In this month's issue of the Journal of Pediatric Gastroenterology and Nutrition, Professor Ann Ashworth summarizes what have become the cornerstone principles in the management of severe protein-energy malnutrition (PEM). These principles have been codified in two World Health Organization (WHO) manuals, emphasized in conferences and curricula on all continents, and practiced at thousands of institutions worldwide. However, the specter of a high case-fatality rate for children with PEM still haunts poor populations in the developing world and challenges clinicians. Ashworth would have us believe that by simply putting into practice what is well known, this specter can be dispersed. As a provider of hospital care for malnourished children in Africa for 15 years and an academic nutritionist, I am fully supportive of her specific recommendations for patient care. However, I suspect that the widespread implementation of WHO protocols may not result in dramatic improvements in the case-fatality rate for those with severe PEM.
Ashworth reports that WHO management principles are not widely practiced. Although it is tempting to assume that this is the cause of poor outcomes, Ashworth's previous work did not demonstrate an association between the practice of WHO management protocols and outcome (1). Publication bias is such that reports of failure of WHO management protocols to improve case-fatality rate are unlikely to be widely disseminated. Ashworth points out that prescribed dietary energy and protein intakes at many institutions are greater than the WHO recommendations, but how much food do these children actually receive? Children with severe PEM are profoundly anorexic, and the availability of food and supervised feeding of patients is rare in resource-poor hospitals in the developing world. Ashworth states that hypoglycemia, hypothermia, cardiac failure, and systemic infection account for most PEM–related deaths. Hypoglycemia and hypothermia are preventable complications that should be anticipated and treated, but there is little evidence that they are responsible for an appreciable fraction of the deaths (2,3). Instead, hypoglycemia and hypothermia may simply be manifestations of severe illness (i.e., modes of death rather than causes). While it is immanently reasonable that children with PEM who are at high risk for systemic infection be treated promptly with broad-spectrum antibiotics, the use of antibiotics does not reverse the life-threatening, deleterious metabolic derangements and physiologic compromises of bacterial sepsis. Cardiac failure occurs without excessive sodium and fluid administration and may be linked to micronutrient deficiencies such as selenium (4).
Ashworth implies that HIV is not an impediment to improved outcomes, yet the case-fatality rate is higher for HIV–infected children with severe PEM (4,5). Approximately 50% of all children with PEM admitted to hospitals in Southern and Eastern Africa are infected with HIV and the fraction of children with severe PEM and HIV is growing rapidly in Asia. Ashworth chides hospitals by saying that if relief organizations can achieve successful outcomes “within the confines of a tent,” then hospitals can too. I would expect hospitals to find it more difficult to achieve successful outcomes because relief organizations are feeding a starving yet previously healthy populace, whereas hospitals are admitting children who are often chronically ill and have suffered prolonged nutritional compromises. Relief organizations usually provide adequate staff and supplies to accomplish their mission; the mission of hospitals in the developing world is at the mercy of bankrupt national health services and nongovernmental development organizations with changing agendas. Care must be exercised when comparing case fatality rates from different institutions. As Ashworth correctly emphasizes, some deaths from PEM in the developing world may occur at the hospital before admission to the nutrition unit; these may not be counted when the case-fatality rate is calculated. Other reports have excluded deaths within the first 24 hours, using the rationale that these children have presented too late for therapy to prevent their demise. As with any epidemiologic comparison, comparisons are not warranted when denominators are different.
In 1995 in Malawi, my colleagues and I started a pilot project to support nutritional rehabilitation units (NRUs), in-patient facilities where severe PEM is treated (6). The project provided standard WHO management protocols and teaching sessions to NRU physicians at their facilities, so the actual constraints under which they were operating could be understood and addressed. The project worked with the World Food Program to insure adequate supply of food to NRUs and provided NRUs with minerals (e.g., potassium, magnesium), micronutrients, multivitamins, cooking pots, and regular follow-up visits by a physician or a nutritionist every month. In 1996 the project was expanded to include all 67 NRUs in southern Malawi, which treat over 20,000 children annually for severe PEM. Case-fatality rates fell from 35% to 20% as a result of the project, but they did not fall to 5%. To determine the causes of death, an intensive nursing study was performed, which followed WHO management recommendations, including the administration of low-energy, low protein food every 2 hours and use of broad-spectrum parenteral antibiotics (4). The case-fatality rate was 25%, with almost all of those children dying from overwhelming infection or severe electrolyte derangements; HIV was a contributing factor in about half of the deaths.
Significant geographical differences probably do exist for patients with severe PEM as a result of the multifactorial and environmental etiology of the disease. That the WHO recommendations are based on work done in the 1960s and 1970s and are uniform throughout the world indicates that research support for this important global medical problem has been lacking. Ashworth's specific treatment recommendations represent the best advice for treating children with severe PEM today. However, as an academic, international nutritionist, I am embarrassed that this is the state of our understanding. There needs to significant scientific investment in the area of PEM in the future to extend the benefits of improved outcome to the most vulnerable children in the world.
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