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International child health

Aim: To test whether nurses can use the WHO Integrated Management of Childhood Illness (IMCI) nutrition algorithm to identify reliably severe protein-energy malnutrition in children. Methods: Nurses were trained to identify severe protein-energy malnutrition using IMCI training materials. They identified visible severe wasting and bipedal oedema, and categorized weight-for-age using a growth chart, in consecutive children attending outpatient clinics. Their findings were compared with weight-for-height Z (WHZ) score, bipedal oedema assessed by a trained observer and weight-for-age Z score. Results: 352 children were recruited of whom 34 (9.7%) were severely wasted (WHZ score <−3) and 18 (5.1%) had bipedal oedema. In the detection of severe wasting, the nurses’ assessments showed 56% sensitivity, 95% specificity and 56% positive predictive value (PPV) and for bipedal oedema 22%, 99% and 57% respectively. Overall, the nurses identified only half of 50 children with severe wasting and/or bipedal oedema and wrongly identified a further 13 children as severely malnourished. Plotting weight for age by the nurses showed 62% sensitivity, 99% specificity and 89% PPV for the detection of children with very low weight. Conclusions: Severe malnutrition was both under-diagnosed and wrongly diagnosed by nurses trained in the use of the IMCI nutrition algorithm in a clinic setting in The Gambia. These guidelines for health workers and the training materials; particularly in respect to calculation of age; need further development to improve the detection of malnourished children.