ANTIBIOTICS AND SEVEREMALNUTRITION

Dr. Allen Cherer

Childhood undernutrition is a major global healthproblem and severe acute malnutrition remains amajor cause of childhood mortality. It is estimatedthat 19 million preschool age children, mostly fromthe World Health Organization African and South-

East Asia Regions, suffer from severe acutemalnutrition, contributing to major childhood

morbidity, mortality, intellectual impairment, anddisease susceptibility.

Of the 7.6 million deaths annually amongchildren who are under 5 years of age,

approximately 35% are nutrition related and4.4% of deaths are specifically attributable tosevere wasting. Children with severe acutemalnutrition suffer severe wasting that may

(kwashiorkor) or may not (marasmus) beaccompanied by swelling of the body from

fluid retention.

It occurs when infants and children do not haveadequate energy, protein, and micronutrients intheir diet, and at times is combined with recurrentinfections.Diagnostically, it is defined as a mid-

upper arm circumference less than 115 mm or aweight for height that is severely reduced. There isstrong epidemiological evidence that low weight-for-height, weight-for-length, or mid-upper armcircumference are highly associated with a 5-20

fold increased risk of mortality.

For decades, the primary management for severeacute malnutrition comprised inpatientrehabilitation with fortified milk formulas.Management guidelines then transitioned to

incorporate the use of ready-to-use therapeutic food(RUTF), usually a fortified spread of peanut paste,

milk powder, oil, sugar, and a micronutrientsupplement, in outpatient settings in those cases ofsevere acute malnutrition where appetite was

preserved and there were no evident complicatingmedical clinical signs.

Nevertheless, a significant number of children failedto recover. Since many studies had demonstrated ahigh percentage of clinically significant infectionsamong children with severe malnutrition, treatment

guidelines recommending the use of routineantibiotics were developed. In 2013, a double-blind,

randomized, placebo-controlled clinical trial in ruralMalawi conducted by Trehan and colleagues wasreported in the New England Journal of Medicine.

The study found that the routine addition ofa seven day course of amoxicillin or cefdinirto the outpatient management of severeacute malnutrition was associated withmarked improvement in recovery and

mortality rates and significant increases inweight and mid-upper arm circumferences.

Subsequently, the 2013 WHO guidelines(previously updated in 1999) for treatmentof children with severe acute malnutritionwithout health complications requiringhospitalization called for high energy food

and routine antibiotics.

The new guidelines were considered superiorto previous ones in that they reflected newopportunities and technologies in caring forgreater numbers of children in the outpatientsetting. In addition, the guidelines specifically

addressed children with severe acutemalnutrition who were less than 6 months of

age or were infected with HIV.

Most recently, a study from the Harvard T. H.

Chan School of Public Health and publishedin the New England Journal of Medicine in2016 calls into question the routine use ofantibiotics in the management of severe

acute malnutrition.

The double-blind, randomized trial of amoxicillinvs. placebo in a population of children in Nigerbetween October 2012 and November 2013

demonstrated no superiority in terms of recoveryrate among children treated with amoxicillin and

no differences in overall mortality.

The implication is that in an era of increasingantibiotic resistance, routine antibiotic

administration may pose a greater risk to childhealth. Nevertheless, the study did demonstrate onsecondary analysis a faster rate of recovery (28 daysvs 30 days) among children treated with amoxicillin,

decreased risk of death in children over 24 months ofage, and decreased risk of transfer for clinical

complications.

Since the study population too was notcomparable to that of Trehan and colleaguesin Malawi and the level of ancillary care andfollow up was not the same, further studiesare indicated prior to recommending achange in current treatment guidelines.