Putting the Management of Severe Malnutrition Back on the International Health Agenda

Abstract

Severe malnutrition, defined by severe wasting (weightfor-height < –3 z-scores or < 70% of the median National Center for Health Statistics/World Health Organization [NCHS/WHO] reference) and/or the presence of nutritional edema, is a life-threatening condition requiring urgent treatment. How many lives would better treatment of severe child malnutrition save? The prevalence of severe malnutrition is estimated as around 2% in the least-developed countries and 1% in other developing countries [1], which translates to about 10 million severely malnourished children at one time. About 10 million children under five die each year [2, 3]. Some 4 million of these are neonatal deaths, which are not generally preventable by addressing severe malnutrition, but a significant proportion of the remaining 6 million may be preventable in this way. Malnutrition, severe or otherwise, is estimated to be a contributing factor in over 50% of child deaths [4], and it is estimated that the reduction in child mortality and morbidity (i.e., loss of disability-adjusted life-years [DALYs] averted) if malnutrition were eliminated would be at least one-third [5]. No direct estimates are available of the contribution of severe malnutrition to child deaths. However, the figure suggested by Collins et al. [6] in this volume of possibly 1 million child deaths (out of 6 million) associated with severe malnutrition is certainly possible. This estimate should be compared with those from other sources of data [7], but nevertheless its order of magnitude suggests that severe malnutrition in children is an important public health problem. Moderate malnutrition contributes more to the overall disease burden than severe malnutrition, since it affects many more children, even if the risk of death is lower [8]. Moreover, preventing all forms of malnupreventing all forms of malnupreventing trition remains the priority. However, existing prevention programs are imperfect, especially in the poorest countries or in countries undergoing an emergency crisis, and the prevalence of moderate plus severe malnutrition (as underweight) persists at around 25% and is falling only slowly. Many children still go on to become severely malnourished, even when prevention programs are in place, and these children will require treatment. Hence therapeutic programs are still needed as “safety nets” in parallel with prevention programs. Thus, extensive benefit would ensue from more effective and widely available treatment of severe malnutrition. Yet until recently, developing and applying better treatment methods has had low priority—severe malnutrition can almost be regarded as a neglected disease. For example, in the Lancet series on child survival,