Elsevier

The Lancet

Volume 353, Issue 9168, 5 June 1999, Pages 1919-1922
The Lancet

Articles
Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol

https://doi.org/10.1016/S0140-6736(98)07499-6Get rights and content

Summary

Background

Severely malnourished children have high mortality rates. Death commonly occurs during the first 48 h after hospital admission, and has been attributed to faulty case-management. We developed a standardised protocol for acute-phase treatment of children with severe malnutrition and diarrhoea, with the aim of reducing mortality.

Methods

We compared severely malnourished children with diarrhoea aged 0–5 years managed by non-protocol conventional treatment, and those treated by our standardised protocol that included slow rehydration with an emphasis on oral rehydration. The standardised-protocol group included children admitted to the ICDDR, B Hospital, Dhaka between Jan 1, 1997, and June 30, 1997, while those admitted between Jan 1, 1996, and June 30, 1996, before the protocol was implemented, were the non-protocol group.

Findings

Characteristics on admission of children on standardised protocol (n=334) and non-protocol children (n=293) were similar except that more children on standardised protocol had oedema, acidosis, and Vibrio cholerae isolated from stools. 199 (59·9%) of children on standardised protocol were successfully rehydrated with oral rehydration solution, compared with 85 (29%) in the nonprotocol group (p<0·0001). Use of expensive antibiotics was less frequent in children on standardised protocol than in the other group (p<0·0001). Children on standardised protocol had fewer episodes of hypoglycaemia than non-protocol children (15 vs 30, p=0·005). 49 (17%) of children on nonprotocol treatment died, compared with 30 (9%) children on standardised protocol (odds ratio for mortality, 0·49, 95% CI 0·3–0·8, p=0·003).

Interpretation

Compared with non-protocol management, our standardised protocol resulted in fewer episodes of hypoglycaemia, less need for intravenous fluids, and a 47% reduction in mortality. This standardised protocol should be considered in all children with diarrhoea and severe malnutrition.

Introduction

Despite improved understanding of pathophysiology and treatment of the severely malnourished child, the median case-fatality rate has remained relatively unchanged at 20%–26% for the past 50 years.1 Even in the 1990s, mortality rates of 49% have been reported for malnourished children in hospital, although very low rates also occur.1 High case-fatality rates in hospital have been attributed to faulty case-management,1 which arises because staff are unaware of how to treat severely malnourished children and lack prescriptive guidelines.

The ICDDR, B runs the Clinical Research and Service Centre (CRSC) in Dhaka, Bangladesh, which treats more than 110 000 patients for diarrhoeal disease each year. The overall mortality rate in the CRSC is only 0·45%, but the mean mortality rate among severely malnourished children with diarrhoea is about 15%, and most of these deaths occur in the 48 h after admission. Before now, inpatient treatment procedures for all diarrhoeal children were essentially the same, irrespective of malnutrition status. We have therefore developed a standardised protocol for acute-phase treatment of children with severe malnutrition and diarrhoea. Key features of the protocol are: slower rehydration with emphasis on oral rehydration; immediate feeding of a defined diet of local, inexpensive foods; routine micronutrient supplementation and broadspectrum antibiotic therapy; and careful management of complications. This study assessed the efficacy of a standardised protocol in lowering of mortality in severely malnourished children.

Section snippets

Patients

We studied severely malnourished children aged 0–5 years admitted to the CRSC with diarrhoea, whose weight-for-height or weight-for-age was less than 70% and 60% of the US National Center for Health Statistics median, respectively, or who had oedema. We did not undertake a randomised controlled trial, because standardised management was believed to be beneficial and restriction on its use unethical.2 We compared outcome, including mortality rates, in children treated by the standardised

Results

334 children were treated by the standardised protocol, and 293 children had non-protocol treatment. Baseline characteristics were similar in the two groups, but more children on standardised protocol had oedema of the feet (106 [31·7%] vs 40 [13·6%], p=0·0005, table 1). Significantly more children on standardised protocol than non-protocol children had Vibrio cholerae and other Vibrio spp isolated from stools, although the proportions of children with shigella and salmonella were similar

Discussion

With a standardised protocol, mortality among our severely malnourished children admitted to hospital with diarrhoea and serious complications was substantially lowered. There are conflicts of opinion over the management of severe malnutrition and its complications, which can result in confusion for health-care providers. Before our protocol was implemented, the opinions of our experienced physicians differed about whether or not feeding should be continued in a child with abdominal distension

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