The preventable, malnutrition-associated deaths of 5.6 million children each year is “a humanitarian disaster that cannot be allowed to continue”.¹ A recent update using data from 2001 and the disability-adjusted life year approach confirmed that undernutrition remains the single leading cause of health loss in the world today.² Child underweight for age accounts for 8.7% of the total disease burden in people living in low- and middle-income countries, mainly countries in South Asia and sub-Saharan Africa. Specific micronutrient deficiencies are responsible for additional disease burdens.

Severe malnutrition is common in hospitals in economically poor countries. In a large study of children admitted to a rural district hospital in Kenya between 1999 and 2002, 16% (1282/8190) of children had severe wasting (weight-for-height z score ⩽–3), kwashiorkor or both. Children with severe wasting had a mortality rate of 19.9% compared with 4.4% among all admissions.³ Comparable data has been reported from West Africa.⁴

The overall responsibility for the management of severe malnutrition in hospitals falls on paediatricians. We understand the central importance of nutrition to a child’s current health and the ability to reach his or her full potential for growth and neurocognitive development. Malnutrition in early childhood can result in short stature and impaired neurological development that will increase the risk of morbidity and mortality and impair performance at school and, ultimately, the ability to contribute to society in adult life.

Karaolis et al⁵ are to be congratulated for undertaking a well-designed, detailed review of how the World Health Organization (WHO) guidelines work in practice in exactly the type …