Malnutrition is a major health problem in low- and middle-income countries, particularly in children less than 5 years of age. Recent estimates suggest that 3.5% of children worldwide, or nearly 20 million, are severely malnourished. Severe acute malnutrition (SAM), characterized by a weight of less than 70% of the median weight for height and/or by visible severe wasting and/or by the presence of nutritional oedema, is a life-threatening condition. In the absence of appropriate treatment, case-fatality rates in hospitalized children (inpatient) range from 30% to 50%.
In many poor countries, the majority of children who have severe acute malnutrition are never brought to health facilities. In this circumstance, only an approach with a strong community component can provide them with the appropriate care. Evidence shows that about 80 % of children with severe acute malnutrition who have been identified through active case finding, or through sensitizing and mobilizing communities to access decentralized services themselves, can be treated at home (outpatient). The other 20 % needs to be transferred for inpatient treatment. Current estimates suggest that about 1 million children die every year from severe acute malnutrition.
In the early 2000s, malnutrition got a squishy new peanut-flavored enemy. Kids fed a calorie-rich paste of peanuts, sugar, milk, and the whole alphabet of vitamins and minerals recovered at rates nearly twice that for previous treatments (fortified milk formulas). The ready-to-use therapeutic food (RUTF) has some advantages: it is a ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination. It can be stored for three to four months without refrigeration, even at tropical temperatures.
However, some 15% of the severely malnourished children still didn’t recover on RUTF and died. A new study in Malawi recently published in the New England Journal of Medicine (NEJM) reports on the potential of using antibiotics as part of the management of severe acute malnutrition to diminish this “non response” to nutritional treatment.
To summarize the study and its main results: the malnourished children enrolled in the study were treated at home and received antibiotics or placebo during the first 7 days plus RUTF for a period of one month. Overall, 88.3% of the children enrolled in the study (RUTF ± antibiotics) recovered from severe acute malnutrition. Among them, the rate of weight gain was significantly increased among those who received antibiotics. Furthermore, the overall mortality rate was 5.4% but antibiotics plus RUTF cut mortality by 36 to 44 % compared to RUTF alone. This means that for every 100 children treated, two to three lives could be saved; treating a million could save more than 20,000. One of the potential explanations of the observed improvement in recovery and mortality rates is the fact that antibiotics decreased the potential development of sepsis during nutritional treatment.
Interestingly, the authors also looked at the baseline characteristics of the children enrolled in the study and how these parameters can affect both survival and nutritional recovery when treated with antibiotics and RUTF.
This aspect of the study’s analysis was not discussed in the two articles published in Mother Jones and the New York Times that I have read. In fact, this kind of analysis helps to understand the residual 4.5 % mortality rate and the potential “non response” to antibiotics and RUTF for a specific population. It highlights also the importance to perform a good clinical diagnostic and a socio-economic analysis to better understand the family situation and identify the children at risk before enrollment. Finally, it shows the necessity to continue to invest in prevention strategies.
For example, the study showed that the children who recovered were significantly older and were more likely to have their father alive and still at home. In fact, the authors found that younger age, marasmic kwashiorkor*, greater stunting, poor appetite, HIV exposure or infection, and a cough before enrollment were associated with an increase risk of treatment failure, including an increased risk of death.
Investing in prevention strategies is critical. Exclusive breast feeding during the first 6 months, and continuing breast feeding and promoting improved complementary feeding practices for all children aged 6–24 months — with a focus on ensuring access to age-appropriate complementary foods (where possible using locally available foods) can prevent malnutrition at a younger age. This strategy can also ensure healthy growth and development, minimizing the incidence of stunting. In Malawi, the rate of exclusive breastfeeding is quite high (71% in 2010 vs 44% in 2000) when compared to other Sub-Saharan African countries but there is still room for improvement.
Furthermore, HIV can be a key limitation of the benefit of antibiotics and RUTF in the treatment of severe acute malnutrition. In the context of Malawi, an estimated 11% of the adult population is infected with HIV and the prevention of mother-to-child transmission of HIV is still low (~30% in 2010). Indeed, only 40% of eligible HIV+ pregnant women received ART in 2010. In the study published in NEJM, only 31.6% of the children were tested for HIV, and those who were known to be HIV seropositive, especially if not receiving ART, had the higher risks of treatment failure and death.
In fact, the World Health Organization (WHO) recommends the use of ARTs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period. Furthermore, WHO recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARTs during that period. This approach reduces the risk of HIV transmission and improves the infant’s chance of survival by boosting the immune system, reducing energy loss and improving child’s appetite to food. In this condition, the HIV-positive children who receive ART can respond appropriately to RUFT in the treatment of severe acute malnutrition. Moreover, the main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and Preventing Mother-to-Child Transmission (PMTCT) of HIV services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services. More works need to be done in this direction…
Finally, the study published in NEJM concluded that further studies are needed to evaluate long-term outcomes of routine antibiotic use (like drug resistance) in children with uncomplicated severe acute malnutrition and to determine whether a specific high-risk target population can be better defined. We are waiting for more results and new recommendations…
* A malnutrition disease, primarily of children, resulting from the deficiency of both calories and protein. The condition is characterized by severe tissue wasting, dehydration, loss of subcutaneous fat, lethargy, and growth retardation.