DEATHS AMONG CHILDREN WITH THIRD DEGREE MALNUTRITION; INFLUENCE OF THE CLINICAL TYPE OF THE CONDITION

Management of severe malnutrition and diarrhea

Children with severe malnutrition and diarrhea have high mortality rates that have been attributed to faulty case-management. Health workers are often unaware of the unique treatment requirements of severely malnourished children resulting in improper case-management. Moreover, the lack of prescriptive guidelines promotes the exercise of discretion in case-management that is often detrimental. Appropriate feeding from the start of treatment, routine micronutrient supplementation, broad-spectrum antibiotic therapy, less use of intravenous fluids for rehydration, and careful management of complications are factors that can reduce death, morbidity and cost of treating children with severe malnutrition and acute illnesses including diarrhea. In this paper is discussed a standardized protocol based upon the above mentioned factors for the management of severely malnourished children with acute illnesses including diarrhea. Implementation of the protocol resulted in a 47% reduction in mortality in these children.

Diarrhoea in kwashiorkor

Diarrhoea was a common problem in the kwashiorkor seen in Kampala, contributing to the mortality and delay in recovery. Enteric infection was found in only a few children (8%), but when present it caused particularly severe diarrhoea and was frequently complicated by septicaemia.Sugar intolerance often occurred to lactose and other sugars, both monosaccharide and disaccharide. The children were most commonly intolerant of lactose, and some of these may have had a hereditary lactase deficiency.Antibiotics are rarely indicated for the treatment of diarrhoea in kwashiorkor in Kampala. If reducing substances are found in the stool of a child on a milk diet, a diet based on sucrose is substituted, and if intolerance persists a fructose diet is given. A few children are intolerant of all sugars, including fructose, and for these the prognosis is grave.

The short-term prognosis of severe primary infantile malnutrition

1. Among a series of 343 children with severe primary malnutrition there were 248 for whom, on admission, there were reliable records of age, weight, height, liver size, severity of oedema, skin lesions and angular stomatitis, and concentration of total serum protein, haemoglobin and sodium. For eighty-four of these children the serum bilirubin concentration was also known.

2. The correlations of these characteristics of the children on admission, with mortality, and with the rate of recovery were investigated.

3. Age, weight, oedema and haemoglobin concentration were not significantly related to mortality or to rate of recovery. A multiple regression analysis showed that an increased serum bilirubin concentration and a decreased serum sodium concentration indicated a bad prognosis, and these two factors contributed almost the whole of the multiple correlation coefficient of 0.63 with respect to mortality and 0.59 with respect to speed of rccovery.

4. We conclude that in our series of children death was more closely associated with liver failure or overhydration than with protein depletion, and suggest that the administration of ton much protein or water to an acutely ill malnourished child may precipitate death.

5. This analysis shows that the mortality observed in our series cannot be adequately explained by any combination of the characteristics considered above; there must, therefore, be other factors of importance for which we do not have suitable measurements.