Inpatient management of children with severe acute malnutrition: a review of WHO guidelines.

Introduction Each year, severe acute malnutrition--defined as a weight-for-height z-score of less than -3 or a mid-upper arm circumference of less than 115 mm--is the direct cause of an estimated 540 000 child deaths and an important underlying contributor to many other child deaths, especially those due to pneumonia and diarrhoea. (1,2) The prevalence of--and case fatality rate for--malnutrition are particularly high in infants. (3,4) Severe acute malnutrition without medical complications can now be effectively managed in the community, with ready-to-use therapeutic foods. 5 The presence of complications such as anorexia, infections or metabolic dysfunction still warrants inpatient management. The World Health Organization (WHO) indicates that, by following its inpatient management guidelines, less than 10% of children with complicated severe acute malnutrition should die. (2) However, despite reported compliance with these guidelines, health centres in sub-Saharan Africa have reported mortality rates of 10-40% among severely malnourished hospitalized children. (3,6) The corresponding published rates in Asia tend to be lower, possibly because: Asian health systems are generally stronger than their African counterparts; therapeutic innovations have been introduced in some Asian facilities that have not yet been used in Africa; and children with uncomplicated severe malnutrition are sometimes admitted to Asian health facilities--but not, generally, to African health facilities. (7,8) In sub-Saharan Africa, human immunodeficiency virus (HIV) is believed to contribute greatly to malnutrition-related mortality--although, a recent meta-analysis demonstrated an overall case fatality rate of 15% among paediatric inpatients with severe malnutrition without HIV infection. (6) It is unlikely that severe acute malnutrition will be eliminated in the foreseeable future, as preventative interventions would have to reach the 52 million children who have moderate acute malnutrition. (1) Optimizing the management of complicated severe malnutrition therefore remains an important strategy for reducing malnutrition-related mortality. WHO's first guidelines on the management of malnutrition --published in 1981 and focused on protein-energy malnutrition (9)--were replaced in 1999 by guidelines on the management of severe acute malnutrition. (10) These two documents summarized decades of clinical experience and described the achievement of low malnutrition-related case fatality rates in some specific settings. (9-11) Further guideline revisions were made in 2003 (2) and 2013. (4) Relevant joint statements from WHO and other United Nations agencies were issued in 2007 (5) and 2009. (12) The combination of these joint statements, the 1999 guidelines and the revisions of 2003 and 2013 constitutes the current WHO severe acute malnutrition guidelines and underpins WHO's related training material. (13) Although weak health systems and the inadequate implementation of guidelines undoubtedly contribute to the high number of preventable deaths attributed to complicated severe acute malnutrition," this condition causes high case fatality even in relatively well resourced centres that report full implementation of the WHO guidelines. This review attempts to identify evidence gaps within the guidelines on inpatient management of severe acute malnutrition that, if filled, may help reduce mortality below the levels that can be accomplished solely by adherence to existing guidelines. We reviewed each individual recommendation contained within current WHO guidelines--including those relating to the post-discharge care that forms an integral extension of hospital management. We traced the lineage and quantified the evidence cited in support of each recommendation. We also searched trials registries systematically, to determine which evidence gaps may be closed by the results of ongoing or recently completed trials. Methods We identified WHO's recommendations for severe acute malnutrition management by searching Google Scholar using "severe acute malnutrition" and "author: WHO" as the search terms--and by downloading the publications on the WHO nutrition website in December 2015. …