THE World Health Organisation (WHO) has released new treatment guidelines for the almost 20 million children under-five worldwide who have severe acute malnutrition.
Severe acute malnutrition is when children suffer severe wasting that may or may not be accompanied by swelling of the body from fluid retention. It occurs when infants and children do not have adequate energy, protein and micronutrients in their diet, combined with other health problems such as recurrent infections. It is diagnosed when the circumference of the upper arm is less than 115 mm or when the weight for height of a child is severely reduced.
Children with severe acute malnutrition are among the most vulnerable people in the world. They are very thin: most of their fat and muscle has been used by their bodies to stay alive.
The updated WHO guidelines recommend that children with severe acute malnutrition who do not have health complications that require hospitalization, receive special, high-energy food and antibiotics to treat infection. This allows them to recover at home with their families. They also give guidance on how to treat them for HIV and, if necessary make recommendations on how to treat severely malnourished infants under six months.
“The guidelines are critical because many national health plans currently overlook children with severe acute malnutrition... If these children don’t get the right medical and nutritional care, very often they die,”
Dr Francesco Branca, Director, WHO Department of Nutrition for Health and Development
“The guidelines are critical because many national health plans currently overlook children with severe acute malnutrition. This can be fatal. If these children don’t get the right medical and nutritional care, very often they die,” says Dr Francesco Branca, Director of WHO’s Department of Nutrition for Health and Development.
New guidelines reflect new opportunities and technologies
The new guidelines supersede those issued by WHO in 1999 which recommended that all severely malnourished children be hospitalized, given fortified formula milk and appropriate treatment including antibiotics.
The guidelines have been updated to reflect new opportunities and technologies that allow severely malnourished children who have an appetite and no evident medical complications to be effectively treated at home with specially-formulated foods that provide energy and nutrients and antibiotic medicines.
“It’s generally better for children and better for their families if they’re treated as outpatients,” says Dr Elizabeth Mason, Director of WHO’s Department of Maternal, Newborn, Child and Adolescent Health. “It can be easier for families who need to continue providing and caring for other children, and it allows vulnerable, malnourished children to stay home and avoid the risk of getting hospital infections.”
The proactive use of antibiotics is important because the immune system of a child who is severely malnourished can virtually shut down. This lack of immune response means both that the body cannot fight off infection and that tests may not detect infection, even when one is present. Evidence shows that giving a broad spectrum antibiotic such as amoxicillin enables the child’s body to fight off common infections like pneumonia and urinary tract infections which can be fatal to this group of children.
However, the new recommendation is specifically for children with severe acute malnutrition—not those who are simply undernourished. Widespread use of antibiotics among children who do not need them would increase the risk of infections becoming resistant to lifesaving antibiotics—a situation that would harm the health and survival of all children.
Severely malnourished children with HIV
Another new aspect of the guidelines relates to the treatment of severely malnourished children with HIV. The 1999 guidelines did not recommend HIV testing of children with severe acute malnutrition. At that time, there was poor availability and little experience of treating children with antiretroviral drugs.
Circumstances today are very different. We now know that antiretrovirals significantly increase survival of children with HIV, and access to these drugs is improving. The new guidelines recommend that children with severe acute malnutrition in countries where HIV is common be routinely tested for the virus, and those who are positive should start on antiretroviral drugs as well as special foods and antibiotics to treat their severe malnutrition.
Infants under 6 months with severe acute malnutrition
The other group whose needs are addressed for the first time in these guidelines are infants under 6 months with severe acute malnutrition. WHO recommends that all babies under 6 months are exclusively breastfed for optimal nutrition and protection against infections. This is particularly important for babies who are severely malnourished. Health services should give special support to mothers of these infants to breastfeed as well as treating the child with antibiotics.
If there is no realistic prospect of a severely malnourished baby being breastfed, the family may need breast milk from another woman, e.g. a family member, a neighbour, a wet nurse or a milk bank. If this is not possible, they will need infant formula and support to prepare and use it safely.