Caring for Severely Malnourished Children: Book Review

The last issue of Field Exchange reported on the publication of a new book 'Caring for Severely Malnourished Children' by Ann Ashworth and Ann Burgess. The book describes how to manage severely malnourished children in hospitals and other health units with inpatient facilities. Due to criticisms of the content by Prof. Mike Golden, the authors, TALC and the publisher together agreed to have the book reviewed. Three independent experts in the field were asked to address the following questions:

1. Does the book deviate from WHO guidelines on treatment of severe malnutrition.
2. If so would these deviations be detrimental to children's health.
3. Does the book provide the information required for health workers to manage severely malnourished children successfully.

The findings of the reviewers were as follows;

Does the book deviate from WHO guidelines?

Only minor changes were noted.

1. The use of a larger daily dose of folic acid i.e. 2.5mg instead of the recommended 1 mg
2. The option of using 2% magnesium sulphate when CMV or the electrolyte/mineral solution is unavailable
3. The option of using crushed Slow-K tablets when CMV or potassium chloride solution is unavailable
4. Advocating the use of metronidazole.

Would these deviations be detrimental to children's health?

All reviewers agreed that these would not be detrimental. The first three are alternatives to the formulations advised by WHO and relate to the availability of suitable preparations, so that the question is about whether it is preferable to give something or nothing. Their conclusion was that a pragmatic choice to provide a formulation that is available is appropriate. Concerns over whether a larger dose of folic acid interferes with antifolate antimalarial drugs like Fansidar are addressed by the reviewers. There is no firm evidence of an effect but the consensus is that there is ongoing debate and well designed studies are needed to further address the issue of dosage and risk of malaria.
The WHO guidelines state that the use of metronidazole is accepted practice in many units and the reviewers agreed that it is effective in treating small bowel overgrowth (SBO). There is some discrepancy among the reviewers as to the importance attached to SBO in malnutrition.

Does the book provide the information required for health workers to manage severely malnourished children successfully?

All reviewers answered this question in the affirmative. One concluded the book "is an excellent summary of optimal management under prevailing conditions". Another stated "the manner in which the book is set out is helpful, and meets the need for a book more orientated to nurses and healthcare workers than the WHO manual". Athird stated that the book "is far superior to any other options available and provides in clear language an approach which would improve the care of children in general and the care of severely malnourished children in particular".

This book is available at a subsidised low price (£3.15 + postage) only from Teaching-aids At Low cost (TALC), PO Box 49, St Albans, Herts. AL1 5TX, United Kingdom (info@talcuk.org). The book is also available on CD ROM which in addition includes a comprehensive guide for trainers 'Improving the Management of Severe Malnutrition' and the TALC slide set 'Treatment of Severely Malnourished Children'. The combined cost of the book + CD is £4.50 + postage. The book is also available from Macmillan country offices and through local bookshops. For contact details of local offices, please see www.macmillan-africa.com/Contacts.