Treatment of Severe Malnutrition in Children: Experience in Implementing the WHO guidelines in Turbo, Colombia
Carlos Bernal, Claudia Vela´squez, Gloria Alcaraz, and Jorge Botero
By implementing the WHO guidelines, low mortality rates were achieved in children with severe acute malnutrition in class I hospitals
Objective: To evaluate the implementation of theWorld Health Organization guidelines for the treatment of children with severe acute malnutrition in a class I hospital.
Paitents and Methods: Descriptive and prospective study of 335 children under the age of 6, admitted between 2001 and 2005 for severe acute malnutrition (83%) and moderate acute malnutrition associated with illness (17%). The care of the children was provided by clinicians and medical staff trained under World Health Organization guidelines.
Results: Kwashiorkor was a common result in children with severe acutemalnutrition (60.8%); 58%were younger than 1 year old. Complications upon admission were diarrhea (68.4%) and anemia (51.1%), and the most common complication during hospital stay was sepsis (9%). Overall, 61.7% attained 1 standard deviation of weight for height after an average stay of 3 weeks in the hospital; 5.1% were sent to tertiary care hospitals. Overall, mortality during the 5 years was 5.7%, with sepsis the most common cause. In the first year, the mortality rate was 8.7%; it decreased to 4.0% in the last year. The mortality rate was significantly higher in children with edema. Children with moderate acute malnutrition had similar complications and mortality when compared with children with severe acute malnutrition (5.3%).
Conclusions: Once the World Health Organization guidelines were implemented, low mortality rates were achieved in children with severe acute malnutrition in class I hospitals.
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This is an interesting example of how at the primary care level, without laboratory support, low access to specialized care and technology, is possible to obtain very good results in the treatment of severely malnourished children using the WHO protocol.
It is illustrative to see how the mortality rate dropped progressively during the 4 years of the study reaching a 50% lower rate by considering important, but often neglected factors, such as the continued staff training, early diagnosis and prompt start of therapy, availability of vitamins and micronutrients, and presence of family.
It is also remarkable the adaptation of the F75 and F100 formulas to regional nutritional resources, the local economic and socio-cultural conditions. As mentioned by the authors it eased the preparation and the acceptance by mothers and children. The adaptation to the local conditions is an important factor that should be promoted further to decrease the need of imported and often not easily available industrially prepared formulas.
Another important issue that should be more reported on is the access to health care for the malnourished children. In the Colombian context, the authors report that malnutrition is not recognized as a diagnosis by the Colombian Health Care System, and therefore hospital admissions are not justified by the system on the basis of malnutrition alone. Therefore, outside the unit where the study took place, admissions are done using the complications as diagnosis, which could jeopardize the prompt management and also underestimate the dimensions of the problem when reporting prevalence of diseases of the country.
As expected majority of the children included in the study were less than 2 years old, but is interesting to notice that 20% of them were less than 6 months old, suggesting that the exclusive breastfeeding rates and the introduction of complementary feeding in the local context need to be further studied.
It is encouraging to see how an initiative taken by a small group of people prompted the regional government to pay more attention to the nutritional problems of the infant population establishing similar units across the region and the development of a comprehensive ambulatory program to address this very essential but widely neglected problem.
Comment by Daniel Gallego — 2009-01-12 18:41 | # - re
I agree totally with Daniel's comment. The fact is that case fatality is reduced when severely malnourished children are treated effectively and there are many examples attesting to this fact apart from the Colombian example, such as in South Africa.
The main issue is to give SAM the needed attention, which I think is lacking since support and attention are equally needed to address the other disease burdens. However, many children will not grow to their full potential because of malnutrition and many countries in sub-Sahara Africa are unlikely to meet MDG4 if nothing is done. Therefore nutritionists and governments in developing countries where malnutrition, and specifically SAM persist must act.
Policies must not only be written but also implemented, capacity building initiatives and strengthening available systems for the management of SAM are also required.
These needless deaths must be avoided by all means.
Comment by reggie — 2009-01-13 11:29 | # - re