Nutrition News for Africa

Abstract - October 31, 2006

An article by Collins S et al. entitled “Management of severe acute malnutrition in Children” was published in the September 26, 2006 edition of The Lancet.

Severe acute malnutrition (SAM), is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Center for Health Statistics reference values, the presence of bilateral pitting edema of nutritional origin or a mid-upper-arm circumference of less than 110mm in children aged 1-5 years. Case-fatality rates in hospitals treating SAM in developing countries average 20-30% and have remained unchanged since the 1950s despite the fact that clinical management protocols capable of reducing case-fatality rates to 1-5% have been in existence for 30 years.

While the child survival movement commonly acknowledges the importance of undernutrition, the importance of acute malnutrition is seldom mentioned. There are about 60 million children with moderate acute and 13 million with severe acute malnutrition worldwide. About 9% of sub-Saharan African and 15% of south Asian children have moderate acute malnutrition and about 2% of children in developing countries have SAM.

At present, an exclusive inpatient approach to the clinical care of SAM is recommended. The core of accepted WHO management protocols is in two phases (stabilization and rehabilitation). There is evidence that these protocols can substantially decrease case-fatality rates in both stable environments and during emergency humanitarian interventions but studies also suggest that the availability of sufficient resources, particularly skilled and motivated health staff is a vital determinant of success and effectiveness. In 20 of the African countries most affected by acute malnutrition there are fewer than 4 doctors and 22 nurses per 100,000 people. In practice, shortages of skilled staff commonly preclude the effective and sustainable implementation of WHO guidelines for the management of SAM. In the 1970s these problems prompted moves to demedicalise the treatment of SAM and move the locus of treatment away from hospitals to communities. The results were initially mixed, but the recent development of ready-to-use therapeutic food has greatly eased the difficulties associated with providing suitable high-energy, nutrient-dense food that is safe for use in outpatient programs.

During the past 5 years, a growing number of countries and international relief agencies have adopted a community-based model for the management of acute malnutrition, called community-based therapeutic care. This model provides a framework for an integrated public-health response to acute malnutrition, treating most patients with SAM solely as outpatients and reserving inpatient care for the few with SAM and complications. The model also aims to integrate treatment with various other interventions defined to reduce the incidence of malnutrition and improve public health and food security and has shown promise as an intervention to assist children with SAM infected with HIV. The use of mid-upper-arm circumference as the sole anthropometric indicator for screening and admission into community-based therapeutic care also facilitates community participation, helping to devolve responsibility for selection of patients towards the community. These new approaches for the management of SAM have greatly reduced case-fatality rates and initial data indicate that they are very cost effective. The author recommends that: WHO should adopt the term “acute malnutrition”; the child survival agenda must give greater priority to treatment of SAM there should be a better communication of the fact that there are successful and cost-effective interventions for SAM; and, an appropriate indicator of acute malnutrition such as mid-upper-arm circumference should be integrated into programs to diagnose acute malnutrition more effectively. The author concludes that achieving the fourth Millennium development Goal of a two-third reduction in childhood mortality will not be possible unless SAM is addressed effectively.