The World Health Organization (WHO) recently published a manual of the management of severe malnutrition (1). The recommended treatment protocol evolved from years of research in research departments (2,3), and its main points have circulated among nongovernmental organizations working in relief operations since 1993 (4). Experience from nongovernmental organizations suggests that this protocol can be applied even in extremely difficult field conditions in a large number of children and results in low overall mortality (5,6).
Should we anticipate a sharp decrease in malnutrition-related mortality after the publication of the WHO manual? Should we argue that the problem of severe malnutrition is solved, that improving the skills of physicians or health workers is the answer? Obviously, this is partly true, and a review by Schoffield and Ashworth (7) gives an impressive list of faulty clinical practice that is widespread in the hospital wards of developing countries and that may increase mortality. Undoubtedly, correcting these practices will have a favorable impact. Professor Ann Ashworth's article in this issue of the Journal of Pediatric Gastroenterology and Nutrition will help to correct these inadequacies. However, the optimism about the practical impact of the WHO manual needs to be qualified. Reduction of mortality in a few selected centers does not mean that the same decrease in mortality will be observed everywhere. It is a sobering thought to remember that a previous manual was already published 20 years ago and that little sustained effect on malnutrition associated mortality was observed in the following years (8).
Several conditions have to be met before this new manual may have an impact. First, it should be widely available to health workers, and strong support should be provided for its implementation. This is currently not the case because this manual remains little-known outside specialized nongovernmental organizations. * However, without clear support from international agencies, it is doubtful that use of this manual will ever be implemented. Such support was obviously lacking after the publication of the 1981 manual (9).
The described protocol should also be foolproof, and any properly briefed health worker with minimal training should be able to implement it without mistake. Experience from relief operations suggests that it may not be the case of the present WHO manual, especially for the rehydration period and the beginning of the refeeding phase (10). To simplify rehydration and lower the risk of sodium overload, WHO now recommends using a lowsodium (45 mEq/L) and high-potassium (40 mEq/L) solution (Resomal) for severely malnourished children. It should be clear that this sodium concentration of this solution is not sufficient to prevent hyponatremia in case of cholera (4,11). However, it does not eliminate the risk of sodium overload in other settings either, and excesses of deaths were reported in places where this solution was administered too generously, with little supervision, especially at the beginning of the rehabilitation phase (10). This section of the manual may need revision.
The protocol must also be simple to implement. The manual recommends the use of two different milk feeds with different proportions of macronutrients for initiation of cure (F75) and for the rehabilitation phase (F100). The rationale for using these two feeds is mainly theoretical, and its practical relevance has never been tested in a controlled trial. Some nongovernmental organizations do not follow this recommendation, without any obvious consequence in terms of morbidity or mortality. Arguably, WHO F100, which administers 100 kcal/100 ml, is hyperosmolar, even if glucose polymers are used as a source of carbohydrates (12), and this may induce diarrhea at the beginning of treatment. However, the same formula could be used and osmolarity could be decreased by simply adding water to the feeds at the beginning of treatment when energy requirements are low and there is no clear advantage in giving energy dense feeds. Recommendations regarding the use of F75 need to be critically reassessed.
The WHO protocol also recommends a residential treatment lasting 2 to 3 weeks. This is another limiting factor: in most settings, this is impossible because no beds can be made available for treating malnourished children for so long in overcrowded pediatric wards. Typically, a recent article on treatment of severe malnutrition in Bangladesh mentions that children admitted with a mean weight for height of 73% of National Center for Health Statistics median stayed on average for 4.5 days (13), which is insufficient to achieve any significant weight gain. Attempts have been made to reduce the duration of residential care by carrying out the rehabilitation phase at home (14). This approach also has the advantage of reducing the cost of treatment (15), but it would be risky to administer powdered WHO F100 in unhygienic environments with no access to clean water. Clearly, diets used during this rehabilitation phase need to be adapted for home-based nutritional rehabilitation. In this respect, the efficacy of solid rehabilitation foods resistant to bacterial contamination now used in some relief operations needs to be carefully evaluated (16).
Finally, availability of diets needed to treat severe malnutrition according to the WHO protocol also limits its implementation. All ingredients are not always available, and their preparation requires the presence of a dietician. Use of imported ready-to-use powdered products, which are common in emergency relief operations, seems unsustainable in most poor countries. Development of effective locally produced rehabilitation diets is urgently needed. Locally produced spreads, similar to those now used in some relief programs, might offer an interesting alternative to imported powdered products.
The publication of the WHO manual has the merit of setting a goal for the management of severe malnutrition. Undoubtedly, it will reduce mortality when carefully implemented, although AIDS may limit its efficacy in high-prevalence areas (17,18). However, as it is, this protocol may have limited effectiveness. Efforts are still needed to improve the treatment of malnutrition, simplify it, lower its cost, and make it sustainable with minimal external inputs.
This manual can be downloaded in English, French, or Spanish from the World Health Organization Web site:
1. World Health Organization. Management of severe malnutrition. A manual for physicians and other senior health workers.
Geneva: World Health Organization, 1999.
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17. Beau JP, Imboua Coulibaly L, et al. Impact d'une prise en charge nutritionnelle sur la mortalité d'enfants malnutris infectés ou non par le virus de l'immunodéficience humaine. Cahiers Santé 1999; 9: 163–7.
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