Critical appraisal of the management of severe malnutrition: 2. Dietary management

Abstract

In the dietary management of severe acute malnutrition in children, there is evidence to support the WHO Manual's protocol of cautious feeding of a low energy and protein formula with small frequent feeds in the initial phase of treatment, particularly in kwashiorkor. However, this initial milk diet (WHO F-75) might benefit from increasing the sulphur amino acid, phosphorus and potassium content and reducing the lactose content, but further studies are needed. Careful tube-feeding results in faster initial recovery and weight gain, but has a significant risk of aspiration in poorly supervised settings. Ready-to-use therapeutic food is an important recent advance in the dietary management of malnutrition in ambulatory settings, allowing more effective prevention programmes and earlier discharge from hospital where community follow-up is available. It should be included in future protocols. There is very good evidence on the use of micronutrients such as zinc, and preliminary evidence suggests that smaller doses of daily vitamin A are preferable to a single large dose on admission for severe malnutrition.

Management of acute moderate and severe childhood malnutrition

“…The recommended daily energy intake of 100 kcal/kg/day is provided by a milk based formula called F-75. 18 The body of evidence supporting the use of these recommended practices and the standard F-75 therapy is based primarily on clinical judgment and expert opinion. To prevent hypoglycaemia, prompt feeding on admission is recommended.…”

Inpatient management of severe malnutrition: time for a change in protocol and practice

“…At their request, we previously reviewed the evidence for the WHO treatment protocol, suggesting the need for changes. [4][5][6] The aim of the present article is to examine some of the new evidence and review from a clinical perspective the author's experience of treating severe malnutrition in many different settings, but especially in hospitals in southern Africa with a high prevalence of HIV infection.…”

Kwashiorkor from a severe dietary restriction in an 8‐month infant in suburban Detroit, Michigan: case report and review of the literature

“…In a recent series of ten patients with kwashiorkor in the US presented by Liu et al. 10–21 , half of the patients presented with low serum zinc levels, where all of these patients improved clinically after refeeding in conjunction with zinc supplementation. Moreover, the two conditions are very clinically similar in presentation, where both present clinically with dry, scaly eczematous skin that can evolve into vesicular, bullous, and pustular lesions 10–21 .…”

“…Kwashiorkor differs from other forms of malnutrition in that it is the specific deficiency of dietary protein which results in the unique features of massive edema of the hands and feet, profound irritability, anorexia, a desquamative rash, hair discoloration, and a large fatty liver 10–17 . Other conditions in the differential diagnosis for kwashiorkor include other nutritional deficiencies, such as zinc, free fatty acid, or multiple carboxylase deficiency; marasmus; immunodeficiencies; metabolic disorders; malabsorption syndromes; cystic fibrosis; and Langerhans cell histiocytosis 10–21 . Acrodermatitis enteropathica (zinc deficiency) often overlaps with kwashiorkor, where patients with kwashiorkor often present with low serum zinc levels and clinical features of both conditions.…”

“… 10–21 , half of the patients presented with low serum zinc levels, where all of these patients improved clinically after refeeding in conjunction with zinc supplementation. Moreover, the two conditions are very clinically similar in presentation, where both present clinically with dry, scaly eczematous skin that can evolve into vesicular, bullous, and pustular lesions 10–21 . One of the primary features allowing differentiation of acrodermatitis enteropathica from kwashiorkor is the distribution of lesions, which in acrodermatitis enteropathica, there is a predilection for a periorificial and acral pattern on the face, the scalp, the hands, the feet, and the anogenital areas 10–21 .…”