Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines

Abstract

Hospital case-fatality rates for severe malnutrition in the developing world remain high, particularly in Africa where they have not changed much over recent decades. In an effort to improve case management, WHO has developed treatment guidelines. The aim of this review is to critically appraise the evidence for the guidelines and review important recent advances in the management of severe malnutrition. We conclude that not only is the evidence base deficient, but also the external generalisability of even good-quality studies is seriously compromised by the great variability in clinical practice between regions and types of health facilities in the developing world, which is much greater than between developed countries. The diagnosis of severe wasting is complicated by the dramatic change in reference standards (from CDC/WHO 1978 to CDC 2000 in EpiNut) and also by difficulties in accurate measurement of length. Although following treatment guidelines has resulted in improved outcomes, there is evidence against the statement that case-fatality rates (particularly in African hospitals) can be reduced below 5% and that higher rates are proof of poor practice, because there is wide variation in severity of illness factors. The practice of prolonged hospital treatment of severe malnutrition until wasting and/or oedema has resolved is being replaced by shorter hospital stays combined with outpatient or community follow-up because of advances in dietary management outside of hospital.

Experience in Managing Severe Malnutrition in a Government Tertiary Treatment Facility in Bangladesh

“…septicaemia, severe pneumonia, etc., as also mentioned by Brewster et al . (18). It is worthwhile to mention that more than half (53.3%; 8/15) of fatality in children admitted to the Nutrition Unit of CMCH was due to septicaemia.…”

Phase II trial of isotonic fluid resuscitation in Kenyan children with severe malnutrition and hypovolaemia

“…Ordinarily, these features would be considered by paediatric life-support providers as constituting a very advanced state of shock, when outcome is generally poor. For children fulfilling these criteria, preferential use of low-volume hypotonic fluids (0.45% sodium content) is recommended since it is commonly considered that malnourished children are at increased risk of developing congestive heart failure and sodium and water overload[8]. There is substantial debate over best treatment with scientific rationale advanced to justify this highly promoted WHO guideline, but what is clear is that the evidence base is weak and unsupported by the relevant physiological studies or clinical trials [8,9].…”

Symposium 5: Joint BAPEN and Nutrition Society Symposium on ‘Feeding size 0: the science of starvation’ Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock

“…It is argued that with strict adherence to these guidelines the mortality should be < 5% (13,14) . Whilst high case-fatality rates are often attributed to faulty case management, the evidence for this assertion is poor and other workers have suggested that outcome is largely dependent on other antecedent factors, including the frequency of additional life-threatening complications (4,(15)(16)(17)(18) . The current guidelines have largely been based on expert or consensus opinion.…”

“…The current guidelines have largely been based on expert or consensus opinion. Consequently, there are several aspects that are controversial (3,15) . A major challenge is that they have been developed to be relevant to many varying contexts and geographic settings that include: diverse populations such as those exposed to displacement (refugees) where acute starvation in previously healthy populations may be compounded by diarrhoea in unsanitary settings (19) ; acute malnutrition secondary to epidemics of cholera, dysentery (13) or measles; cases admitted from populations with stable endemic undernutrition.…”