Submitted to: Lancet
Publication Type: Review Article
Publication Acceptance Date: 4/1/2008
Publication Date: 4/12/2008
Citation: Heikens, G.T., Bunn, J., Amadi, B., Manary, M., Chhagan, M., Berkley, J.A., Rollins, N., Kelly, P., Adamczick, C., Maitland, K., Tomkins, A. 2008. Case management of HIV-infected severely malnourished children: Challenges in the area of highest prevalence. Lancet. 371(9620):1305-1307. Interpretive Summary:
Technical Abstract: Malnutrition is an important contributing factor to 5.6 million of the 10 million child deaths a year, with severe malnutrition the cause of more than 1.5 million of these deaths. The Lancet Child Survival Series presented the clinical context and successful interventions for the most common causes of child deaths worldwide, but the case management of severely malnourished children was not addressed. As global efforts to achieve Millennium Development Goals 4 and 6 gather pace, and antiretroviral therapy (ART) becomes increasingly available, we have to respond to the additional challenge of severe malnutrition in the context of HIV infection. Working in child health services in sub-Saharan Africa, we are seeing greater numbers of critically and chronically ill, severely malnourished children than before--higher than the numbers suggested recently. In the ideal situation, use of WHO therapeutic guidelines for management of severe malnutrition and a continuum of care for malnourished children through community therapeutic care programs would successfully improve survival in children without HIV infection. An alarming consequence of the HIV epidemic is an increase in the need by severely malnourished, seriously ill children for facility-based treatment. Ready-to-use therapeutic foods that facilitate effective home-based therapy have resulted in recovery rates for uncomplicated severe malnutrition of more than 90%, with reported case-fatality rates of less than 5%; however, in sub-Saharan Africa mortality is three times higher in HIV-infected children with severe malnutrition than in non-infected children. The HIV pandemic in sub-Saharan Africa has substantially altered the epidemiology, clinical presentation, pathophysiology, case management, and survival of severely malnourished children. Case-fatality rates range from 20% to 50%, despite the use of WHO guidelines. Furthermore, severe erosion of health systems means that current guidelines are difficult to apply. New therapeutic guidelines, based on evidence from the region of highest HIV prevalence, are urgently needed.