Children with severe malnutrition present as complicated, and often frustrating, cases to health workers in developing countries. Much has been learned about the pathophysiology of malnutrition and the requirements for successful rehabilitation, but case-fatality rates remain high. A survey of treatment centres worldwide showed outmoded and conflicting teaching manuals, potentially fatal practices, and inappropriate diets (1).
Reductions in mortality and improvements in weight gain have been achieved on implementation of a standardized treatment protocol (2-5). Avoidance of intravenous rehydration, routine use of broad-spectrum antibiotics, cautious refeeding with low-sodium diets, and other changes in case management are credited with improved outcomes. It has been suggested that the mere presence of a standardized protocol increases discipline and attention to detail and results in fewer errors by health workers (6). As long as severe malnutrition is prevalent, efforts to improve its treatment and outcome remain a priority. Implementation of a standard in-hospital treatment protocol is an essential first step (6-7).
WHO published guidelines for the inpatient management of severe malnutrition in children (8, 9). The difficulties that arise from implementation, as well as the potential benefits, needed to be documented through formal evaluation. A randomized trial of the guidelines was not appropriate, because withholding the potential benefits from the control group would be difficult to justify and because blinding was not possible. A qualitative study in African hospitals was conducted to document the process of implementation and the feasibility and sustainability of each component of the guidelines.
Selection of hospitals
We searched the literature for articles on severe malnutrition in developing countries published during the past five years. The authors of identified articles and other recommended experts in malnutrition management were asked to suggest hospitals, including those they were affiliated with, in which this study could take place.
Health workers of the suggested hospitals were invited to participate in the study and to submit background information about admission patterns, the frequency of malnutrition, and current practice. Hospitals were chosen for a preliminary visit on the basis of this information. The basic requirements for selection included: a system of recording admissions of and outcomes for children; documentation of a case-fatality rate >20% for severely malnourished children <5 years of age over a period of at least one year; administrative support for food supply, essential drugs, and staff allocation; and interest and commitment of the health care staff to improve the management and outcome of severe malnutrition.
Paediatricians with experience in improving care practices for severe malnutrition in African hospitals (J.L.D., A.P.) carried out a preliminary visit to hospitals in which implementation of the guidelines was considered feasible. The local situation was assessed on the basis of the above criteria, and a final selection of hospitals was made.
Implementation of the guidelines
The guidelines were implemented by a paediatrician (J.L.D.) who visited the selected hospitals three times during a one-year period. A participatory approach was taken to give the hospitals' staff a feeling of ownership and responsibility in the process and outcome (10).
During the initial visit, which lasted two weeks, admission and death records were reviewed and current practices in the management of severe malnutrition were evaluated. Possible reasons for the high case-fatality rate for severely malnourished children, the guidelines, and how the guidelines could be adapted to the local setting were discussed with individuals or small groups. The visiting paediatrician showed how height and weight-for-height should be measured, weights charted, dally weight gain computed, and drinking cups standardized. …