Letter on background to 1999 WHO guidelines on malnutrition, by Mike Golden

Dear ENN,

Further to your article on the technical debate regarding the management of severe malnutrition, I wish to offer some contextual information to the development of the World Health Organisation (WHO) guidelines, and agency field protocols.

Initial guidelines for the treatment of malnutrition, written in the 1970s in Jamaica, were published by the Pan American Health Organisation (PAHO) and subsequently by the World Health Organisation (WHO) in the 1980s. They were based upon practice at the tropical medicine research unit (TMRU) in Jamaica, treating small numbers of children (about 50 children a year). The researchers, clinicians and staff were all highly trained and had ample access to sophisticated instruments, literature and funds. They were 'overstaffed' to facilitate research measurements, which allowed labour intensive individual treatment to be given. The guidelines were not even implemented in the paediatric wards next to the unit where they were written.

Non-governmental organisations (NGOs) and agencies used the practical guidelines published by Medecins sans Frontieres (MSF) - in most hospitals no generally accepted guidelines were being used. In the early 1990s, when I drafted the current WHO guidelines , I simplified them as much as I thought safe. The big step was to formulate the diets, instead of giving individual ingredients by weight of child. Nevertheless, the basis of the management was the experience of a research ward.

The draft guidelines were given to the NGOs in 1994. Action Contre le Faim (ACF) took these draft guidelines, wrote practical protocols based upon the principles and provisions, and persuaded Nutriset to start to produce the diets commercially. Their protocols have since been adopted by most NGOs. These NGOs have now treated many hundreds of thousands of children using the guidelines and have amassed an enormous body of data, information and experience. For example, in Burundi from January 1999 to December 2001, 80,419 severely malnourished patients' characteristics and outcomes were entered into the national database, coordinated and maintained by UNICEF. The main expertise in applying the protocols and the effects of their variation now lies with the NGOs. However, in most places the data are not systematically collected or analysed. Yvonne Grellety made a very detailed analysis of over 10,000 patients from 13 countries in Africa. Interestingly, she confirmed, en masse, the importance of the old physiological data showing the sensitivity of these children to sodium and their propensity to develop heart failure in several different situations and analyses.

The original draft guidelines have been treated as a 'living document' that has gone through an evolutionary process - like computer software, we no longer use dos 3.1 (the operating system used for the original draft). The analyses, together with frequent field evaluations, in many different contexts and countries, shows where the critical points in the protocols lie and where difficulties of training, understanding, application and scale arise in practice, particularly in resource limited situations or emergencies. This has resulted in a number of changes in both detail and emphasis. The modified protocols are greatly simplified. They are relatively easy to apply in the field by nurses and nurse-assistants. The results being obtained are, in some places, as good or better than those obtained in the research ward in Jamaica. It is relatively easy to get good results from an adequately resourced, dedicated team in a research setting, it is quite a different matter to maintain good results in routine service. Nevertheless, at a national scale the results are a success story. The mortality rate (2000/2001) for Angola was 6% (3,976 deaths, 66,165 discharges) and 5% (3,552 deaths, 74,759 discharges) in Burundi. The current data for Ethiopia appear to have an even lower motality rate, with the best centres reporting around 1% mortality.

The main changes are of emphasis. Some aspects we thought were vital fifteen years ago are now known to be either minor or in some cases detrimental. Conversely, other aspects that were not emphasised were omitted, or compromises made in the original guidelines are now seen to be critical. The aspect of emphasis and approach is far from trivial. It determines where resources are directed when they are limited.

The challenge is to find a mechanism for both translating this very extensive body of knowledge into internationally endorsed guidelines within a reasonable time span, and to create a procedure for regularly updating the guidelines so that they are not outdated or used to produce derivative training material years later, when the State of the Art has moved on.

Yours
Professor Mike Golden
Email: mike@pollgorm.net

More like this

FEX: Foods for the Treatment of Malnutrition

Summary of Conference Presentation At the Dublin conference on Emergency Supplementary Feeding (February 18 to 21, 1997), reported on in the last issue of Field Exchange, Prof....

FEX: Evaluation of SCUK Emergency Nutrition Intervention in Malawi During 2002-2003

Selling maize husks in Malawi The 2001 harvest in Malawi was particularly poor and it was recognised by June/July that there would be a substantial maize deficit. Furthermore...

FEX: Comment on: Including infants in nutrition surveys

Experiences of ACF in Kabul city By Michael Golden, Department of Medicine and Therapeutics, University of Aberdeen, AB25 2ZD, Scotland. Perinatal mortality and birth-weight...

FEX: A pragmatic approach to treating severe malnutrition in emergencies: is F75 always beneficial?

By Saskia van der Kam Saskia is the headquarters nutritionist in MSF Holland. This article describes MSF's experience of implementing a therapeutic feeding programme for...

FEX: Debate on the Management of Severe Malnutrition

by Marie McGrath, Fiona O'Reilly and Jeremy Shoham (ENN). Over the past six months, ENN has been a party to debate regarding technical aspects of the management of severe...

FEX: Letter on cup feeding infants, by Mike Golden

Field exchange addressed the following question to Prof Mike Golden of Aberdeen University Dear Mike, In a meeting a couple of weeks ago on 'infant feeding in emergencies'...

FEX: Community management of acute malnutrition in Mozambique

By Edna Germack Possolo, Yara Lívia Novele Ngovene and Maaike Arts Edna Germack Possolo is Chief of the Nutrition Department of the Ministry of Health, Republic of Mozambique...

en-net: Geographical area for coverage survey

I am planning a SQUEAC survey in Haiti. Our PTAs are spread through 5 Communes (Provinces) which are relatively close together. The problem is that in the middle of this 5...

en-net: Treatment of SAM in older people through outpatient

Treating older people (>=60 year old) with uncomplicated SAM with RUTF at home as out patients: which doses should we use? Some recommend 100kcal/kg/day. Should it be...

en-net: Steps to measure MUAC

Countries like Ethiopia is already introduced new method of MUAC measurement for extension health workers. it is just Estimating the midpoint of the left upper arm. the the old...

FEX: Meeting on approaches to address moderate malnutrition in emergencies

The Emergency Nutrition Network (ENN) and Save the Children UK (SC UK) recently held a meeting on approaches to address moderate malnutrition in emergencies (29th-30th May...

FEX: ENN/GIFA project

Summary of presentation1 The Core Group2, composed of UNICEF, UNHCR, WFP, WHO, ENN and GIFA/IBFAN have developed and disseminated module 13 on Infant Feeding in Emergencies....

en-net: malnutrition rate

Dear All, Urgently want to know in any nutritional survey what is the difference we can expect in the percentage of SAM children we will find using WFH criteria and with MUAC...

FEX: Letter on nomenclature used in malnutrition programmes, by Mike Golden

Nomenclature used in programs for tackling malnutrition Dear Editor, The following terms, inter alia, have been used in describing programs/centres. CTC Community...

FEX: Operational research in low-income countries: what, why, and how?

Summary of research1 A Lancet published article puts forward a definition of operational research, articulates its relevance to infectious-disease-control programmes, and...

en-net: Thresholds for intervention using WHO standards

Global acute malnutrition prevalence thresholds have been commonly used to guide intervention in Emergencies (> 15% GAM or 10-14% GAM with aggravating factors = nutritional...

FEX: Integrating OTP into routine health services CONCERN’s experiences

By Emily Mates Emily Mates is a public health professional with a focus in nutrition. She recently left Concern Worldwide, Ethiopia where she worked for many years in...

FEX: From the editor

Rabia, seven months, with her mother at an OTP Aim and structure of this special issue This Field Exchange special issue on ‘Lessons for the scale up of Community-based...

FEX: Caring for Severely Malnourished Children

By Darryl Cowley and Professor David Morley (Teaching-aids At Low Cost) This book describes how to manage severely malnourished children in hospitals and other health units...

FEX: Focus on coverage assessment

During the past 10 years, the management of acute malnutrition has undergone a major paradigm shift that has changed the previous inpatient ‘clinical’ model of care into a...

Close

Reference this page

Professor Mike Golden (2003). Letter on background to 1999 WHO guidelines on malnutrition, by Mike Golden. Field Exchange 20, November 2003. p17. www.ennonline.net/fex/20/letters