Indian Pediatrics - Editorial

Correspondence

Indian Pediatrics 2007; 44:871-872

Management of Severely Malnourished Children

We read with interest the IAP guidelines 2006 on the hospital based management of severely malnourished children adapted from the WHO guidelines(1). We really appreciate the effort of the IAP Task Force for making these guidelines widely available through the Indian Pediatrics. The recommendations come at a time when despite the India's economic boom, the percentage of underweight children younger than 3 years has risen over the past 10 years(2). However, there are some discrepancies between the IAP and the WHO recommendations. Some of these discrepancies have been highlighted in the accompanying editorial(3). Also, the level of evidence should be mentioned for each recommendation, so that readers can make informed decisions. Keeping in mind the busy pediatricians, the guidelines should be simple, easy to use and unambiguous. We wish to raise the following points:

1. The IAP recommends the use of reduced osmolarity ORS with concentration of Na+ as 75 mmol/L, whereas WHO recommends even lower concentration of Na+ (ReSomal) with a sodium concentration of about 37.5 mmol/L. Giving high sodium could be inappropriate, and can cause complications, including death(4).

2. For the treatment of shock, IAP recommends (Appendix-1) intravenous bolus of 10 mL/kg over 20-30 minutes, and packed RBCs followed by a repeat fluid bolus over the same period, whereas WHO recommends 15 mL/Kg of fluid during the first hour, and then the blood, if required(1).

3. IAP recommends the simultaneous use of IV fluids and packed RBCs if the Hb is less than 10 g/dL or there is active bleeding. This is not feasible as blood is generally not available immediately. Furthermore, the cut off Hb for giving blood transfusion is quite high. This may cause unnecessary use of blood and volume overload in a severely malnourished child. Active bleeding should also be defined further to improve clarify to the readers.

4. The IAP guidelines also do not clearly state the type and amount of maintenance fluid to be given after correction of shock or dehydration in a severely malnourished child who is not tolerating entral feeds.

5. What is the basis of recommending steroids in severely malnourished children? This may result in unnecessary use of steroids in malnourished children who are already in a catabolic state.

6. It would be nice if certain Do’s and Don'ts in the treatment of severely malnourished are given in a boxed form for better understanding and implementation of the guidelines.

Ashok Kumar,
Shalu Gupta,
Department of Pediatrics,
Institute of Medical Sciences,
Banaras Hindu University,
Varanasi 221 005, India.

References

1. Task Force of the Indian Academy of Pediatrics. IAP guidelines 2006 on hospital based management of severely malnourished children (adapted from the WHO guidelines). Indian Pediatr 2007; 44: 443-461.

2. Chatterjee P. Child malnutrition rises in India despite economic boom. Lancet 2007; 369: 1417 - 1418.

3. Ashworth A, Jackson A, Uauy R. Focussing on malnutrition management to improve child survival in India. Indian Pediatr 2007; 44: 413-416.

4. World Health Organization. The pocket book of hospital care for children. Guidelines for the management of common illness with limited resources. Geneva: WHO; 2005.