GLOBAL CHILD HEALTH

Improving child survival: Malnutrition Task Force and thepaediatrician’s responsibilityA A Jackson, A Ashworth, S Khanum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arch Dis Child 2006;91:706–710. doi: 10.1136/adc.2006.095596

Malnutrition (underweight) contributes to approximately60% of all child deaths, yet health professionals, policymakers, and donor agencies often fail to recognise itsrelevance to child survival. There is a need for thepaediatric community to champion the importance ofadequate nutrition for normal growth and development,and of placing sufficient emphasis on the prevention andtreatment of malnutrition. Many severely malnourishedchildren die from inappropriate treatment. Case fatalityrates of 25–30% are commonly found and in somehospitals as many as 50–70% will die. Many of thesedeaths are avoidable. Weaknesses in health systems,inappropriate training of doctors and nurses, inadequatesupervision, and lack of support for staff all contribute tocompromised quality of care. The International Union ofNutritional Sciences, with support from the InternationalPediatric Association, Launched a global Malnutrition TaskForce in 2005. The main objective is to ensure that anintegrated system of prevention and treatment ofmalnutrition is actively supported as a fundamental aspectof care, and becomes an integral part of all trainingprogrammes.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article forauthors’ affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Prof. A A Jackson, Instituteof Human Nutrition,Southampton GeneralHospital (MP 113),Tremona Road,Southampton SO16 6YD,UK; aaj@soton.ac.uk

Accepted 3 April 2006. . . . . . . . . . . . . . . . . . . . . . .

In this commentary we highlight the role ofmalnutrition (measured as low anthropo-metric status) as a major contributory cause

of child death and urge the paediatric commu-nity to champion the need to improve both itsprevention and treatment. In 2000, governmentspledged to reduce under-5 mortality by twothirds by 2015 (Millennium Development Goal4); huge efforts will be needed if this goal is to beattained in the 10 years that remain. It isinconceivable that the target can be achievedwithout adequate attention to nutrition, butappropriate attention to nutrition brings thetarget within reach at a stroke. Currently, acrossthe world some 10.8 million children under5 years of age die every year (30 000 per day).1

Most of these deaths are preventable and almostall occur in poor countries. Sub-Saharan Africaand south Asia account for 41% and 34% ofglobal child deaths respectively,1 so efforts toimprove child survival in these regions areespecially important.

Tackling malnutrition is essential as lowweight-for-age (,21 SD) underlies 53–60% ofchild deaths,2 3 representing 5.7–6.4 million

malnutrition related child deaths/year. Neonataldisorders, diarrhoea, pneumonia, and malariaare the main reported causes of under-5 mortal-ity (table 1), but malnutrition as an underlyingcause does not appear in routine statistics and soits importance is easily overlooked. As a result,health professionals, policy makers, and donoragencies often fail to recognise its relevance inchild survival strategies and do not placesufficient emphasis on its prevention and treat-ment. Part of the explanation for the importantunderlying role of malnutrition in child deaths isthat almost all nutritional deficiencies, includingvitamin A and zinc, impair immune function andother host defences,4 leading to a cycle of longerlasting and more severe infections and everworsening nutritional status. Thus inadequateintake, infection, and poor nutritional status areinexorably entwined. Well nourished childrenrarely die from diarrhoea and common childhoodinfections, and maintaining a good nutritionalstatus should be an integral part of improvingchild survival.

Adequate nutrition is also essential for normalgrowth and development, which represent theessence of good health. Achieving this potentialmaximises neuro-cognitive development andcreates the individual capacity to withstand awide range of environmental stressors. Foreffective and safe practice, all healthcare workersneed a basic understanding of the role ofnutrition in growth and development, but aboveall paediatricians represent the critical profes-sional group that should possess a deeperunderstanding of nutrition for the wellbeing ofevery child.

WHY IS MALNUTRITION EASILYOVERLOOKED?At national, community, and hospital levels, nodata are readily available for advocacy in terms oflives to be saved by preventing or treatingmalnutrition. Most national statistics on mortal-ity are compiled from records in which a singlecause of death is reported: malnutrition as anunderlying cause does not feature. At the countrylevel, data describing the prevalence of under-weight, wasting, and stunting are collected innational surveys, but these fail to reveal anythingabout the enormity of their contribution to childmortality. Severe wasting has been estimated tocontribute to 1.7 million child deaths/year byCollins et al5 from the UNICEF global databaseand applying the epidemiological approach ofPelletier.6 This startling figure is certainly anunderestimate as it does not include deathsamong children with the oedematous form of

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severe malnutrition (kwashiorkor), as children are notusually examined for oedema in national health or nutritionsurveys. In some geographic regions, kwashiorkor deathsoutnumber deaths from other forms of severe malnutrition,so actual child deaths from severe malnutrition will farexceed the estimate of 1.7 million/year. Whereas the plight ofseverely malnourished children may be highlighted in thenews coverage of humanitarian emergencies, the daily grindof silent suffering is unobserved. The economic value inpreventing and treating malnutrition as integral to theachievement of health development is not adequatelyappreciated, and the issue remains hidden at the nationallevel.

At the community level, malnutrition is also largely hiddenbecause disinvestment in primary health care has meant thatoutreach services in many countries have been disbanded.Consequently malnourished children are not identified andmany die at home without professional health care. Nationalhealth worker training in the WHO programme of IntegratedManagement of Childhood Illness (IMCI) has stagnated at,10% in most countries due to insufficient investment andhealth system constraints.7 Even where IMCI training iscontinuing, the nutrition component is sometimes reduced ornot attempted because of time constraints, and clinic staffmay not be equipped to provide nutrition counselling orspecific advice for effective prevention and treatment ofmalnutrition.

In hospitals in developing countries, severely malnourishedchildren comprise a significant proportion of paediatricdeaths. This is not because there are more admissions forsevere malnutrition than for other conditions but because ahigher proportion of them die. Many die unnecessarily due tooutdated practices and because doctors and nurses areunaware of their special needs.8 This disproportionatecontribution of severe malnutrition to inpatient paediatricdeaths is rarely recognised by doctors or administrators:children may not be routinely weighed on admission andmalnutrition is likely to be entered as a diagnosis only if thereare no other presenting clinical conditions. Most severelymalnourished children are reported as cases of gastroenteritisor pneumonia, so malnutrition may not appear in hospitalstatistics.

Health policy makers are being encouraged to adapt childsurvival strategies to fit the local epidemiology and becountry focused. If local data are not readily availableregarding malnutrition related deaths, there is a serious riskthat malnutrition will not receive the emphasis it deserves innational child survival strategies. The paediatric communitymust therefore be vigilant and advocate for its inclusion.

IMPROVING CASE MANAGEMENT OF SEVEREMALNUTRITIONMany malnourished children die from inappropriate treat-ment. Severely malnourished children undergo physiological

and metabolic changes to conserve energy and preserveessential processes, including reductions in the functionalcapacity of organs and slowing of cellular activities.9 If thesechanges are ignored when prescribing treatment, severelymalnourished children are put at increased risk of death fromhypoglycaemia, hypothermia, electrolyte imbalance, heartfailure, and untreated infection. Consequently case fatalityrates of 25–30% are commonly found.8 Rates are even higherin some hospitals where as many as 50–70% die. In twoSouth African hospitals, 50% of deaths in 2000–01 amongseverely malnourished children were attributed to doctorerror and 28% to nurse error. Had these preventable deathsbeen avoided, mortality would have been 5% instead of 24%.Weaknesses within the health system, especially inappropri-ate doctor and nurse training, inadequate supervisionprovided by nurses, and lack of simple support systems forstaff, compromised quality of care and contributed to theincreased loss of life.10

Recognising that poor paediatric care underlies andcontributes significantly to increased mortality, WHO hasdeveloped guidelines for treating severe malnutrition11 12 anda training course for doctors and nurses.13 The evidence baseis wide ranging.14 The guidelines set out 10 steps for routinecase-management. The initial stabilisation phase focuses onthe following:

N Feed every 2–3 hours, day and night to prevent hypogly-caemia and hypothermia

N Keep warm

N Rehydrate with low sodium fluids; monitor closely forsigns of fluid overload; avoid intravenous fluids, except inshock

N Give 100 kcal/kg body weight/day and 1 g protein/kg/day

N Give potassium and magnesium to correct electrolyteimbalance; restrict sodium

N Give micronutrient supplements; do not give iron

N Give broad spectrum antibiotics even when clinical signsare absent as infections can be silent.

The rehabilitation phase includes:

N Rebuilding wasted tissues with high energy, high proteindiets and micronutrients

N Psychosocial stimulation to improve mental development

N Preparation for continuing care and follow up afterdischarge.

Where the guidelines have been fully implemented, mortalityhas been reduced by at least half. Examples of impact aregiven in table 2. If all hospitals in developing countriesfollowed the WHO case management guidelines for severemalnutrition, perhaps a million or more lives would be saved.This will require recognition of the importance of malnutri-tion in clinical practice, establishing a severe malnutritionward or ‘‘corner’’ where correct treatment is provided dayand night, having adequate supplies, and having ward andemergency staff trained in malnutrition case management.Two major obstacles are that most doctors and nurses areunaware of the guidelines as they are not part of their basictraining; and health systems fail to provide the supportivesupervision and leadership, and sometimes the resources, toput the guidelines into practice effectively. Very high case-loads constrain quality improvement. In Kenyan districthospitals, for example, one nurse may have responsibility forup to 50–60 ill children (James Berkley, personal commu-nication). Even with prioritisation of tasks and trainingmothers and other carers to assist with feeding etc, such highcaseloads are incompatible with adequate care, and the

Table 1 Distribution of global child deaths by cause andthe percentage attributable to underweight (,21 SDweight-for-age)

CauseDistribution of childdeaths by cause (%)

% attributable to beingunderweight

Neonatal disorders 33 Work in progressDiarrhoea 22 61Pneumonia 21 53Malaria 9 57AIDS 3 Work in progressMeasles 1 45

Source: Black et al.1

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paediatric community must demand greater investment inhealth in developing countries, especially at the district level.

Important strides have been made in improving casemanagement of severely malnourished children in humani-tarian emergencies, and caring for families in their commu-nities is being emphasised rather than encouraging them tomove and congregate in huge camps, where diseases easilyspread.23 Community outreach workers screen children forwasting and oedema; those who have mild/moderate oedemaor are severely wasted but have a good appetite and are alertand appear clinically well, are treated at home with ready-to-use therapeutic food, with weekly or fortnightly super-vision. Only those who have poor appetite or are ill, or havesevere oedema, or oedema plus wasting, are referred forinpatient care.23 This reduces congestion and crowding in theinpatient facilities, and may reduce hospital caseloads. In 21programmes in Malawi, Ethiopia, and Sudan, more than22 000 children have been treated in this way, with a casefatality rate of 4.8%.5 This illustrates the importance ofcommunity outreach, early diagnosis and effective action,and has also been applied in non-emergency, resource-poorsettings.24

ROLE OF THE PAEDIATRIC COMMUNITYThe current widespread problem of mismanagement ofsevere malnutrition has its origins in poor training andpractice of doctors, nurses, and other health professionals. Itis unusual for the appropriate case management of severemalnutrition to be included in undergraduate medicaltraining.25 It is similarly neglected in undergraduate nursetraining. Even in Africa where doctors and nurses in districthospitals will be treating such children on a daily basis, theteaching of case management of severe malnutrition fails toreceive appropriate emphasis. The result of this persistent

oversight is clear: severely malnourished children withdehydration, pneumonia, and other infections are treatedjust like well nourished children with these conditions withdisastrous consequences. Paediatricians can help change thispractice by advocating that all children be checked onadmission for severe wasting and oedema, and that severelymalnourished children be treated according to WHO guide-lines, even though they may have presented with a co-morbidity.

Even in industrialised countries, paediatricians will fromtime to time see individuals with severe malnutrition, and alldoctors will at some time in their career come across patientswith poor nutritional status. Standards of clinical care areoften set by practice in developed countries, and it is expectedthat minimum standards of safe care are established early inany professional career.25 26 The paediatric community has aresponsibility to ensure the WHO malnutrition guidelines areincluded in paediatric texts and in medical and nursingcurricula, especially in Africa and Asia. At present, even someof the most prestigious and widely used paediatric textbookscontain information about case management that is wrongand harmful. Paediatricians must provide newly qualifieddoctors with support and supervision in correct case manage-ment of severe malnutrition and should be responsible forensuring that the guidelines are implemented in all teachinghospitals so that trainee doctors and nurses can learn correcttreatment through supervised practice. Paediatricians shouldhave a key leadership role in setting up and supportingmultidisciplinary teams to deliver improved inpatient care,and in establishing audit and feedback mechanisms. Theyalso have a role in forming linkages at the community level toensure continuing care after discharge, and intersectorallinkages to address underlying causes of malnutrition and illhealth.

Table 2 Examples of impact on case fatality rates of implementing the WHO guidelines

CountryCase fatality (%)before

Case fatality (%)after Main changes made

AsiaBangladesh15 16 17 (49/293) 4 (71/1795) IV fluids restricted to those in shock

Slower rehydrationAntibiotics started straightawayGiven less protein, Na, lactose initiallyTube fed if anorexicGiven K, Mg, Zn, Cu, folic acid, multivitamins

India17 8 (4/50) 4 (4/100) IV fluids restricted to those in shockLow Na ORS (ReSoMal)F75 milk (less protein, Na, lactose initially)

India* 22 (19/88) 7 (2/28) IV fluids only if in shockLow Na ORS (ReSoMal)Given potassiumGiven less protein, Na, lactose initially

Myanmar18 16 (25/157) 9 (16/186) Comprehensive changes18 (10/55) 5 (3/66) Comprehensive changes

Latin AmericaBrazil19 34 (47/139) 16 (19/117) Comprehensive changes but still overusing blood transfusions

AfricaMalawi20 55 (11/20) 16 (3/19) Comprehensive changes but still not fully implemented for dehydration,

hypoglycaemia and hypothermia

South Africa 3521 (10/29) 18 (23/125) Comprehensive changes but still not fully implemented for dehydration,initial care and night feeds in ref 21, and not always implemented withsufficient care in ref 10

2510 (18/71) 18 (18/98)4610 (12/26) 21 (10/48)45� 9 (10/113)3022 6 (8/138)

*Personal communication (Gupta R, Sharma DK).�Personal communication (Ashworth A).

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There is a need to advocate for reinvestment in primaryhealth care, especially in the poorest countries, to deliveraccessible preventive and promotive interventions27 28 andidentify malnutrition at an early stage so that it can betreated in the community. This will require training commu-nity health workers and other cadres,28 and integratingprimary health care with activities to improve economicdevelopment and living conditions, including food security.Too often interventions to promote health and nutrition arevertical, isolated from social development, and do not addressthe underlying causes. Nevertheless there are examples ofgood health and nutrition at low cost from Costa Rica, Cuba,Sri Lanka, China, and Kerala State in India29 30 wherecommunity mobilisation, a strong political commitment,and equitable access to health services were accompaniedby declines in malnutrition and child deaths.30 Healthprofessionals in rich countries can play their part bysupporting movements such as Medact and responding tothe call for action in the People’s Health Charter30 whichseeks to counter the threats to health posed by, for example,economic globalisation, third world debt, structural adjust-ment programmes, and pricing policies of multinationalpharmaceutical companies.

THE WAY FORWARDIn order to ensure that case management of severemalnutrition becomes an effective element within the overallambition of improving child survival, there clearly has to besubstantial improvement in awareness and in the acquisitionof the skills needed for effective case management.Paediatricians have a critical responsibility in ensuring thatopportunities are created, and that as a profession they donot act as a block to progress. The International Union ofNutritional Sciences (IUNS) launched a global Task Force onMalnutrition in September 2005, with support from theInternational Pediatric Association (IPA). The main objec-tives are to:

N Establish three regional networks (south and southeastAsia; sub-Saharan Africa; Latin America) to coordinatetechnical expertise and develop capacity building partner-ships

N Raise the profile of malnutrition among health policymakers and donor agencies and advocate for increasedrecognition of its importance in child survival

N Work with partners to build capacity to prevent and treatmalnutrition, especially in countries with high childmortality

N Advocate for inclusion of malnutrition in medical andnursing curricula and for the WHO case managementguidelines to be implemented in all paediatric wardswhere severe malnutrition is found

N Encourage health workers to undertake operationalresearch to monitor and improve their performance andprovide data for advocacy action

N Raise resources

N Publish and disseminate the findings and experiences.

Through the joint efforts of nutritionists within the IUNS andpaediatricians through the IPA it should be possible to build astrong collaborative alliance which can work to ensure thatthis particular strand of the child survival strategy is notoverlooked, but actively supported as a fundamental enablingstrand of effective care. Collectively, they have the capabilityof bringing together the critical abilities and enthusiasm innutrition and child care to ensure that the fundamental shiftin approach which is needed can be achieved and sustained.The challenge is substantial and it is imperative that all

paediatricians engage to play their part in making thisfundamental change a reality. Coordination and organisationwithin and between the three regional networks will becritical. Within its international portfolio, the Royal Collegeof Paediatrics and Child Health (RCPCH) has alreadyaccepted responsibility for making a contribution to thetraining of paediatricians in sub-Saharan Africa. By ensuringthat appropriate case management is included as an integralcomponent of all training programmes, and responsiblyexamined as an integral aspect of the training of allpaediatricians, the College has the opportunity to set anexceptional example of better practice which will directly andindirectly save many lives each year. The RCPCH, with theIPA, represents one of the few professional bodies in theworld that fully embraces a responsibility for internationalaffairs within its concern for all children, and at the sametime has a high level of skill and experience in paediatricnutrition. Moving the activity of the Task Force onMalnutrition from a good idea to a force with the ability tomake an important difference is a difficult challenge. Thespecial mix of experience, capability, skill, and advocacyembraced within the College provides the opportunity forcreating an example of how to ensure better practice and tomake a difference by doing simple things well, which wouldbe of great help and benefit across the world.

The shame of children dying of malnutrition is a blot onthe conscience of us all, and children deserve better. In arational world appropriate care would be put in place tomanage problems at an early stage. Ultimately, a clearunderstanding of how best to care for the sickest childrenimproves care in the community, which in turn leads to ahigher level of awareness and prevention of the problem inthe first place.31

Authors’ affiliations. . . . . . . . . . . . . . . . . . . . .

A A Jackson, Institute of Human Nutrition, University of Southampton,UKA Ashworth, London School of Hygiene and Tropical Medicine, UK;Convenor, Malnutrition Task ForceS Khanum, World Health Organisation, Geneva, Switzerland

Competing interests: none declared

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Force and the paediatrician's responsibilityImproving child survival: Malnutrition Task

A A Jackson, A Ashworth and S Khanum

doi: 10.1136/adc.2006.0955962006 91: 706-710 Arch Dis Child 

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