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CLINICAL REVIEW: Mark J Manary and Heidi L Sandige Management of acute moderate and severe childhood malnutrition BMJ 2008; 337: a2180 [Full text]

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Cautions in complicated severe malnutrition

Richard A Sturge   (18 December 2008)

Nutrition Rehabilitation Units

Ronald F Ingle   (29 January 2009)

Cautions in complicated severe malnutrition 18 December 2008
Richard A Sturge, NGO Volunteer Doctor 45 Eaton Rise, London, W5 2HE Send response to journal: Re: Cautions in complicated severe malnutrition	This Clinical Review clearly summarises the current approach to the management of acute malnutrition in childhood without going into detail about the relevant importance of macro- and micro-nutrients. However, it does contain two questionable statements. Firstly, children with complicated severe malnutrition are immunocompromised, may not exhibit the usual features of infection and, as the authors state, require routine antibiotics. However, unless there are strong indications parenteral antibiotics are best avoided. Therapeutic feeding in developing counties often takes place in less than perfect hygienic conditions, even in hospitals. Intramuscular injections are problematic where muscle mass is scanty and injection abscesses relatively common. Intravenous access may be difficult to achieve and carries even more risk of introduced infection. Secondly, the authors correctly state that rehydration with standard oral rehydration solution (ORS) involves an excessive sodium load for functionally impaired kidneys. However, their suggestion of rehydration with F-75 therapeutic milk risks too high a nutrient challenge in the early phase of re-feeding. Current practice is to rehydrate with modified ORS (ReSomal) which contains half the sodium content of standard ORS and can either be obtained as a ready made powder to dissolve in water or can be made up by diluting standard ORS with water and adding electrolytes and sugar. Parenthetically, WHO and UNICEF now recommend low osmolarity ORS at 75 mmol sodium per litre for dehydrated children without malnutrition as this has been shown to lead to reduced stool volume compared with the older standard ORS at 90 mmol sodium per litre. Competing interests: RAS has worked in therapeutic feeding centres in developing countries
Nutrition Rehabilitation Units 29 January 2009
Ronald F Ingle, Retired Rural Practitioner Hillcrest 3610, South Africa Send response to journal: Re: Nutrition Rehabilitation Units	Doctors and nurses in Transkei, South Africa in the 1970s were challenged by their experience of childhood malnutrition to discover the vital dynamics of interactive health education. Excepting marasmus, we transferred the management of frank kwashiorkor from Wards to "NRUs" - satellite home-like places where the focus of care became the mother, her role in the recovery of the child, the prevention of relapse, and, later, the spreading of messages to her neighbours. The technicalities of the article I respond to are humbling. But since it is addressing the sub- Saharan context, I think the NRU strategy deserves mention.(1) (1) Beach H, Lwana P. Nutrition Rehabilitation Units. A Transkeian experiment. S Afr Med J. 1974; 48(52): 2177-80. Competing interests: None declared