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

Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines

Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi.

BACKGROUND: The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). METHODS: In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6-60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ? 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. RESULTS: The proportion of children with acidic stool (pH ?5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes. CONCLUSIONS: This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings. TRIAL REGISTRATION: ISRCTN13916953 Registered: 14 January 2013

Wasting disease in African children: the challenges ahead

Malnutrition is an important contributing factor in 5.6 million children who die annually. Severe acute malnutrition (SAM) is a direct cause in 2.7 million deaths . While the clinical syndrome kwashiorkor has impressed clinician and journalist alike, it are stunting, wasting disease and micronutrient diseases like anaemia, vitamin A and iodine deficiency which contribute most to the large global burden of malnutrition(-related) diseas

75 years of Kwashiorkor in Africa

Childhood malnutrition has been with us since the early days of humanity. Its epidemiology, determinants and aetiology, nomenclature, pathophysiology, case management and ultimately prognosis has kept many –practitioners, scientists and policymakers- lifelong intrigued and involved. In the following (incomplete) overview we use kwashiorkor as the icon for life threatening childhood malnutrition and discuss its history in Africa and the relevant achievements in its case management today

Child Survival in sub Sahara Africa: the role of CAPGAN and regional child health practitioners & scientists

Close to a decade ago the Millennium Development Goals (MDG) were developed and unanimously accepted by the General Assembly of the United Nations. The think tank behind the MDGs, the Earth Institute at Columbia University in New York led by the economist Jeffry Sachs,developed 8 overarching goals, which -if achieved- would liberate the world from poverty. Child Survival is the direct goal of MDG 4, and strongly and indirectly related to MDG 5 (reduction of maternal mortality), MDG 6 (combating HIV, Tuberculosis and Malaria), and indirectly to MDG1-3

Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema

Kwashiorkor is severe childhood malnutrition characterised by oedema, often showing as swelling in the hands and feet. (1) In the last 20 years the WHO nomenclature has referred to kwashiorkor as oedematous malnutrition

Challenges in the Management of HIV-Infected Malnourished Children in Sub-Saharan Africa

Infection with HIV, and oftentimes coinfection with TB, complicates the care of severely malnourished children in sub-Saharan Africa. These superimposed infections challenge clinicians faced with a population of malnourished children for whose care evidence-based guidelines have not kept up. Even as the care of HIV-uninfected malnourished children has improved dramatically with the advent of community-based care and even as there are hopeful signs that the HIV epidemic may be stabilizing or ameliorating, significant gaps remain in the care of malnourished children with HIV. Here we summarize what is currently known, what remains unknown, and what remains challenging about how to treat severely malnourished children with HIV and TB

Impaired glucose absorption in children with severe malnutrition

Objective To quantify intestinal glucose absorption in children with two types of severe malnutrition, kwashiorkor and marasmus, compared with healthy children. Study design Children with kwashiorkor (n = 6) and marasmus (n = 9) and control subjects (n = 3) received a primed (13 mg/kg), constant infusion (0.15 mg/kg/min) of [6,6H2]glucose for 4.5 hours. Two hours after start of the infusion an oral bolus of glucose 1.75 g/kg labeled with [U-13C]glucose 10 mg/g was given and was followed by periodic blood sampling. Mathematical modeling was applied to determine oral glucose absorption. Results Median total glucose absorption was 5.9 mmol/kg, interquartile range (IQR) 4.5-6.7 mmol/kg and 4.4 (IQR 2.9-5.9) mmol/kg in children with kwashiorkor and marasmus compared with 7.7 (IQR 5.8-9.0) mmol/kg in control subjects; P = .03 compared with marasmus). Children with the lowest glucose absorption were found specifically in the kwashiorkor group and marasmic children with hypoalbuminemia. Severe impairment in absorption correlated with urinary 8-hydroxydeoxyguanosine secretion (r = -0.62, P = .01). Conclusions Severe malnutrition is associated with an impaired glucose absorption and decreased glucose absorption correlates with oxidative stress in these children. (J Pediatr 2011; 158: 282-7)