Manejo de la malnutrición severa infantil


1: BMJ  2003 Jan 18;326(7381):146-51 [Texto completo]

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 diarrhea.

Ahmed T, Begum B, Badiuzzaman, Ali M, Fuchs G.

International Centre for Diarrheal Disease Research, Dhaka, Bangladesh.

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.

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4: Curr Opin Clin Nutr Metab Care  2000 Jan;3(1):31-8

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.

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.

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5: World Health Organization. Geneva: WHO, 2000. [Texto completo]

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 Jun 5;353(9168):1919-22

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 Dec 24-31;344(8939-8940):1728-32

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 strategy.

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Clinical Trial


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.



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