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Treatment of severe malnutrition.

More than 50% of deaths in children aged 0 to 4 years is associated with malnutrition, and high priority is therefore given to its prevention and treatment. Regrettably, hospital treatment of severely malnourished children is often poor and outmoded and consequently fatality rates are high. Data from 67 studies worldwide show that the median fatality rate has not changed for the past 5 decades, and one in four severely malnourished children died during treatment in the 1990s (1). In any decade, however, there are some centers that do very well, with fewer than 5% dying, whereas others do badly, with approximately 50% dying. This disparity in outcome is not a result of differences in severity. It is a result of treatment practices. Where mortality is low, a set of basic principles is followed. Where mortality is high, the treatment is inappropriate. To improve treatment and reduce mortality, the World Health Organization (WHO) published a manual (2) and guidelines for the management of severe malnutrition in first-referral facilities (3). These activities form part of the WHO/United Nations International Children’s Emergency Fund (UNICEF) initiative of Integrated Management of Childhood Illness. This article highlights the serious problem of mismanagement of severe malnutrition and explains why many children die during treatment. It also describes how changing treatment practices saves lives. The focus is on management in hospitals in less developed countries, but the principles apply anywhere. REDUCTIVE ADAPTATION