de la malnutrición severa infantil
1: BMJ 2003
Jan 18;326(7381):146-51 [Texto
Management of the severely malnourished child:
perspective from developing countries.
Bhan MK, Bhandari N, Bahl R.
Department of Paediatrics, All India Institute
of Medical Sciences, Ansari Nagar, New Delhi-110029, India.
2: World Health Organization. Geneva:WHO, 2002. [Texto
completo en formato PDF]
Global forum for health research. Child
health research: a foundation for improving child health.
3: Indian J Pediatr 2001 Jan;68(1):45-51
Management of severe malnutrition and
Ahmed T, Begum B, Badiuzzaman, Ali M, Fuchs G.
International Centre for Diarrheal Disease
Research, Dhaka, Bangladesh. email@example.com
Children with severe malnutrition and diarrhea
have high mortality rates that have been attributed to faulty case-management.
Health workers are often unaware of the unique treatment requirements of
severely malnourished children resulting in improper case-management.
Moreover, the lack of prescriptive guidelines promotes the exercise of
discretion in case-management that is often detrimental. Appropriate
feeding from the start of treatment, routine micronutrient supplementation,
broad-spectrum antibiotic therapy, less use of intravenous fluids for
rehydration, and careful management of complications are factors that can
reduce death, morbidity and cost of treating children with severe
malnutrition and acute illnesses including diarrhea. In this paper is
discussed a standardized protocol based upon the above mentioned factors
for the management of severely malnourished children with acute illnesses
including diarrhea. Implementation of the protocol resulted in a 47%
reduction in mortality in these children.
4: Curr Opin Clin Nutr Metab Care
New concepts on nutritional management of
severe malnutrition: the role of protein.
Scherbaum V, Furst P.
Institute for Biological Chemistry and Nutrition,
University of Hohenheim, Stuttgart, Germany. firstname.lastname@example.org
Current guidelines for the management of severe
malnutrition are mainly based on new concepts regarding the causes of
malnutrition and on advances in our knowledge of the physiological roles
of micronutrients. In contrast to the early 'protein dogma', there is a
growing body of evidence that severely malnourished children are unable to
tolerate large amounts of dietary protein during the initial phase of
treatment. Similarly, great caution must be exercised to avoid excessive
supply of iron and sodium in the diet, while keeping energy intake at
maintenance levels during early treatment. Because severely malnourished
children require special micronutrients, a mineral-vitamin mix is added to
the milk-based formula diets, which are specially designed for the initial
treatment and the rehabilitation phase. To further improve nutritional
rehabilitation and reduce cases of relapse, 'ready-to-use therapeutic food'
and 'ready-to-eat nutritious supplements' with relatively low protein (10%
protein calories) and high fat content (54-59% lipidic calories) have been
developed. Although current dietary recommendations do not differentiate
between oedematous and nonoedematous forms of malnutrition or between
adults and children, there are indications that further clarification is
still needed for applying dietary measures for specific target groups.
5: World Health Organization. Geneva:
Management of the child with a serious
infection or severe malnutrition. Guidelines for care at the first-referral
level in developing countries.
6: Lancet 1999
Mortality in severely malnourished children
with diarrhoea and use of a standardised management protocol.
Ahmed T, Ali M, Ullah MM, Choudhury IA, Haque
ME, Salam MA, Rabbani GH, Suskind RM, Fuchs GJ.
Clinical Sciences Division, ICDDR, B: Centre for
Health and Population Research, Dhaka, Bangladesh.
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 non-protocol 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 non-protocol 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.
7: Lancet 1994
Controlled trial of three approaches to the
treatment of severe malnutrition.
Khanum S, Ashworth A, Huttly SR.
Centre for Human Nutrition, London School of
Hygiene and Tropical Medicine, UK.
Domiciliary treatment of severely malnourished
children could have economic and practical advantages over other methods.
We compared three approaches in a controlled trial. 437 children in Dhaka
(< 60% weight-for-height, and/or oedema) aged 12-60 months were
sequentially allocated to treatment as inpatients, to day-care, or to care
at home after one week of day-care. Institutional and parental costs
incurred to reach 80% weight-for-height were compared. Costs for inpatient,
day-care, and at-home groups averaged 6363, 2517, and 1552 taka (60 taka =
UK pound 1). Mortality was low (< 5%) in all three groups. Day-care
treatment approached inpatient care for speed of recovery at less than
half the cost, but it was unpopular with parents. The at-home group took
significantly longer to attain 80% weight-for-height than the other groups,
but did so at the lowest average cost. Parental costs were highest for the
at-home group as no food supplements were provided; nevertheless this was
the most popular option. We conclude that at-home management of severely
malnourished children after 1 week of inpatient care is a cost-effective
8: Arch Dis Child 1994 Oct;71(4):297-303
Community based, effective, low cost approach
to the treatment of severe malnutrition in rural Jamaica.
Bredow MT, Jackson AA.
Department of Community Child Health, Bristol
Royal Hospital for Sick Children.
Moderate and severe malnutrition are endemic in
much of the developing world and in association with pockets of
deprivation in the developed world. The cost in terms of individual and
social development is high. The principles of effective management are
clearly documented. A low cost, community based treatment programme for
moderately and severely malnourished children under 3 years of age was
established at a health centre in rural Jamaica. Children were followed up
monthly and defaulters were rigorously recalled. Management consisted of
carefully delivered dietary advice, antibiotics, anthelminthics, and
vitamin supplements. All children improved and the response of 36 children,
who were treated in the first year, showed an accelerated weight gain,
with catch-up growth and the maintenance of length gain. There was a
significant increase in the weight for age, at 1.9% per month over six
months, which exceeds the rate reported with food supplementation
programmes and nutrition rehabilitation centres.