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

M ore than 10 million children under the age of fi ve 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]. Community-based programs, including the Integrated Management of Childhood Illness initiative of the World Health Organization (WHO) (see http:⁄⁄www.who.int/ child-adolescent-health/integr.htm), have been developed to address the synergy between childhood malnutrition and infection, and these programs include nutritional rehabilitation [4]. Such programs detect severely malnourished children by measuring mid-upper arm circumference, treat such children with ready-to-use therapeutic foods [5], and if necessary refer them to facility-based management. This is a cost-effective approach for secondary prevention and treatment of severe malnutrition [6,7]. A small proportion of severely malnourished children (15%) are very sick and require hospitalisation. 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. Since 1970 there has been vigorous debate over where and how to optimally rehabilitate malnourished children [14–16]. The mortality risk of these children is thought to relate to several factors [17], including electrolyte imbalance [18], hepatic dysfunction, infection, anthropometric status [19], and micronutrient status, as well as to differences between treatment regimens. The pathophysiology of primary malnutrition [20] and kwashiorkor [21] is to a large extent understood and has informed treatment guidelines improving the case fatality from primary malnutrition to levels below 5% [22,23]. Equally important, understanding the pathophysiology of primary malnutrition and kwashiorkor has enabled nutrition rehabilitation to grow to an unprecedented scale through humanitarian assistance and community-based programs [1,24]. Residual high mortality has been ascribed to faulty practices [25–27], but to date no published randomised controlled trials have been carried out to support these statements. 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 …