Community care could prevent deaths of thousands of severely malnourished children

BMJ 2007; 334 doi: (Published 14 June 2007) Cite this as: BMJ 2007;334:1239
  1. John Zarocostas
  1. Geneva

    An innovative way of treating severe acute malnutrition, combining timely detection and community based care with traditional hospital treatment for children with medical complications, could help prevent the deaths of hundreds of thousands of children, UN agencies say.

    Worldwide about 20 million children under the age of 5 years have severe acute malnutrition, most of whom live in South Asia and sub-Saharan Africa, says the World Health Organization, and about one million die from the condition every year.

    The new approach has already greatly improved survival of children with severe acute malnutrition in emergencies in countries such as Ethiopia, Malawi, Niger, and Sudan, the agencies noted.

    Evidence shows that about three quarters of children with severe acute malnutrition can be treated at home with highly fortified, ready to use therapeutic foods, says a joint statement issued last week by WHO, the World Food Programme, the United Nations' standing committee on nutrition, and Unicef.

    “Severe acute malnutrition is defined by a very low weight for height, by visible severe wasting, or by the presence of nutritional oedema . . . In children aged 6-59 months, an arm circumference less than 110 mm is also indicative of severe acute malnutrition,” WHO says.

    Children with severe acute malnutrition are five to 20 times more likely than well nourished children to die, WHO estimates show.

    Margaret Chan, WHO's director general, said, “It is urgent that this approach, along with preventive action, be added to the list of cost effective interventions being used to improve nutrition and reduce child mortality.”

    Ready to use therapeutic foods “have proven very effective in addressing severe acute malnutrition in children,” said Ann Veneman, executive director of Unicef. “So these interventions are an important tool in reducing child mortality.”

    Such foods are soft or crushable and can be eaten easily without water by children from the age of 6 months. They have a similar nutrient composition to the “F100” therapeutic diet used in hospitals, the agencies said.

    Unlike F100, ready to use therapeutic foods are not based on water and thus are less likely to be susceptible to bacterial infection and can be used safely at home without refrigeration, even in areas where the hygiene conditions are not the best, the agencies added.

    Another advantage is that the technology to produce these foods is simple and can be used in any country with a minimal industrial capacity.

    In some instances it may also be possible, the agencies say, to construct an appropriate therapeutic diet using locally available dense foods with added micronutrient supplements, but they caution that this approach requires “careful monitoring, because nutrient adequacy is hard to achieve.”

    A child being treated for severe acute malnutrition will need about 10 kg to 15 kg of ready to use therapeutic foods over a period of six to eight weeks. They also need to receive a “short course of basic oral medications to treat infections,” the agencies say. Follow-up, they add, “should be done weekly or every two weeks by a skilled health worker in a nearby clinic or in the community.”

    The agencies also recommend that countries provide training and support for community health workers to identify severely malnourished children who need urgent treatment and to recognise those children with associated complications who need referral.

    Countries should also ensure funding to provide free treatment of severe acute malnutrition and integrate the management of severe acute malnutrition with other health activities.


    • Community-Based Management of Severe Acute Malnutrition is available at

    View Abstract