Table 1. Ancestry of evidence cited in support of the World Health Organization’s recommendations on the inpatient management of children with severe acute malnutrition.
| Recommendation | History |
Evidence base, year published |
||||
|---|---|---|---|---|---|---|
| First released | Last modified | Direct RCT | Direct observational | Indirect | ||
| Micronutrients | ||||||
| 200 000 IU of vitamin A for patients with eye signs of deficiencya | 1981 | – | 1998, 2007, 2012 | – | – | |
| 200 000 IU of vitamin A for patients with measles1 | 2003 | – | 1998, 2007, 2012 | – | – | |
| 200 000 IU of vitamin A for patients not receiving vitamin A via feeds or other supplementsa | 2013 | – | 1998, 2007, 2012 | – | – | |
| 5000 IU of vitamin A per daya | 2013 | – | 1998, 2007, 2012 | – | – | |
| Zinc for patients with diarrhoea unless receiving zinc-fortified feeds | 2013 | – | – | – | – | |
| No difference in zinc and vitamin A dosing based on HIV statusb | 2013 | – | – | – | 2010 | |
| Copper, folic acid, iron, magnesium and potassium to be given daily for at least 2 weeks | 1992 | 1996 | – | – | – | |
| Feeding | ||||||
| Feed immediately on admission, then every 2–3 hours. Transition from F-75 therapeutic milk feed to RUTF when patient stable, with appetite and decreasing oedemac | 2003 | – | – | 1998 | 1989, 1998,a 1998,b 1998,c 2009 | |
| Transition from F-100 therapeutic milk feed to RUTF when weight gain is rapid and patient accepting dietc | 2003 | – | – | 1998 | 1989, 1998,a 1998,b 1998,c 2009 | |
| For patient aged < 6 months, support breastfeeding – or relactate – with supplementary feeds and do not give undiluted F-100d | 1981 | 2013 | 2009 | 2000 | 2009 | |
| No difference in feeding approach based on HIV status | 2013 | – | – | – | – | |
| Can give RUTF in acute or persistent diarrhoea cases | 2013 | – | – | – | 1994, 1995,1997, 2002, 2005 | |
| Fluid management | ||||||
| Give ReSoMal for mild–moderate dehydration in non-cholera cases | 1999 | – | 2003 | 2000 | 1999, 2000, 2001 | |
| Give standard low-osmolarity ORS for mild–moderate dehydration in suspected cases of cholera | 2013 | – | 2009 | – | – | |
| For shock or severe dehydration, give intravenous Ringer’s lactate solution or half-strength Darrow’s solution, each supplemented with 5% dextrosee | 1999 | 2013 | 2010 | – | – | |
| Every 5–10 minutes, monitor patients receiving intravenous fluids to check for overload | 1999 | – | – | – | – | |
| Give blood transfusion, at 10 ml/kg, for shock if no improvement after 1 hour of intravenous therapy, and for severe anaemia | 1999 | – | – | – | – | |
| Do not give blood transfusions > 24 hours post-admission | 2013 | – | – | 2006 | – | |
| ART | ||||||
| Start lifelong ART if patient aged < 24 months9 | 2013 | – | – | – | 2009, 2010 | |
| Start lifelong ART, based on CD4 counts or clinical staging, if patient aged ≥ 24 monthsf | 2013 | – | – | – | 2009, 2010 | |
| Start ART after stabilization of complications | 2013 | – | – | – | 2009, 2011, 2012 | |
| Hypoglycaemia and hypothermia | ||||||
| If patient conscious, give 50 ml bolus of 10% dextrose – by mouth or nasogastric tube – then F-75 every 30 minutes for 2 hours | 1969 or before | 1996 | – | – | – | |
| If patient unconscious, lethargic or convulsing, give 10% dextrose intravenously, at 5 ml/kg, and then 50 ml of 10% dextrose by mouth | 1969 or before | 1996 | – | – | – | |
| Infection | ||||||
| Give empiric ampicillin and gentamycin and then, if no response, chloramphenicol | 1969 or before | 1996 | – | – | – | |
| Patients aged < 6 months should receive same antibiotics as older children | 2013 | – | – | – | – | |
| Give measles vaccine to non-immunized children aged ≥ 6 months | 1996 | – | – | – | – | |
| Discharge from inpatient or outpatient care | ||||||
| Transfer to outpatient care on clinical condition rather than anthropometry | 2013 | – | – | – | – | |
| Move patients aged < 6 months to outpatient care if their daily weight gain exceeds the median growth velocity standard or is > 5 mg/kg/day for 3 days | 2013 | – | – | – | – | |
| Discharge from outpatient care when WHZ is ≥ –2 or MUAC is ≥ 125 mm | 2013 | – | – | – | – | |
| The anthropometric measure that qualified a child for admission should be used to monitor the child’s outpatient progressg | 2013 | – | – | – | – | |
| If oedema was the only observed complication, normal anthropometrics can be used to monitor outpatient progress | 2013 | – | – | – | – | |
| Discharge from outpatient care should not be based on percentage weight gain | 2013 | – | – | – | 2004, 2012 | |
| Emotional support | ||||||
| Provide patient with emotional and sensory support | 1969 or before | – | – | – | – | |
ART: antiretroviral therapy; HIV: human immunodeficiency virus; IU: international unit; MUAC: mid-upper arm circumference; ORS: oral rehydration solution; RCT: randomized controlled trial; RUTF: ready-to-use therapeutic foods; WHZ: weight-for-height z-score.
a All vitamin A recommendations are supported by the same randomized trials.
b Citation for vitamin A and zinc dosing in HIV infection is a Cochrane review of five vitamin A and two zinc randomized trials indirectly related to the management of complicated severe acute malnutrition.
c The F-75 and F-100 therapeutic milk feeding recommendations are supported by the same studies.
d If maternal breastfeeding is not possible, wet nursing should be encouraged.
e If neither solution available, use 0.45% saline with 5% dextrose.
f Based on indirect evidence discussed in two sets of World Health Organization guidelines.21,22
g That is, if the diagnosis was made on low MUAC, use MUAC – and not WHZ – to quantify recovery.