Severe malnutrition: Report of a consultation to review current literature, 6-7 September 2004
More than 3.5 millions mothers and children under 5 die unnecessarily each year due to the underlying cause of undernutrition. In hospitals in developing countries severely malnourished children comprise a significant proportion of pediatric deaths, due at least in part to unacceptably high case-fatality rates. To improve the quality of inpatient care and reduce child deaths, WHO has developed case-management guidelines for severe malnutrition. Management of severe acute malnutrition according to WHO guidelines reduced the case fatality rate by 55%. The most recent guidelines were peer-reviewed in 1998. No special provision was made for the management of severely malnourished children with HIV/AIDS, nor of infants aged <6 months. In September 2004, WHO therefore held an Informal Consultation to consider treatment for these two groups as well as any advances in knowledge that might require the guidelines to be updated. The report of the Consultation should be read together with the other WHO guidelines.
With regard to HIV/AIDS, the consultation agreed that prophylactic cotrimoxazole should be given to all HIV-exposed or HIV-infected children with severe malnutrition to prevent opportunistic infection. As regards antiretroviral therapy, there are no published studies of its effectiveness in severely malnourished children and only limited studies in non-malnourished children. A programme of research was advocated, including the pharmacokinetics and safety of different antiretroviral drugs and regimens in severely malnourished infants and children. Gaps in knowledge were also identified in relation to feeding severely malnourished infants <6 months and research is needed to provide the evidence-base to guide case-management of this age group. No changes to other aspects of treatment were suggested, although gaps in the evidence-base were identified and development of a defined plan of research was proposed. It was agreed that current coverage of the guidelines is poor and will need to be scaled-up in achieving the Millennium Development Goal of improved child survival.