In a brilliant display of insight, every article in the very first issue of Journal of Tropical Pediatrics, back in 1955, directly addressed malnutrition as the major underlying etiology of morbidity and mortality among children in the tropics. The topics covered by these articles spanned the range of issues in childhood malnutrition, including how health services should best be organized to address malnutrition , the influence of maternal malnutrition  and low birth weight , the importance of breastfeeding , effective complementary feeding  and the clinical manifestations of kwashiorkor [6, 7]. What was remarkably important for the global health agenda >60 years ago remains, tragically, just as relevant today. While dramatic improvements in childhood survival have been made over the last several decades , malnutrition (in all of its various forms) remains the underlying cause of death for nearly half of all children aged <5 years worldwide . The final common pathway for many of these deaths is acute malnutrition, particularly severe acute malnutrition (SAM) , consisting of severe wasting (marasmus) and/or edematous malnutrition (kwashiorkor) (Fig. 1). Given the concordance of risk factors such as abject poverty, the lack of a varied high-quality diet, and frequent infections, most often SAM is superimposed on chronic malnutrition , which is clinically manifested as underweight and stunting . Remarkable progress has been made in the management of SAM over the last couple of decades, most notably the development of systematic clinical protocols for inpatients that prioritize attention to life-threatening complications , and the development and endorsement of the community-based model of management for SAM . When appropriate staffing, supplies, and systems are made available, these models of care can significantly decrease morbidity and mortality among some of the most vulnerable children imaginable . Fig. 1. View largeDownload slide An educational poster at a health center in rural Malawi demonstrating two different forms of SAM: marasmus (left) and kwashiorkor (right). Fig. 1. View largeDownload slide An educational poster at a health center in rural Malawi demonstrating two different forms of SAM: marasmus (left) and kwashiorkor (right). Nevertheless, there is still a tremendous and urgent need for further progress—in an understanding of the underlying pathophysiology, the role of comorbidities, in the evidence base for diagnosis and management, in the development and implementation of improved inpatient and outpatient treatment protocols, and in the expansion of treatment coverage to broader geographic areas where more children can be diagnosed and treated. While the global community has (quite appropriately) brought renewed focus to the overwhelming burden of childhood tuberculosis, malaria, HIV, diarrhea, pneumonia, and a host of neglected tropical diseases, SAM remains tragically neglected in its own right . Exemplifying this was the recent rejection of ready-to-use therapeutic food (RUTF)—the backbone of modern SAM therapies—from the World Health Organization’s Model List of Essential Medicines , joining the milk-based formulas F-75 and F-100 (the other cornerstones of SAM therapy) as exclusions from this important international reference. Unlike most diseases in tropical pediatrics, the actual underlying etiology of SAM unfortunately remains poorly understood. A host of recent studies have pointed in different and sometimes contradictory directions, including the role of aflatoxins , disruptions in the enteric microbiome , and a continued back-and-forth debate about the role of protein insufficiency in the pathogenesis of kwashiorkor [20, 21]. Why some children living in the same impoverished conditions, exposed to the same pathogens and environmental toxins, and eating the same poor diets become severely malnourished, while others in the same community manage to avoid this fate remains enigmatic. While the strengths of modern 21st century science have been brought to bear on the basic biology of tropical pediatric diseases as diverse as malaria, AIDS, and sickle cell anemia, SAM remains neglected in this respect. Such a disregard in the study of the fundamental risk factors, mechanism, and pathophysiologic changes associated with SAM necessarily hampers our ability to optimally prevent and treat SAM. Particularly important going forward would be a better understanding of the immunologic deficiencies and the role of acute infections in triggering acute relapses after SAM , as both early and delayed mortality because of infection remain disproportionately high. Given the myriad challenges in conducting high-quality clinical research in resource-limited hospitals throughout Africa and Asia, it is not surprising that the evidence base for the inpatient management of SAM remains relatively weak , with many recommendations outdated and lacking specific clinical trial evidence to support their use . Improved attention to—and funding of—rigorous clinical trials can help challenge established dogma and advance practice that incorporates recent developments in critical care and takes advantage of modern therapeutic feeding products. Controversies and uncertainties linger about fluid resuscitation, antimicrobial usage, optimal feeding regimens, and a host of other issues. An example of important dilemmas in the management of SAM that have been successfully addressed with high-quality clinical trials and rigorous quality improvement methodologies is the appropriate use of RUTF in inpatient settings [25, 26]. The overwhelming majority of children with SAM can (and should) be successfully managed as outpatients in a community-based program using RUTF  and a short empiric course of antibiotics . The maturation and spread of these programs has made it possible to reach orders of magnitude more children than could previously access care using traditional inpatient treatment protocols, which should now be restricted to those children with acute medical complications and/or difficulty accessing outpatient care . However, as these programs have expanded, a number of important questions and challenges have emerged that provide the opportunity to more effectively identify and treat even more patients. This is one aspect of SAM that (relatively at least) has not been quite as neglected, with a number of recent high-quality trials that have helped inform optimal care and respond to some of the challenges reported by frontline health workers. One notable and encouraging aspect is that these studies are being conducted just as often by international nongovernmental organizations as by traditional academic researchers. This has, appropriately, meant that the dominant theme has been to improve the geographic coverage of care and accessibility to therapeutic food products in order to maximize the number of children that are identified and treated . Among the major challenges in this field has been the need to develop new formulations of RUTF that are locally sustainable and culturally acceptable in diverse settings and appealing to diverse populations of children without compromising recovery rates. A number of new formulations have been tried with varying degrees of success [30–32], leading to growing optimism that we may be at the beginning of an era of more affordable foods customized and proven effective in local contexts. Streamlining service delivery for children with SAM at the community level has also been an important area of recent inquiry, with significant advances demonstrating the effectiveness of lower doses of RUTF in times of supply shortage  and the effectiveness of integrated programs that manage SAM and moderate acute malnutrition jointly . In an important advance, it was demonstrated recently that access to care can also be improved for rural populations without significantly sacrificing outcomes in a treatment model that decreases the frequency of visits . As community-level care for children with SAM proves its effectiveness, it becomes all the more important to identify malnourished children early. Several promising developments in this domain have been made as well, including developing diagnostic criteria for children <6 months of age  and those >5 years of age . The expanded use and acceptance of the mid-upper arm circumference for screening and diagnosis has also meant that it may now be possible for mothers and other caregivers to diagnose many cases of SAM on their own at home, bringing their children to medical attention sooner and before they are as wasted or suffering from as many complications . Nonetheless, better and more precise tools should be developed to detect and quantify the exact degree of malnutrition in each individual patient. Successes in decreasing mortality from SAM should not make the tropical pediatric community complacent, as effective methods to decrease relapse following recovery remain relatively lacking  and interventions to protect cognitive development among malnourished children only recently starting to be developed . Discussions around childhood malnutrition are inherently fraught with political undertones , linked as the conversation is with agricultural interests, foreign aid, economic development, and ultimately conflicting perspectives on equity and inclusion for the most vulnerable members of society. SAM remains additionally marginalized and neglected from a scientific perspective. While some progress has been made in an understanding of the pathophysiology of the disease and in both inpatient and outpatient treatment programs, it is startling how little we still know about SAM considering how important a contributor it is to childhood morbidity and mortality worldwide. If ever there were a neglected tropical disease, it would be SAM. Following in the footsteps of our predecessors at the launch of this journal, we are not the first to argue that SAM needs more urgent consideration, nor—tragically—are we likely to be the last. Complacency is not an acceptable option. REFERENCES 1 Williams CD. 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Journal of Tropical Pediatrics – Oxford University Press
Published: Jan 5, 2018
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