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Clinical Review

Management of the severely malnourished child: perspective from developing countries

BMJ 2003; 326 doi: (Published 18 January 2003) Cite this as: BMJ 2003;326:146
  1. Maharaj K Bhan (, professor,
  2. Nita Bhandari, scientist,
  3. Rajiv Bahl, scientist
  1. Department of Paediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India
  1. Correspondence to: M K Bhan

    Careful assessment and appropriate treatment and rehabilitation using standard protocols that are easy to follow reduce morbidity and mortality

    In the 1990s, the number of underweight children in developing countries declined from 177 million to 149 million.1 The incidence of severe malnutrition also declined but, despite this, severe malnutrition remains an important problem (fig 1). 2 3 In India, for example, 2.8% of children under 5 are severely wasted.3 Malnutrition is a contributing factor in nearly 60% of deaths in children for which infectious disease is an underlying cause.4 Malnutrition is also linked to an increased risk of death in children with diarrhoea and acute infections of the lower respiratory system and it may be linked to malaria—and possibly measles—too.5

    Fig 1

    Percentage of undernourished children in India during the 1990s. NFHS=national family health survey

    Death rates caused by severe malnutrition have changed little over the past few decades in hospitals of developing countries (median 23.5% during the 1990s) because malnutrition was inappropriately managed.6 Recent studies from Bangladesh and Brazil, however, have reported a substantial decline in case fatality after the adoption of new treatment protocols by hospitals. 7 8 This review describes the new treatment regimens that have been introduced and the evidence that justifies their use.9

    Summary points

    The high case fatality rates in children with severe malnutrition can be substantially reduced by adopting standardised treatment protocols

    Children with weight for height below 70% of the National Centre for Health Statistics median, bipedal oedema, or visible severe wasting should be hospitalised for initial stabilisation and preferably until full recovery

    In severely malnourished children with diarrhoea, intravenous fluids should be restricted to patients showing signs of shock; other severely malnourished children should be given an oral rehydration salts solution with a lower sodium concentration and a higher …

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