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Challenges in the management of malnutrition in children

12 Apr 2013
Farah Naz Qamar, Ali Faisal Saleem, Zulfiqar Ahmed Bhutta,
group
Background:

Malnutrition causes more than 300,000 deaths per year in children younger than 5 years in developing countries. It is the third leading cause of death in children under 5 in sub-Saharan Africa. In addition to the mortality, delayed nutritional recovery in severe acute malnutrition (SAM) is responsible for 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. In the most recently published systematic analysis of causes of death, 7.2% of child deaths between the ages of 1-4 years and 2% deaths in the neonatal stage occur due to nutritional deficiencies. The contribution of malnutrition to the leading causes of death in children under 5 years of age (malaria and HIV) remains to be determined. Despite an overall decrease in deaths due to malnutrition from 1990 to 2010, it still remains a public health priority.

Food insecurity, coexistent HIV infection, management of nutritional deficiencies in preterm babies and maternal macro and micro nutrient supplements are major issues in the management of malnutrition. Furthermore, controversies related to dietary management - home based vs. hospital-based management, management of infections and cost effectiveness and sustainability of the nutrition management programmes - remain unanswered.

There is a serious dearth of trials on the management of children with severe acute malnutrition (SAM) who are HIV positive and malnutrition in infants younger than 6 months old. Malnutrition management in children under 6 months of age is complex, and is complicated by issues of lactation failure, association with tropical enteropathies and the limitation of dietary options for feeding the young infant.

Issues related to nutritional supplementation and antibiotic management in malnourished children:

Ready to use therapeutic food (RUTF) interventions started more than a decade ago; they have proven nutritional superiority and effectiveness and also make community management of the malnourished possible. RUTF is a strong contributor to decreasing the under-5 mortality rate (U5MR). Cost and sustainability are the current limitations of RUTF for developing countries. The means cost per child for facility based treatment is approximately $300 compared to $150 for community based management of a child with SAM without complications. Research on the best options for locally produced RUTF for developing countries is underway. However, head to head comparisons of commercially made RUTF to homemade diet are still lacking.

RUTF is beneficial and effective in the majority of HIV-positive children with acute malnutrition; however the recovery in this group is slower with a high fatality rate compared to HIV-negative children. Therefore breastfeeding, access to RUTF, universal availability of antiretroviral (ARV) and cotrimoxazole prophylaxis are imperative in managing HIV-positive, acutely malnourished children. In addition to RUTF, micronutrients are an important determinant in the successful management of SAM. Vitamin A (VA) Copper (Cu), Iron (Fe) and Zinc (Zn) deficiencies are prevalent in acutely malnourished children and are associated with increased morbidity. Apart from VA and Zn, very few studies have evaluated the impact of other micronutrient supplementation in nutritional deficiency states. Data from the global burden of disease study 2010 highlights that mortality due to micronutrient deficiencies has remained unchanged in the last 20 years.

Infections add to the mortality and morbidity in malnourished children. There is a strong and consistent relationship between malnutrition and an increased risk of death from infectious diseases. There is a bidirectional relationship between malnutrition and infections and a large proportion of deaths in the severely malnourished are due to systemic infections. The World Health Organization (WHO) recommends antibacterial cover with ampicillin and gentamicin to all hospitalized children with complicated severe acute malnutrition. There is a remarkable paucity of trials anywhere in the world on which to base the WHO recommended routine broad spectrum antibiotics. Choice of appropriate antibiotic agents for the malnourished is complicated by high antimicrobial resistance, HIV prevalence and regional differences in the etiological agents. The several options that can be studied in randomized controlled trials are macrolides, third generation cephalosporins and fluoroquinolones.

Follow up of severely malnourished children:

A close follow-up of SAM following discharge is crucial for successful management, since complications, i.e., relapse, development of complications and mortalities, can happen during this period. Weekly follow-up for at least two months is recommended, as these patients have a tendency to relapse. A quarter of these children fail to follow up in six months due to migration, social, political and logistic reasons.

In addition to growth retardation, cognitive and development (motor, adaptive, language and personal social) deficit is also an issue in malnourished children. These behavioral and cognitive deficits last for a long period, however these functions have not been fully assessed. Attention, working memory, learning and memory and visuospatial ability remain low even with increasing age.

The aim of our research is appropriate treatment of infections along with nutritional rehabilitation and close follow up, of severely malnourished children. We believe that reducing the infection burden by the use of a regionally appropriate antibiotic combination in severe acute malnutrition, will improve rates of nutritional recovery. We plan to conduct a randomized controlled trial on children with SAM in tertiary care settings, comparing the WHO recommended antibiotic regimen to simpler oral antibiotics, based on the microbiological spectrum in these children, along with supplementation with macro and micronutrients and follow up at home for nutrition rehabilitation and cognitive development. Recommendations for a rational, simplified antibiotic regimen may follow as a result of this trial, which will be useful to develop evidence-based clinical guidelines by national and international agencies such as WHO and other academic bodies, for the appropriate management of SAM in children.

Relevance:

There is a documented high prevalence of pneumonia, bacteremia and urinary tract infections in children with SAM, leading to a case fatality as high as 30%. Adherence to the WHO recommendation of parenteral antibiotics is difficult in low resource settings because of financial and socio-cultural constraints. Management with oral antibiotics will facilitate early discharge and may be an acceptable alternative approach in resource limited settings to improve clinical outcomes. Furthermore, an economic evaluation (cost-effectiveness analysis) will be carried out from the societal perspective and we assume that the higher recovery rate in the alternate oral antibiotic group will reduce hospital time, parental expenses - travel and lost work for example, as well as improve the DALY due to better nutritional recovery.