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  • Review Article
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Management of children with acute malnutrition in resource-poor settings

Nature Reviews Endocrinology volume 5, pages 597–603 (2009)Cite this article

Abstract

Approximately 11% of children worldwide suffer from moderate or severe acute malnutrition, which is defined as low weight for height or mid-upper arm circumference with respect to international standards, or the presence of bipedal edema. These children have a considerably increased risk of dying. Experience from the past two decades indicates that children with uncomplicated moderate or severe acute malnutrition can be managed successfully as outpatients, by use of appropriate treatment of infections and either lipid-based, ready-to-use therapeutic foods or appropriately formulated home diets, along with psychosocial care. Children's caregivers prefer community-based treatment, which is also less costly than inpatient care. Children with severe acute malnutrition and life-threatening complications require short-term inpatient care for treatment of infections, fluid and electrolyte imbalances, and metabolic abnormalities. Initial dietary management relies on low-lactose, milk-based, liquid formulas but semi-solid or solid foods can be started as soon as appetite permits, after which children can be referred for ambulatory treatment. National programs for the community-based management of acute malnutrition (CMAM) provide periodic anthropometric and clinical screening of young children, and referral of those who meet established criteria. This Review describes the main components of the treatment of young children with acute malnutrition in resource poor settings and some recent advances in CMAM programs.

Key Points

  • Moderate and severe acute malnutrition are relatively common in resource-poor settings, which leads to high rates of infant and child mortality

  • Children can be screened for acute malnutrition by measurement of either weight for height or mid-upper arm circumference and inspection for the presence of bipedal edema

  • Treatment algorithms have been developed that are based on the severity of malnutrition and the presence of clinical complications or reduced appetite

  • Children with severe acute malnutrition and good appetite can be managed as ambulatory patients by infection treatment and the use of ready-to-use therapeutic foods (RUTF) or appropriately formulated home diets

  • The optimal management of children with moderate acute malnutrition (namely use of RUTF versus specialized home-prepared diets) is being investigated to develop simple, effective and affordable dietary regimens

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Figure 1: Screening and treatment algorithm for acutely malnourished children, 6–59 months of age (based on material from the WHO/UNICEF 2009 Guidelines and WHO 2006 Growth Standards40,34).

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References

  1. Briend, A., Prudhon, C., Prinzo, Z. W., Daelmans, B. M. & Mason, J. B. Putting the management of severe malnutrition back on the international agenda. Food Nutr. Bull. 27 (Suppl. 3), S3–S6 (2006).

    Article  Google Scholar 

  2. Amadi, B. et al. Reduced production of sulfated glycosaminoglycans occurs in Zambian children with kwashiorkor but not marasmus. Am. J. Clin. Nutr. 89, 592–600 (2009).

    Article  CAS  Google Scholar 

  3. UNICEF. State of the World's Children 2009: Maternal and Newborn Health (UNICEF, New York, 2009).

  4. Myatt, M. & Duffield, A. Weight-for-height and MUAC for estimating the prevalence of acute undernutrition? [online] (2007).

  5. Prudhon, C., Prinzo, Z. W., Briend, A., Daelmans, B. M. & Mason, J. B. Proceedings of the WHO, UNICEF, and SCN informal consultation on community-based management of severe malnutrition in children. Food Nutr. Bull. 27 (Suppl. 3), S99–S104 (2006).

    Article  Google Scholar 

  6. WHO, World Food Programme, United Nations System Standing Committee on Nutrition & UNICEF. Community-based management of severe acute malnutrition [online] (2007).

  7. Black, R. E. et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243–246 (2008).

    Article  Google Scholar 

  8. Schroeder, D. G. & Brown, K. H. Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. Bull. World Health Organ. 72, 569–579 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Pelletier, D. L., Frongillo, E. A. Jr, Schroeder, D. G. & Habicht, J. P. The effects of malnutrition on child mortality in developing countries. Bull. World Health Organ. 73, 443–448 (1995).

    CAS  PubMed  PubMed Central  Google Scholar 

  10. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers [online] (1999).

  11. Briend, A. et al. Ready-to-use therapeutic food for treatment of marasmus. Lancet 353, 1767–1768 (1999).

    Article  CAS  Google Scholar 

  12. Collins, S. et al. Key issues in the success of community-based management of severe malnutrition. Food Nutr. Bull. 27 (Suppl. 3), S49–S82 (2006).

    Article  Google Scholar 

  13. Kauffman, C. A., Jones, P. G. & Kluger, M. J. Fever and malnutrition: endogenous pyrogen/interleukin-1 in malnourished patients. Am. J. Clin. Nutr. 44, 449–452 (1986).

    Article  CAS  Google Scholar 

  14. Manary, M. J. & Brewster, D. R. Potassium supplementation in kwashiorkor. J. Pediatr. Gastroenterol. Nutr. 24, 194–201 (1997).

    Article  CAS  Google Scholar 

  15. Dutta, P. et al. Double blind, randomised controlled clinical trial of hypo-osmolar oral rehydration salt solution in dehydrating acute diarrhoea in severely malnourished (marasmic) children. Arch. Dis. Child. 84, 237–240 (2001).

    Article  CAS  Google Scholar 

  16. Alam, N. H., Hamadani, J. D., Dewan, N. & Fuchs, G. J. Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea. J. Pediatr. 143, 614–619 (2003).

    Article  CAS  Google Scholar 

  17. Fergusson, P. & Tomkins, A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Trans. R. Soc. Trop. Med. Hyg. 103, 541–548 (2009).

    Article  Google Scholar 

  18. Ashworth, A., Bell, R., James, W. P. & Waterlow, J. C. Calorie requirements of children recovering from protein-calorie malnutrition. Lancet 2, 600–603 (1968).

    Article  CAS  Google Scholar 

  19. Brown, K. H. et al. Effects of dietary energy density and feeding frequency on total daily energy intakes by recovering malnourished children. Am. J. Clin. Nutr. 62, 13–18 (1995).

    Article  CAS  Google Scholar 

  20. Fjeld, C. R., Schoeller, D. A. & Brown, K. H. Body composition of children recovering from severe protein-energy malnutrition at two rates of catch-up growth. Am. J. Clin. Nutr. 50, 1266–1275 (1989).

    Article  CAS  Google Scholar 

  21. Diop, E. I., Dossou, N. I., Ndour, M. M., Briend, A. & Wade, S. Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial. Am. J. Clin. Nutr. 78, 302–307 (2003).

    Article  CAS  Google Scholar 

  22. Manary, M. J., Ndkeha, M. J., Ashorn, P., Maleta, K. & Briend, A. Home based therapy for severe malnutrition with ready-to-use food. Arch. Dis. Child. 89, 557–561 (2004).

    Article  CAS  Google Scholar 

  23. Ciliberto, M. A. et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am. J. Clin. Nutr. 81, 864–870 (2005).

    Article  CAS  Google Scholar 

  24. Ndekha, M. J., Manary, M. J., Ashorn, P. & Briend, A. Home-based therapy with ready-to-use therapeutic food is of benefit to malnourished, HIV-infected Malawian children. Acta Paediatr. 94, 222–225 (2005).

    Article  CAS  Google Scholar 

  25. Sandige, H., Ndekha, M. J., Briend, A., Ashorn, P. & Manary, M. J. Home-based treatment of malnourished Malawian children with locally produced or imported ready-to-use food. J. Pediatr. Gastroenterol. Nutr. 39, 141–146 (2004).

    Article  Google Scholar 

  26. Collins, S. & Sadler, K. Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study. Lancet 360, 1824–1830 (2002).

    Article  Google Scholar 

  27. Ciliberto, M. A., Manary, M. J., Ndekha, M. J., Briend, A. & Ashorn, P. Home-based therapy for edematous malnutrition with ready-to-use therapeutic food. Acta Paediatr. 95, 1012–1015 (2006).

    Article  Google Scholar 

  28. Linneman, Z. et al. A large-scale operational study of home-based therapy with ready-to-use therapeutic food in childhood malnutrition in Malawi. Matern. Child. Nutr. 3, 206–215 (2007).

    Article  Google Scholar 

  29. Lopriore, C., Guidoum, Y., Briend, A. & Branca, F. Spread fortified with vitamins and minerals induces catch-up growth and eradicates severe anemia in stunted refugee children aged 3–6 y. Am. J. Clin. Nutr. 80, 973–981 (2004).

    Article  CAS  Google Scholar 

  30. Heikens, G. T., Schofield, W. N., Dawson, S. M. & Waterlow, J. C. Long-stay versus short-stay hospital treatment of children suffering from severe protein-energy malnutrition. Eur. J. Clin. Nutr. 48, 873–882 (1994).

    CAS  PubMed  Google Scholar 

  31. Khanum, S., Ashworth, A. & Huttly, S. R. Controlled trial of three approaches to the treatment of severe malnutrition. Lancet 344, 1728–1732 (1994).

    Article  CAS  Google Scholar 

  32. Hossain, M. I. et al. Impact of community-based follow-up care, with or without food supplementation and/or psychosocial stimulation, on the recovery of severely underweight Bangladeshi children: a randomized intervention trial. Proceedings of the XII Asian Conference on Diarrheal Disease, Yogyakarta (in press).

  33. Ashworth, A. Efficacy and effectiveness of community-based treatment of severe malnutrition. Food Nutr. Bull. 27 (Suppl. 3), S24–S48 (2006).

    Article  Google Scholar 

  34. WHO & UNICEF. WHO child growth standards and the identification of severe acute malnutrition in infants and children [online] (2009).

  35. Golden, M. H. Proposed Recommended Nutrient Densities for Moderately Malnourished Children [online] (2008).

  36. World Food Program. Improving corn-soy blend and other fortified blended foods, why and how (World Food Program, Rome, 2008).

  37. Maleta, K. et al. Supplementary feeding of underweight, stunted Malawian children with a ready-to-use food. J. Pediatr. Gastroenterol. Nutr. 38, 152–158 (2004).

    Article  CAS  Google Scholar 

  38. Matilsky, D. K., Maleta, K., Castleman, T. & Manary, M. J. Supplementary feeding with fortified spreads results in higher recovery rates than with corn/soy blend in moderately wasted children. J. Nutr. 139, 773–778 (2009).

    Article  CAS  Google Scholar 

  39. Karaolis, N. et al. WHO guidelines for severe malnutrition: are they feasible in rural African hospitals? Arch. Dis. Child. 92, 198–204 (2007).

    Article  Google Scholar 

  40. World Health Organization. WHO growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development (WHO, Geneva, 2006).

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Acknowledgements

Helen Keller International's programs to institutionalize the community-based management of acute malnutrition in Burkina Faso, Mali and Niger are funded by the United states Agency for International Development Office of Foreign Disaster Assistance, the Richard and Rhoda Goldman Fund and the Monsanto Fund, with in-kind support from UNICEF and the World Food Program.

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Authors and Affiliations

  1. Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA

    Kenneth H. Brown

  2. Africa Regional Office, Helen Keller International, Dakar, Senegal

    Daniele H. Nyirandutiye & Svenja Jungjohann

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  1. Kenneth H. Brown
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  3. Svenja Jungjohann
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Correspondence to Kenneth H. Brown.

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Brown, K., Nyirandutiye, D. & Jungjohann, S. Management of children with acute malnutrition in resource-poor settings. Nat Rev Endocrinol 5, 597–603 (2009). https://doi.org/10.1038/nrendo.2009.194

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