Introduction

At the 26th Congress of the International Pediatric Association (IPA) in Johannesburg in August 2010, a Resolution was adopted stating that:

• ▶ paediatricians and related health professionals should take responsibility for leadership in addressing the urgent problem of severe malnutrition in all its forms, as it is a major cause of death and disability of children;

• ▶ IPA member societies should assure that all paediatricians and related health professionals have the identification and treatment of severe malnutrition as a core competency, and are certified accordingly;

• ▶ national societies should examine the curriculum, training activities and evaluation processes to ensure the inclusion of the identification and treatment of severe malnutrition as a core competency.

The Johannesburg Resolution is supported in addition by the Royal College of Paediatrics and Child Health, and by WHO, Unicef and other UN agencies. A similar Resolution was adopted by nutritionists attending the Africa Nutritional Epidemiology Conference in Nairobi in October 2010.

Background

These Resolutions are part of steady progress towards improving the quality of care for severely malnourished children and ultimately ensuring that the treatment of severe malnutrition becomes a routine part of medical, nursing and health worker training and practice worldwide.

Evidence from developing countries of high death rates, outdated practices and a general lack of understanding about the treatment necessary for successful management of malnourished children emerged over 15 years ago.1 Since then improvements have occurred but they are not yet widespread, and the need for improvements in industrialised countries has largely gone unrecognised. Joosten et al2 recently drew attention to this serious problem, reporting 6–19% prevalence of acute malnutrition among paediatric admissions to hospitals in the UK, Netherlands, Germany, France and the USA.

WHO published an updated manual on the management of severe malnutrition in 19993 and technical guidelines have also been published. Efforts to reduce child deaths were given additional impetus by the setting of Millennium Development Goals (MDGs), of which MDG4 aims to reduce mortality among children aged <5 years by two-thirds by 2015.

Linked to the MDGs was the establishment of the International Malnutrition Task Force by the International Union of Nutritional Sciences in conjunction with the IPA, with the key objectives of advocating for increased recognition of the significance to child survival of preventing and treating malnutrition, and the inclusion of malnutrition in medical and nursing curricula.4 The scale of child mortality and morbidity attributable to malnutrition was brought into sharp focus by The Lancet's series on ‘Child Survival’ in 2003 and on ‘Maternal and Child Undernutrition’ in 2008. Black et al5 estimated that 61% of diarrhoeal deaths could be attributed to being underweight. The corresponding figures for pneumonia and malaria deaths attributable to underweight were 53% and 57%, respectively. In children hospitalised with severe malnutrition, death rates are often high because staff are untrained and still use outdated treatment practices. It is this widespread lack of competency that the Johannesburg Resolution aims to address, and the Resolution has implications for UK and other European clinicians, and not just those in the developing world.

Survey: data collection

Prior to the Johannesburg Congress, background information was collected from national paediatric societies and affiliates (see table 1) by a six-question electronic survey aiming to:

• 1. identify extent of familiarity with WHO guidelines for management of severe malnutrition;

• 2. determine if medical/nursing students are being trained in treatment of malnutrition, and if there is a need of assistance for training;

• 3. determine opinion as to whether the care and management of young children with severe malnutrition should be a core competency for paediatricians.

Paediatric societies (134) and international affiliates (25) were contacted. The overall response rate was low at 21%.

With a low response rate interpretation must be cautious. The low rate could be viewed as a reflection of a lack of awareness of the situation in their country, or indifference to the survey and/or in malnutrition. Nevertheless, the survey suggests that there are continuing problems regarding poor awareness among paediatricians of case-management guidelines for severe malnutrition and absence of training on malnutrition treatment in medical/nursing curricula. Among the respondents there was strong support for making the treatment of severe malnutrition a core competency for paediatricians.

Future action

Paediatricians, as advocates for the protection and well-being of children, are uniquely placed to meet the challenge of this significant cause of death and disability. As practitioners, they must be knowledgeable and competent in treating severely malnourished children. The working groups at the precongress workshop identified a number of activities to help translate their resolutions into action. They recommended that at the national level, key activities should include:

• ▶ situation analyses to provide baseline data to underpin the essential activities of advocacy and training;

• ▶ advocacy to governments to promote and support implementation of the Resolution, and make it government policy;

• ▶ advocacy to Deans of medical and nursing schools to include nutrition/malnutrition in curricula and to engage with evaluation and accreditation processes;

• ▶ in-service training for all health workers on prevention and treatment of malnutrition;

• ▶ developing effective training teams and communication strategies;

• ▶ identifying ‘champions’ who will motivate others;

• ▶ assessing nutritional status at every contact to identify children at risk.

Readers interested in participating are encouraged to contact their national paediatric association, or the authors. Training materials and other resources can be found at http://www.imtf.org.

We call upon UK paediatricians, the Royal College of Paediatrics and Child Health and paediatric associations elsewhere to advocate for, and adopt, policies that will lead to improved competency in the treatment of malnourished children. Of note is that in The Netherlands it is now mandatory for hospitals to screen all children for acute malnutrition at admission and to show the results of treatment.