Menu ENN Search

Implementation of WHO Guidelines on the Management of Severe Malnutrition in South Africa and Ghana

Summary of published research1

Dietitian interacting with ward nurse at Mapuleng hospital, Northern Province, South Africa 2002

In the past, Field Exchange has addressed issues faced by international humanitarian agencies in phasing out emergency therapeutic feeding programmes and leaving behind improved and sustainable capacity for treatment of severe malnutrition. The study summarised below provides additional evidence that at least in non-emergency situations, improved and sustainable practices can be promoted (Ed).

The study set out to investigate the problems, benefits, feasibility and sustainability of implementing World Health Organisation (WHO) guidelines on the management of severe malnutrition2. A postal questionnaire was sent to 12 African hospitals inviting them to participate. Five hospitals were evaluated and two were selected to take part in the study - a district hospital in South Africa (Battor Hospital) and a mission hospital in Ghana (Mapulaneng Hospital). At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation.

Implementation of most of the main principles of the WHO severe malnutrition guidelines was feasible, sustained over a oneyear period, and affordable to the institutions (see table 2). Although relatively labour intensive, the process was successful because hospital staff were involved in planning the changes from the outset, logistical limitations were acknowledged and local modifications to the generic approach were developed. The success can also be attributed to the enthusiasm of the resident paediatricians and the follow up by the visiting paediatrician. As the resources for implementation came from the hospital budgets (except for a supply of mineral and vitamin pre-mix), financial sustainability is likely.

Rehabilitated child at Catholic hospital, Battor, Volta Region, Ghana 2001

Whether the WHO guidelines, once implemented, are effective is another important and relevant question. At Battor, the mortality was unchanged, possibly because diagnoses of severe malnutrition were more precise during the study year - this is supported by a decrease in the number of admissions classified as severely malnourished from 81 at the beginning, to 39 during the study. At Mapulaneng, the mortality halved. This may have been because all cases of severe malnutrition, not only those with complications, were admitted, as suggested by the increase from 29 cases pre-study to 125 cases during the study. Also, the study was not blinded so some bias in the reporting may have occurred during the study year.

Comparisons aside, some would still regard the 18% fatality rate from severe malnutrition at both hospitals during the study period as unacceptably high, considering the guidelines target mortality rates of 5-10%. Guideline components that were not implemented or sustained may have been crucial to achieving further decreases in case-fatality rates. Furthermore, guideline practices believed to be in place may have been implemented inconsistently or poorly in reality. Also, the influence of HIV on malnutrition mortality was not measured specifically. The primary cause of death in some cases was probably advanced acquired immunodeficiency syndrome (AIDS), in which case the deaths would not have been preventable.

Hospital staff questioned the evidence base of some of the guideline components and felt that the evidence behind certain recommendations - such as the single approach for managing marasmus and kwashiorkor, feeding frequencies, routine antibiotics, and requirements of micronutrients other than vitamin A, folic acid and zinc - was inadequate. Documentation of the technical basis of these specific recommendations, or research to provide the necessary evidence, would promote wider acceptance of the guidelines.
The study intentionally selected two general hospitals that seemed to have a good chance of implementing the guidelines. Although the findings cannot be generalised to all small hospitals in Africa, the study gives an idea of what may or may not be feasibly implemented with a minimum of intervention. It is difficult to predict whether similar African hospitals would have the same success in improving care management practices by following the guidelines, particularly without external consultant support. Conversely, more intensive input and support might allow implementation of all components of the guideline but with less assurance of sustainability.

The authors of the study concluded that wider implementation of the guidelines in similar settings is possible but that the guidelines could be improved by including additional information on how to adapt specific components to local situations. Furthermore, additional information is needed about certain components of the guidelines and their impact on mortality.

Table 1 Summary of the feasibility and sustainability of the main components of the WHO guidelines for the management of severely malnourished children
Category Battor and Mapulaneng Hospital Mapulaneng Hosptial

Battor Hospital

Feasible and sustained
  • . Routine admission of all severely malnourished children
    . Using key signs, oedema of both feet or severe visible wasting, for the diagnosis
    . Measurement of height and calculation of weight-for-height
    . Measures against hypoglycaemia, e.g. early feeding on admission, nasogastric tube feeding when necessary
    . Measures against hypothermia, e.g. blankets, heaters, keeping the children dry
    . Restricting the use of intravenous fluids only to those with shock or severe dehydration
    . Preparation and use of starter (75 kcal/100 ml) and catch-up (100 kcal/100 ml) formulae
    . Delaying the administration of supplemental iron
Triage, urgent assessment and management . Allowing mothers to stay with the children all day and night
. Routine administration of oral antibiotics to those without complications
Feasible with adaptation or special provision Frequent feeding, all day and night Supplemental electrolytes, minerals, and vitamins Routine administration of antibiotics to those without complications  
Feasible, but implemented inconsistently or not sustained . Measurement and recording of feeding
. Daily measurement and charting of weights
. Transition from starter (75 kcal/100 ml) to catch-up (100 kcal/100 ml) formula
Not feasible . Preparation and use of rehydration solution for the severely malnourished (ReSoMal)
. Calculation of weight gain in g/kg/day
. Target case-fatality rate of 5-10%
Allowing mothers to stay with the children all day and night Triage, urgent assessment and management

Show footnotes

1Deen J et al (2003). Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. Bulletin of World Health Organisation, 2003, 81 (4), pp 237 - 242

2Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, 1999

More like this

FEX: Thiamine content of F-75 for complicated severe acute malnutrition: time for a change?

Summary of research1 Location: Global What we know: Complicated cases of severe acute malnutrition (SAM) are usually severely ill with comorbidities. What this article adds:...

FEX: Locally produced RUTF in a hospital setting in Uganda

By Tina Krumbein, Veronika Scherbaum, and Hans Konrad Biesalski Tina Krumbein is a graduate nutritionist. This article forms part of her diploma thesis submitted to the...

FEX: Treating severe malnutrition in nonemergency situations: Experiences from Malawi and Guinea

By Dr. Eva Grabosch, M.Sc, CHDC Malnourished boy recovering in the nutrition unit of the Teresian Sisters Hospital, Alinafe, Malawi Dr. Eva Grabosch is a specialist in...

en-net: UNICEF Papua New Guinea looking for SAM management expert for 6-month assignment

Purpose of Consultancy/Institutional Agreement: To provide technical support and mentoring to the Paediatric Hospital in Port Moresby in Papua New Guinea.and two other...

FEX: Review of WHO guidelines for the inpatient management of severe acute malnutrition

Summary of research1 Location: Global What we know: Optimising SAM management is an important strategy for reducing malnutrition-related mortality. What this article adds: A...

FEX: Revised MSF nutrition guidelines III

By Saskia van der Kam and Sophie Baquet, MSF The summary below is based upon a near final draft of the new MSF guidelines.1 The guidelines may therefore undergo some revision...

FEX: Debate on the Management of Severe Malnutrition : A Response

By Professor Ann Ashworth, London School of Hygiene and Tropical Medicine Background Many individuals and organisations, including NGOs, have contributed to the improved...

FEX: Development of a maternal service package for mothers of children with severe acute malnutrition admitted to nutrition rehabilitation centres in India

View this article as a pdf Lisez cet article en français ici By Vani Sethi, Praveen Kumar and Arjan De Wagt Vani Sethi PhD is a public health nutritionist in the...

FEX: Postscript on local capacity building for treatment of severe malnutrition

Ann Ashworth Hill, Professor of Community Nutrition Public Health Nutrition Unit, London School Hygiene and Tropical Medicine International NGOs usually provide better...

en-net: RUTF

Are simplistic charts for calculation of RUTF ration required per day based on weight recommended by WHO?

Most of the RUTF sachets are packed in 92 gms can it be done...

FEX: Evaluation of Relactation by the Supplemental Suckling Technique

A mother feeding her baby using the SST By Odile Oberlin and Caroline Wilkinson, Action Contre la Faim (ACF) Odile Oberlin is a paediatrician working in a Paris hospital and...

FEX: Clinical Trial of BP100 vs F100 Milk for Rehabilitation of Severe Malnutrition

Child eating BP100 in Freetown TFC. By Carlos Navarro-Colorado and Stéphanie Laquière Carlos Navarro-Colorado is a medical doctor, with a MSc Epidemiology. He has ten years...

FEX: Letter on revised MSF Nutrition Guidelines draft, by E.C. Schofield, Ann Ashworth, Mike Golden and Y. Grellety

Dear Field Exchange, Revised MSF nutrition guidelines We would like to comment on the draft of the newly revised MSF guidelines for the treatment of severe malnutrition...

FEX: Treatment of severe malnutrition in Tanzania - a problem with ‘scoops’

By Chloe Angood Chloe Angood has an MSc in Public Health Nutrition and a BA and MA in International Development Studies. She works for the International Malnutrition Task...

FEX: Anthropometric predictors of mortality in undernourished adults in southern Sudan

Summary of published research1 Location: South Sudan What we know: Acute adult undernutrition tends to occur in prolonged severe famines. There is a lack of evidence on which...

FEX: Mortality risk factors in severelymalnourished children hospitalised with diarrhoea

Summary of published research1 Acase-control study conducted in the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) to identify...

en-net: Which quantity of infant formula for SAM <6m?

Following the 2013 WHO guidelines "Updates on the management of severe acute malnutrition in infants and children": " for infants with severe acute malnutrition but no oedema,...

en-net: What to do when ReSoMal and CMV not available?

We are having shortages and cannot find in-country sources for some our needed products. The shortage is expected to last until next year. In particular, I need to know how I...

FEX: Supplementary Feeding Programme - Current Guidelines

Circumstances leading to the setting up of SFPs (from WFP guidelines) Blanket SFP Targeted SFP A generalised SFP for prevention purposes maybe implemented in the absence of a...

FEX: WHO emergency nutrition response in South Sudan

By Marina Adrianopoli and Allan Mpairwe Marina Adrianopoli has been supporting WHO in South Sudan as Emergency Nutrition Focal Point since 2014. She has over 10 years'...


Reference this page

Implementation of WHO Guidelines on the Management of Severe Malnutrition in South Africa and Ghana. Field Exchange 20, November 2003. p11.