Management of acute moderate and severe childhood malnutrition
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2180 (Published 13 November 2008) Cite this as: BMJ 2008;337:a2180All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests