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Re: WHO guidelines for severe malnutrition: a Gambian experience

Dear Editor,

We would like to congratulate Karaolis et al [1] on their comprehensive study and to report our own findings on adherence to WHO guidelines on management of severe malnutrition following training.

The Royal Victoria Teaching Hospital (RVTH) is the main tertiary referral hospital in The Gambia, West Africa. Annual paediatric admissions for 2003 were 6585. There is up to 400% bed occupancy in the rainy season with nurse:patient ratios sometimes as challenging as 1:40.

Severe malnutrition is a common reason for admission and the 4th leading cause of death in the non-neonatal paediatric hospital population (Williams, 2003, unpublished) . A WHO workshop in the management of severe malnutrition was held in the hospital in July 2002 over a 2 week period.

To determine the longer-term effect of the workshop on the management of severe malnutrition at RVTH, we undertook a retrospective review of case notes of all children admitted with severe malnutrition between August 1st and December 31st 2003.

We reviewed the case notes of 87 patients (out of 3783 total admissions) admitted with severe malnutrition according to WHO criteria [2]. The main outcome measures were the case fatality rate and the extent to which the WHO 10 steps for routine care of malnourished children were implemented [2].

The median age was 15 months (range 1-36 months). 21 children died, yielding a case fatality rate of 24 %, with a median time of death 2 days after admission (range 1-20 days). All-cause case-fatalities for the same period was 9.8%. Appropriate broad spectrum antibiotics were used in 72 children (83.7%). Vitamin A was prescribed in 25 children (29.1%).

The findings most at variance with WHO guidelines concerned feeding and use of intravenous fluids. Only 3 children (3.5%) had their feeds documented during the stabilization phase. Although not documented does not necessarily mean not done,through discussion with the carers it seemed that the children were fed far less frequently than recommended. 38 (44.2%) children were given intravenous fluids, of whom only 1 was documented to be in shock. From personal observation we know that the WHO guidelines recommending monitoring of the malnourished child on iv fluids every 10 minutes are not carried out due to the large number of other sick patients requiring nursing attention. The over-use of intravenous fluids and the underfeeding is likely to have contributed to the high case -fatality.

We note with admiration the 1011 child hours of observation in the Karaolis study. However, we believe there is a need for local staff to find suitable – which here means cheap, simple and quick – ways of monitoring care themselves. Without this, improvements will remain dependent on externally led audit and research projects, with the problems that this poses for sustainability and local capacity building.

References:

1.Karaolis N WHO guidelines for severe malnutrition: are they feasible in rural African hospitals? Arch Dis Child 2007;92:198-204.

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Re: Using research experience to improve WHO guidelines for severe malnutrition

Dear Editor,

The paper by Karaolis and colleagues [1] assessed the feasibility of implementing WHO guidelines for inpatient care of severely malnourished children. The authors found that most but not all of the components of the guidelines could be implemented. Previously, we and others [2,3] also found difficulties in severe malnutrition management in under-resourced African hospitals, which we think is worth summarizing. The table below presents some of the WHO recommendations [4,5] and their feasibility according to the three studies that we are aware of.

(NB: The table, as a Word document, was sent as an attachment to adceletters@bmjgroup.com)

The authors made several commendable recommendations such as improving training of health staff, inclusion of the guidelines in paediatric texts and teaching curricula, better communication between nurses and carers, and community-based interventions [1]. However they do not discuss the possibility of using the findings from their and other studies to improve future versions of the guidelines. Some examples are presented below:

1. The relative value of a complicated feeding schedule over a simplified one is not known since the guidelines were developed from considerable clinical and research experience but were not based on randomised controlled trials. In the absence of such data and considering the conditions where these guidelines are likely to be adapted, a simplified feeding schedule might be more appropriate.

2. Other methods of diagnosing severe malnutrition such as mid-upper arm circumference or visible severe wasting may be more practical [6], providing appropriate training has been given.

3. The rationale for ReSoMal for severely malnourished children who require oral rehydration is that the standard WHO-ORS has a sodium content too high and potassium content too low for these patients [4,5]. But alternatives to ReSoMal, such as ORS with additional sips of water plus oral potassium, may be more realistic.

4. It would be very useful if additional research were conducted, for example on antibiotic regimens that would be most appropriate.

Given the difficulty of treatment in hospital and with the recent advent of ready to use therapeutic foods (RUTF), community-based management of severely malnourished children is now recommended [1,7]. However, severely malnourished children with complications will still require in-patient care; thus we have to ensure that guidelines are evidence-based as well as feasible in small hospitals with limited resources.

Jacqueline L. Deen, M.D., M.Sc. (jdeen@ivi.int)

Conflict of Interest : None

References:

1. Karaolis N, Jackson D, Ashworth A, Sanders D, Sogaula N, McCoy D, Chopra M, Schofield C. WHO guidelines for severe malnutrition: are they feasible in rural African hospitals? Arch Dis Child. 2007;92:198-204.

2. Deen JL, Funk M, Guevara VC, Saloojee H, Doe JY, Palmer A, Weber MW. Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. Bull World Health Organ. 2003;81:237-43.

3. English M, Esamai F, Wasunna A, Were F, Ogutu B, Wamae A, Snow RW, Peshu N. Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya. Lancet. 2004 Jun 12;363:1948-53.

4. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, Geneva, 1999.

5. World Health Organization. Management of the child with a serious infection or severe malnutrition: Guidelines for care at the first referral level in developing countries. WHO, Geneva, 2000. WHO/FCH/CAH/00.1.

6. Berkley J, Mwangi I, Griffiths K, Ahmed I, Mithwani S, English M, Newton C, Maitland K. Assessment of severe malnutrition among hospitalized children in rural Kenya: comparison of weight for height and mid upper arm circumference. JAMA. 2005; 294:591-7.

7. Community-based management of severe malnutrition in children. http://www.who.int/child-adolescent- health/publications/NUTRITION/CBSM.htm. Accessed on 11 April 2007.

Table 1: