to be lower in children who experienced more diarrhea. Fever and cough were not associated with either weight or height gain. The high prevalence of illness highlights the need for continued accessible health care and for interventions to reduce disease acquisition.Am J Clin Nutr 1998;67:940-5. KEY WORDSSevere malnutrition, protein-energy malnutrition, infection, diarrhea, follow-up, prognosis, recovery, morbidity, mortality, growth, relapse, Bangladesh, children INTRODUCTIONWith appropriate medical and dietary management, severely malnourished children can be rehabilitated successfully in just a few weeks (1, 2). An important question, however, is to what extent this recovery is sustained once children return home. Limited data show high postdischarge mortality and relapse for some centers (3-9). If many children relapse or die, any short-term success may seem futile, and indeed, there are anecdotal reports that staff motivation is often low in such situations because treatment seems a waste of effort and resources. The reasons why children relapse or die are not well understood. Morbidity and inadequate feeding are likely causes, especially if parents and caregivers have not been given specific guidance or medical care is inaccessible.The Children's Nutrition Unit in Dhaka, Bangladesh, has > 1300 admissions for severe malnutrition each year. The criteria for admission are < 60% of weight-for-height, or edema, or both, taking the median value of the National Center for Health Statistics (NCHS) as the reference population (10). The discharge criterion is 80% of NCHS weight-for-height. In 1987, 85% of those traced 2 y after discharge showed further improvement in their nutritional status and only 1% had died (11). Only 46%...

Our aim was to investigate whether zinc deficiency becomes apparent during nutritional rehabilitation and limits the rate of weight gain. Twenty-five severely malnourished children, who were admitted to the Children's Nutrition Unit in Bangladesh, were alternately allocated to two groups. Their mean dietary Zn intake was 3.7 mg/d and mean caloric intake greater than 150 kcal.kg-1.d-1; one group received a daily Zn supplement of 50 mg for 2 wk. During the first week, weight gain was similar in the two groups, but during the second week, weight gain was 73% more in the Zn-supplemented group (8.83 +/- 1.56 vs 5.09 +/- 1.62 g.kg-1.d-1). The 95% confidence limits were 0.88 less to 8.36 g.kg-1.d-1 more gain in children receiving Zn supplements. The results strongly suggest that Zn supplements are beneficial to severely malnourished children during nutritional rehabilitation. Polymorphonuclear (PMN) cell Zn increased in the group receiving Zn supplements (p less than 0.001), confirming that the Zn content of PMN cells reflects available Zn.

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