Review of WHO guidelines for the inpatient management of severe acute malnutrition

Summary of research¹

Location: Global

What we know: Optimising SAM management is an important strategy for reducing malnutrition-related mortality.

What this article adds: A recent review examined the evolution and evidence supporting existing guidelines on the inpatient management of SAM. Gaps persist and extend across the entire spectrum of guidance on the management of complicated SAM. Absence of relevant published data has forced a reliance on expert opinion (the basis of half the recommendations). Supporting evidence is often of very low quality and not specific to the recommended treatment. Recommendations based on expert opinion (clinical experience and basic science) or weak evidence are not necessarily incorrect but clinical context has changed; changes include an emerging younger infant caseload and outpatient treatment changing inpatient profile. There are significant gaps in evidence-based clinical guidance, which include HIV case management, management post-discharge mortality, antimicrobial therapy and fluid management. WHO guidance has failed to keep pace with developments and experience; more trials are needed to strengthen the evidence base.

Each year, severe acute malnutrition (SAM) is the direct cause of an estimated 540,000 child deaths and contributes to many other child deaths (Black et al, 2013). SAM without medical complications can be effectively managed in the community; however complicated cases still warrant inpatient management. Case fatality rates should be less than 10% if adhering to World Health Organization (WHO) inpatient management guidelines. However, despite reported compliance, mortality rates of 10 to 40% are documented among hospitalised SAM children in sub-Saharan Africa (Kerac et al, 2014; Fergusson and Tomkins, 2009). Optimising SAM management is an important strategy for reducing malnutrition-related mortality.

WHO’s first guidelines on the management of malnutrition (1981) were replaced in 1999 by guidelines on the management of SAM. Both summarised decades of clinical experience and described the achievement of low malnutrition-related case fatality rates in specific settings. Further guideline revisions were made in 2003 and 2013. Relevant joint statements from WHO and other United Nations (UN) agencies were issued in 2007 and 2009. The combination of these documents constitutes the current WHO SAM guidelines. A recent review identified evidence gaps within the guidelines which, if filled, may help reduce mortality further.

The evolution of each recommendation’s development was traced using Google scholar and the WHO website, including documents predating current guidance, and any modifications and references cited in support of the recommendation noted. Each recommendation was evaluated using the GRADE system. To determine the aims and extent of any recently completed, ongoing or pending trials relevant to the management of complicated SAM, the authors searched the WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015.

Eight documents containing 33 current recommendations met the inclusion criteria.

• Expert opinion, in the absence of published evidence, was the basis for 16 (48.5%) of the recommendations. Three (9.1%) and six (18.2%) of the recommendations were drawn from direct observational or indirect evidence (the study population was not complicated SAM children), respectively. The remaining recommendations (24.2%) were each supported by at least one direct randomised trial.
• Twenty-three (69.7%) recommendations had been added or revised since the original 1999 guideline. Six (26.1%) were supported by a directly relevant randomised trial. Three (13.0%) and six (26.1%) were supported by at least one direct observational or indirect study, respectively. The remaining eight (34.8%) recommendations had no supporting citations.
• The 1999 guidelines presented a ten-step management protocol. Five (15.2%) of the 33 current recommendations are identical to or are slight modifications of the recommendations first proposed in the 1996 article. Seven (21.2%) of the current recommendations originated before 1996; five were slightly revised.
• Trials registries included 20 studies related to the topic, 15 of which had been completed and four of which had been published. Two trials reported statistically significant results: one demonstrated that community follow-up increased linear growth and clinical attendance and the other that long-chain n-3 polyunsaturated fatty acid in erythrocytes increased among children with SAM who were given ready-to-use therapeutic foods (RUTF) enriched with polyunsaturated fatty acid. Nine trials were of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented.

Results show that gaps persist and extend across the entire spectrum of guidance on the management of complicated SAM. The absence of relevant published data has forced a reliance on expert opinion. Supporting evidence was often of very low quality and was not specific to the recommended treatment. Guideline reforms have been driven by an overwhelming clinical need rather than by compelling evidence.

Recommendations supported by weak evidence or expert opinion are not necessarily incorrect; many are grounded in basic science research and careful clinical observations. However, the population of paediatric inpatients with SAM has dramatically changed in the last ten to 20 years: human immunodeficiency virus (HIV) has emerged as an important contributing problem; younger infants now represent an increasing proportion of malnourished children; and outpatient care for uncomplicated cases has eclipsed hospital management. Data from previous eras may therefore not be generalisable to the modern child with complicated SAM.

In some areas the absence of clinical data is particularly concerning, such as in the management SAM in HIV-infected children and infants. Post-discharge mortality in SAM cases is high but poorly understood. Empiric antibiotics have been recommended since at least 1969 and the currently endorsed regimen has remained unchanged since standardised in 1996. Antimicrobial therapy and fluid management are both conspicuous knowledge gaps.

In conclusion, WHO’s guidelines on the inpatient management of SAM have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with SAM is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.

Footnotes

¹Tickella KD and Dennob DM. (2016). Inpatient management of children with severe acute malnutrition: A review of WHO guidelines. Bull World Health Organ 2016;94:642–651. doi10.2471/BLT.15.162867

²The Grading of Recommendations Assessment, Development and Evaluation. www.gradeworkinggroup.org/

References

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al. Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013 Aug 3;382(9890):427–51. doi: http://dx.doi.org/10.1016/S0140-6736(13)60937-X PMID: 23746772 2.

Kerac M, Bunn J, Chagaluka G, Bahwere P, Tomkins A, Collins S, et al. Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): A prospective cohort study. PLoS ONE. 2014;9(6):e96030.

Fergusson P and Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg. 2009 Jun;103(6):541–8.