- Email: [email protected]
Improving quality of care for severe malnutrition
CORRESPONDENCE
potential Hawthorne effect of the research visits, and the small numbers in this study are methodological weaknesses, but the findings do confirm the beneficial effect of empirical antibiotics, potassium supplementation, and appropriate feeding regimens on mortality. The 22% of deaths from dehydration, 70% of which were more than 4 days after admission, is unusual and suggest osmotic diarrhoea from lactose intolerance due to the underlying enteropathy. Dare one suggest that lactose-free low osmolality milk should be made available in hospitals selectively for such cases? It is a pity that the lack of good evidence in severe malnutrition has left the way open to acrimony and dogmatic opinions. Any discussion of the management of severe malnutrition would be incomplete without mentioning the important recent advance of ready-touse food which is high in energy and micronutrients and does not support bacterial growth even unrefrigerated. Such food facilitates much earlier hospital discharge, outpatient management with therapeutic feeding, and prevention programmes against severe malnutrition. Since changes in child survival are strongly associated with changes in malnutrition in developing countries,5 this is a more cost-effective approach than hospital feeding. In conclusion, rather than blaming ignorant doctors and lazy nurses for killing malnourished children in hospital, surely a more appropriate conclusion is that there has been a systemic failure in South Africa to address both the low priority accorded to childhood malnutrition (and HIV infection) and the gross income inequity which is the root of the problem. This study illustrates poignantly that the health system, and not just health staff, ought to be doing better than this. David Brewster NT Clinical School (Flinders University), PO Box 41326, Casuarina, Northern Territory 0811, Australia (e-mail: [email protected]) 1
2
3
4
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. Schofield C, Ashworth A. Why have mortality rates for severe malnutrition remained so high? Bull World Health Organ 1996; 74: 223–29. Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at 7 nutritional rehabilitation centres in Malawi. Eur J Clin Nutr 1997; 51: 139–47. Manary M, Brewster DR. Intensive nursing
5
care of kwashiorkor in Malawi. Acta Paediatr 2000; 89: 1–5. Pelletier DL, Frongillo EA. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr 2003; 133: 107–19.
Authors’ reply Sir—David Brewster misrepresents us. Our article did not attach “blame” to doctors and nurses, but highlighted inadequacies in the health system that led to errors that should be remedied. We agree that the underlying problem lies with the health system. This is the major thrust of our paper. We identify specific weaknesses and stress that doctors and nurses cannot be expected to manage malnutrition appropriately if they are untrained. We have used our findings to advocate for change in social welfare and health policy through newspaper articles, television documentaries, and presentations to parliamentary committees. All children with severe malnutrition now have entitlement to the Child Welfare Grant and there are orientation workshops for new doctors in the province as well as monitoring of inpatient care by a recently established quality assurance team. Brewster suggests that severity is the main determinant of high case-fatality rates. Substantial evidence suggests that poor case management is more important. Where WHO guidelines have been fully implemented, deaths have fallen concurrently and strikingly,1 including in Malawi, where, even with incomplete compliance, case-fatality rates fell from 55% to 16%.2 In Zimbabwe and South Africa, where we were doctors-in-charge at central and district hospitals, appropriate care reduced case-fatality rates to around 5%.3 Audit and feedback were beneficial.4 In Eastern Cape, at Holy Cross and St Patrick’s Hospitals (firstlevel referral) with case-fatality rates of 45% and 30%, respectively, rates fell to 14% and 13% coincident with improved care. The evidence is also in our article. When key aspects of care were omitted, case fatality immediately doubled while severity remained unchanged. A strength of our study is that we have comprehensive measures of the quality of care and can relate changes in treatment with patient outcome. In Brewster’s study, there were shortages of antibiotics, potassium, and milk powder, and five centres had no doctor.5 In such conditions high case fatality is to be expected. In our setting, basic hospital supplies were good so it is not surprising that only
THE LANCET • Vol 363 • June 19, 2004 • www.thelancet.com
one death was attributed to “systemsrelated deficiencies” (defined as unavailability of essential items or lack of referral opportunities). We accept that deaths can occur in appropriately treated cases and we clearly state that such deaths were classified as “unavoidable”. Early discharge can be hazardous and requires an adequate health-care infrastructure. This is lacking in Eastern Cape. Those of us who have worked in Southern Africa for most of our careers and are familiar with the situation are extremely doubtful about the sustainability of ready-to-use food when supply systems are so fragile. In Zambia, even maintaining the supply chain for vaccines is difficult at present. The gross national income for South Africa that Brewster cites disguises huge inequalities that we have consistently advocated against. The continuing incidence of malnutrition in South Africa is unacceptable, although not unexpected only 10 years after the end of the apartheid era. Its continuing incidence among Indigenous Australians, however, is a disgrace and we hope that Brewster is—like ourselves—campaigning to address the root causes. *Ann Ashworth, David Sanders, Mickey Chopra, David McCoy, Claire Schofield *Public Health Nutrition Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (AA, CS); School of Public Health, University of the Western Cape, Bellville, South Africa (DS, MC); and Health Systems Trust, Cape Town, South Africa (DM) (e-mail: [email protected]) 1
2
3
4 5
Ahmed T, Ali M, Ullah MM, et al. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet 1999; 353: 1919–22. Morrice JS, Molyneux EM. Reduced mortality from severe protein-energy malnutrition following introduction of WHO protocol in children in Malawi. Arch Dis Child 2003; 88 (suppl 1): A28. Wilkinson D, Scrace M, Boyd N. Reduction in in-hospital mortality of children with malnutrition. J Trop Pediatr 1996; 42: 114–15. Chopra M, Wilkinson D. Treatment of malnutrition. Lancet 1995; 345: 788–89. Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at seven nutrition rehabilitation centres in Malawi. Eur J Clin Nutr 1997; 51: 139–47.
Sir—A striking feature of the report by Ann Ashworth and colleagues (Apr 3, p 1110),1 on the management of severe malnutrition, was the difficulty in reliable identification of malnourished children. Of those identified by doctors and nurses with weight-for-age and clinical signs, only about half met
2089
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
WHO criteria for severe malnutrition (weight-for-length Z score [WLZ] <–3, oedema, or both). The authors noted that implementing triage for new patients was difficult and more research into sensitivity and specificity of clinical signs in the identification of severe malnutrition is needed. We assessed the ability of nurses to detect severe malnutrition in 352 children presenting at a tertiary hospital in The Gambia, west Africa.2 We did the assessment immediately after comprehensive training in the WHO integrated management of childhood illness nutrition algorithm.3 Nurses correctly identified, by clinical signs, only 19 of 34 children with WLZ less than –3 and four of 18 with bipedal oedema diagnosed by a member of the research team. 13 children were incorrectly identified as severely malnourished. Overall, the sensitivity, specificity, and positive predictive value (PPV) of the recognition of severe wasting and bipedal oedema, or both, were 50%, 96%, and 66%, respectively. The detection of very low weight-for-age with a growth chart was also poor (sensitivity 62%, specificity 99%, PPV 89%). Other clinical signs, such as angular chelitis and depigmented hair, were not helpful in our study since they were present in few cases. Ashworth and colleagues postulate that severe malnutrition might not be seen typically in tertiary training hospitals. This theory goes against our experience in The Gambia. In our study, severe wasting was present in 9·7% and bipedal oedema in 5·1% of children attending the hospital. A further study was done of all children admitted between Dec 1, 1999, and Nov 30, 2000, to the ward of the Medical Research Council Laboratories, Fajara, which receives many referred cases. Of 1264 children younger than 5 years, 166 (13·1%) were severely wasted (WLZ <–3) with the highest frequency occurring in 1-year-old children (96/347; 27·7%). Case fatality was 3·49 times (95% CI 1·59–7·61; data not published) greater in severely wasted than non-wasted children. Despite being common in young children attending health facilities in economically poor countries, severe malnutrition is often not recognised even by nurses recently trained in WHO guidelines. More reliable methods for the identification of severe malnutrition are needed. Mid-upperarm circumference is easy to do, predicts mortality in community studies,4,5 and should be assessed in the hospital setting.
2090
*Stephen Allen, Clare Hamer *Clinical School, University of Wales Swansea, Swansea SA2 8PP, UK (SA); and Bristol University Education Centre, Upper Maudlin Street, Bristol UK (CH). (e-mail: [email protected]) 1
2
3
4
5
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. Hamer C, Kvatum K, Jeffries D, Allen S. Detection of severe protein-energy malnutrition by nurses in The Gambia. Arch Dis Child 2003; 89: 181–84. World Health Organization. WHO severe malnutrition manual: management of childhood illness—assess and classify the sick child age 2 months up to 5 years. WHO Division of Diarrhoeal and Acute Respiratory Disease Control and UNICEF; United Republic of Tanzania, 1998: 93–105. Vella V, Tomkins A, Ndiku J, et al. Anthropometry as a predictor for mortality among Ugandan children, allowing for socio-economic variables. Eur J Clin Nutr 1994; 48: 189–97. Briend A, Wojtyniak B, Rowland MG. Arm circumference and other factors in children at high risk of death in rural Bangladesh. Lancet 1987; 330: 725–28.
Sir—Ann Ashworth and colleagues1 emphasise the need to improve hospital care for severely malnourished children in Africa. We assessed treatment practices and case fatality at the Hospital Patiño, Cochabamba, Bolivia, and showed that needs are similar in Latin America. Hospital Patiño is a well-resourced second-level centre supported by a private foundation. It is one of two children’s hospitals in the city and serves mainly urban families and recent rural migrants. Of 2493 children admitted in 2000 and 2001, 92 (3·6 %) were diagnosed with severe malnutrition and almost all (91%) had oedema. The median age of these children was 15·2 months. At admission, 48 of the 92 patients were dehydrated, and in 16 the dehydration was severe (three with shock). Because of the difficulty in diagnosis of dehydration in severe malnutrition and estimation of its severity, the WHO guidelines2 state that rehydration fluid should be given intravenously only to children in shock and duration of treatment should not exceed 2 h. These guidelines were not followed and 42 children were given intravenous fluid; mean duration was 13 h and there was no monitoring for signs of overhydration. Of the 16 children with severe dehydration, seven died. As in South Africa, there was failure to prescribe appropriate antibiotics. Sepsis was frequent (26/92) and of the ten patients who died from sepsis, five had not been prescribed antibiotics with
gram-negative cover, and eight of the 92 children were not prescribed any antibiotics. Management of hypothermia, hypoglycaemia, anaemia, and feeding did not follow WHO guidelines. Children were fed a commercial formula, median 52 kcal/kg (range 20–99) and 1·5 g protein/kg (range 0·5–3·1). When the child’s appetite improved, feedings were given ad-libitum. The case-fatality rate among all inpatients was 5·8%. By contrast, the case-fatality rate among malnourished patients was 17·4% (odds ratio 3·74, 95% CI 2·0–6·79; p <0·0001). Half the deaths occurred within 48 h of admission. Four risk factors for death were identified: severe dehydration on admission (5·79, 1·47–23·3; p=0·006), sepsis (8·54; 1·00–84·2; p=0·0035), hyponatraemia (3·40, 1·00–12·21; p=0·04), and weight-for-height on admission (4·81, 1·13–23·5; p=0·028). The situation at Hospital Patiño differs from the South African hospitals in that the hospital is well-equipped, not overcrowded, and has trained paediatricians. Nevertheless, the quality of care was not acceptable; staff did not know the basic principles of managing children with severe malnutrition and did not see a need to have a standardised protocol, and this led to unnecessary deaths. Results from our assessment support the need for dissemination of medical knowledge, improvement of professional training that includes the WHO guidelines, development of capacities to work in teams and networks, and teaching the value of critical assessment of one’s performance. Efforts are being made to improve the quality of care at Hospital Patiño. Wider efforts are also being made, and in February, 2004, the first Latin American course for the management of severe malnutrition was held at Hospital del Niño, La Paz, Bolivia, with support from the Bolivian Ministry of Health, the Bolivian Society of Paediatrics, and the Pan American Health Organization. *Gerardo Weisstaub, Richard Soria, Magdalena Araya *Institute of Nutrition and Food Technology (INTA), University of Chile, Casilla 138-11. Santiago, Chile (GW, MA); and Pediatrics Center, “Albina R de Patiño”, Cochabamba, Bolivia (RS) (e-mail: [email protected]) 1
2
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO, 1999.
THE LANCET • Vol 363 • June 19, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
potential Hawthorne effect of the research visits, and the small numbers in this study are methodological weaknesses, but the findings do confirm the beneficial effect of empirical antibiotics, potassium supplementation, and appropriate feeding regimens on mortality. The 22% of deaths from dehydration, 70% of which were more than 4 days after admission, is unusual and suggest osmotic diarrhoea from lactose intolerance due to the underlying enteropathy. Dare one suggest that lactose-free low osmolality milk should be made available in hospitals selectively for such cases? It is a pity that the lack of good evidence in severe malnutrition has left the way open to acrimony and dogmatic opinions. Any discussion of the management of severe malnutrition would be incomplete without mentioning the important recent advance of ready-touse food which is high in energy and micronutrients and does not support bacterial growth even unrefrigerated. Such food facilitates much earlier hospital discharge, outpatient management with therapeutic feeding, and prevention programmes against severe malnutrition. Since changes in child survival are strongly associated with changes in malnutrition in developing countries,5 this is a more cost-effective approach than hospital feeding. In conclusion, rather than blaming ignorant doctors and lazy nurses for killing malnourished children in hospital, surely a more appropriate conclusion is that there has been a systemic failure in South Africa to address both the low priority accorded to childhood malnutrition (and HIV infection) and the gross income inequity which is the root of the problem. This study illustrates poignantly that the health system, and not just health staff, ought to be doing better than this. David Brewster NT Clinical School (Flinders University), PO Box 41326, Casuarina, Northern Territory 0811, Australia (e-mail: [email protected]) 1
2
3
4
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. Schofield C, Ashworth A. Why have mortality rates for severe malnutrition remained so high? Bull World Health Organ 1996; 74: 223–29. Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at 7 nutritional rehabilitation centres in Malawi. Eur J Clin Nutr 1997; 51: 139–47. Manary M, Brewster DR. Intensive nursing
5
care of kwashiorkor in Malawi. Acta Paediatr 2000; 89: 1–5. Pelletier DL, Frongillo EA. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr 2003; 133: 107–19.
Authors’ reply Sir—David Brewster misrepresents us. Our article did not attach “blame” to doctors and nurses, but highlighted inadequacies in the health system that led to errors that should be remedied. We agree that the underlying problem lies with the health system. This is the major thrust of our paper. We identify specific weaknesses and stress that doctors and nurses cannot be expected to manage malnutrition appropriately if they are untrained. We have used our findings to advocate for change in social welfare and health policy through newspaper articles, television documentaries, and presentations to parliamentary committees. All children with severe malnutrition now have entitlement to the Child Welfare Grant and there are orientation workshops for new doctors in the province as well as monitoring of inpatient care by a recently established quality assurance team. Brewster suggests that severity is the main determinant of high case-fatality rates. Substantial evidence suggests that poor case management is more important. Where WHO guidelines have been fully implemented, deaths have fallen concurrently and strikingly,1 including in Malawi, where, even with incomplete compliance, case-fatality rates fell from 55% to 16%.2 In Zimbabwe and South Africa, where we were doctors-in-charge at central and district hospitals, appropriate care reduced case-fatality rates to around 5%.3 Audit and feedback were beneficial.4 In Eastern Cape, at Holy Cross and St Patrick’s Hospitals (firstlevel referral) with case-fatality rates of 45% and 30%, respectively, rates fell to 14% and 13% coincident with improved care. The evidence is also in our article. When key aspects of care were omitted, case fatality immediately doubled while severity remained unchanged. A strength of our study is that we have comprehensive measures of the quality of care and can relate changes in treatment with patient outcome. In Brewster’s study, there were shortages of antibiotics, potassium, and milk powder, and five centres had no doctor.5 In such conditions high case fatality is to be expected. In our setting, basic hospital supplies were good so it is not surprising that only
THE LANCET • Vol 363 • June 19, 2004 • www.thelancet.com
one death was attributed to “systemsrelated deficiencies” (defined as unavailability of essential items or lack of referral opportunities). We accept that deaths can occur in appropriately treated cases and we clearly state that such deaths were classified as “unavoidable”. Early discharge can be hazardous and requires an adequate health-care infrastructure. This is lacking in Eastern Cape. Those of us who have worked in Southern Africa for most of our careers and are familiar with the situation are extremely doubtful about the sustainability of ready-to-use food when supply systems are so fragile. In Zambia, even maintaining the supply chain for vaccines is difficult at present. The gross national income for South Africa that Brewster cites disguises huge inequalities that we have consistently advocated against. The continuing incidence of malnutrition in South Africa is unacceptable, although not unexpected only 10 years after the end of the apartheid era. Its continuing incidence among Indigenous Australians, however, is a disgrace and we hope that Brewster is—like ourselves—campaigning to address the root causes. *Ann Ashworth, David Sanders, Mickey Chopra, David McCoy, Claire Schofield *Public Health Nutrition Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (AA, CS); School of Public Health, University of the Western Cape, Bellville, South Africa (DS, MC); and Health Systems Trust, Cape Town, South Africa (DM) (e-mail: [email protected]) 1
2
3
4 5
Ahmed T, Ali M, Ullah MM, et al. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet 1999; 353: 1919–22. Morrice JS, Molyneux EM. Reduced mortality from severe protein-energy malnutrition following introduction of WHO protocol in children in Malawi. Arch Dis Child 2003; 88 (suppl 1): A28. Wilkinson D, Scrace M, Boyd N. Reduction in in-hospital mortality of children with malnutrition. J Trop Pediatr 1996; 42: 114–15. Chopra M, Wilkinson D. Treatment of malnutrition. Lancet 1995; 345: 788–89. Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at seven nutrition rehabilitation centres in Malawi. Eur J Clin Nutr 1997; 51: 139–47.
Sir—A striking feature of the report by Ann Ashworth and colleagues (Apr 3, p 1110),1 on the management of severe malnutrition, was the difficulty in reliable identification of malnourished children. Of those identified by doctors and nurses with weight-for-age and clinical signs, only about half met
2089
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
WHO criteria for severe malnutrition (weight-for-length Z score [WLZ] <–3, oedema, or both). The authors noted that implementing triage for new patients was difficult and more research into sensitivity and specificity of clinical signs in the identification of severe malnutrition is needed. We assessed the ability of nurses to detect severe malnutrition in 352 children presenting at a tertiary hospital in The Gambia, west Africa.2 We did the assessment immediately after comprehensive training in the WHO integrated management of childhood illness nutrition algorithm.3 Nurses correctly identified, by clinical signs, only 19 of 34 children with WLZ less than –3 and four of 18 with bipedal oedema diagnosed by a member of the research team. 13 children were incorrectly identified as severely malnourished. Overall, the sensitivity, specificity, and positive predictive value (PPV) of the recognition of severe wasting and bipedal oedema, or both, were 50%, 96%, and 66%, respectively. The detection of very low weight-for-age with a growth chart was also poor (sensitivity 62%, specificity 99%, PPV 89%). Other clinical signs, such as angular chelitis and depigmented hair, were not helpful in our study since they were present in few cases. Ashworth and colleagues postulate that severe malnutrition might not be seen typically in tertiary training hospitals. This theory goes against our experience in The Gambia. In our study, severe wasting was present in 9·7% and bipedal oedema in 5·1% of children attending the hospital. A further study was done of all children admitted between Dec 1, 1999, and Nov 30, 2000, to the ward of the Medical Research Council Laboratories, Fajara, which receives many referred cases. Of 1264 children younger than 5 years, 166 (13·1%) were severely wasted (WLZ <–3) with the highest frequency occurring in 1-year-old children (96/347; 27·7%). Case fatality was 3·49 times (95% CI 1·59–7·61; data not published) greater in severely wasted than non-wasted children. Despite being common in young children attending health facilities in economically poor countries, severe malnutrition is often not recognised even by nurses recently trained in WHO guidelines. More reliable methods for the identification of severe malnutrition are needed. Mid-upperarm circumference is easy to do, predicts mortality in community studies,4,5 and should be assessed in the hospital setting.
2090
*Stephen Allen, Clare Hamer *Clinical School, University of Wales Swansea, Swansea SA2 8PP, UK (SA); and Bristol University Education Centre, Upper Maudlin Street, Bristol UK (CH). (e-mail: [email protected]) 1
2
3
4
5
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. Hamer C, Kvatum K, Jeffries D, Allen S. Detection of severe protein-energy malnutrition by nurses in The Gambia. Arch Dis Child 2003; 89: 181–84. World Health Organization. WHO severe malnutrition manual: management of childhood illness—assess and classify the sick child age 2 months up to 5 years. WHO Division of Diarrhoeal and Acute Respiratory Disease Control and UNICEF; United Republic of Tanzania, 1998: 93–105. Vella V, Tomkins A, Ndiku J, et al. Anthropometry as a predictor for mortality among Ugandan children, allowing for socio-economic variables. Eur J Clin Nutr 1994; 48: 189–97. Briend A, Wojtyniak B, Rowland MG. Arm circumference and other factors in children at high risk of death in rural Bangladesh. Lancet 1987; 330: 725–28.
Sir—Ann Ashworth and colleagues1 emphasise the need to improve hospital care for severely malnourished children in Africa. We assessed treatment practices and case fatality at the Hospital Patiño, Cochabamba, Bolivia, and showed that needs are similar in Latin America. Hospital Patiño is a well-resourced second-level centre supported by a private foundation. It is one of two children’s hospitals in the city and serves mainly urban families and recent rural migrants. Of 2493 children admitted in 2000 and 2001, 92 (3·6 %) were diagnosed with severe malnutrition and almost all (91%) had oedema. The median age of these children was 15·2 months. At admission, 48 of the 92 patients were dehydrated, and in 16 the dehydration was severe (three with shock). Because of the difficulty in diagnosis of dehydration in severe malnutrition and estimation of its severity, the WHO guidelines2 state that rehydration fluid should be given intravenously only to children in shock and duration of treatment should not exceed 2 h. These guidelines were not followed and 42 children were given intravenous fluid; mean duration was 13 h and there was no monitoring for signs of overhydration. Of the 16 children with severe dehydration, seven died. As in South Africa, there was failure to prescribe appropriate antibiotics. Sepsis was frequent (26/92) and of the ten patients who died from sepsis, five had not been prescribed antibiotics with
gram-negative cover, and eight of the 92 children were not prescribed any antibiotics. Management of hypothermia, hypoglycaemia, anaemia, and feeding did not follow WHO guidelines. Children were fed a commercial formula, median 52 kcal/kg (range 20–99) and 1·5 g protein/kg (range 0·5–3·1). When the child’s appetite improved, feedings were given ad-libitum. The case-fatality rate among all inpatients was 5·8%. By contrast, the case-fatality rate among malnourished patients was 17·4% (odds ratio 3·74, 95% CI 2·0–6·79; p <0·0001). Half the deaths occurred within 48 h of admission. Four risk factors for death were identified: severe dehydration on admission (5·79, 1·47–23·3; p=0·006), sepsis (8·54; 1·00–84·2; p=0·0035), hyponatraemia (3·40, 1·00–12·21; p=0·04), and weight-for-height on admission (4·81, 1·13–23·5; p=0·028). The situation at Hospital Patiño differs from the South African hospitals in that the hospital is well-equipped, not overcrowded, and has trained paediatricians. Nevertheless, the quality of care was not acceptable; staff did not know the basic principles of managing children with severe malnutrition and did not see a need to have a standardised protocol, and this led to unnecessary deaths. Results from our assessment support the need for dissemination of medical knowledge, improvement of professional training that includes the WHO guidelines, development of capacities to work in teams and networks, and teaching the value of critical assessment of one’s performance. Efforts are being made to improve the quality of care at Hospital Patiño. Wider efforts are also being made, and in February, 2004, the first Latin American course for the management of severe malnutrition was held at Hospital del Niño, La Paz, Bolivia, with support from the Bolivian Ministry of Health, the Bolivian Society of Paediatrics, and the Pan American Health Organization. *Gerardo Weisstaub, Richard Soria, Magdalena Araya *Institute of Nutrition and Food Technology (INTA), University of Chile, Casilla 138-11. Santiago, Chile (GW, MA); and Pediatrics Center, “Albina R de Patiño”, Cochabamba, Bolivia (RS) (e-mail: [email protected]) 1
2
Ashworth A, Chopra M, McCoy D, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet 2004; 363: 1110–15. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO, 1999.
THE LANCET • Vol 363 • June 19, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.