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  • Title: Assessment of potential indicators for protein-energy malnutrition in the algorithm for integrated management of childhood illness.
    Author: Bern C, Zucker JR, Perkins BA, Otieno J, Oloo AJ, Yip R.
    Journal: Bull World Health Organ; 1997; 75 Suppl 1(Suppl 1):87-96. PubMed ID: 9529721.
    Abstract:
    Potential indicators were assessed for the two classifications of protein-energy malnutrition in the guidelines for integrated management of childhood illness: severe malnutrition, which requires immediate referral to hospital, and very low weight, which calls for feeding assessment, nutritional counselling and follow-up. Children aged < 2 years require feeding assessment and counselling as a preventive intervention. For severe malnutrition, we examined 1202 children admitted to a Kenyan hospital for any association of the indicators with mortality within one month. Bipedal oedema indicating kwashiorkor, and two marasmus indicators (visible severe wasting and weight-for-height (WFH) Z-score of < -3) were associated with a significantly increased mortality risk (odds ratios, 3.1-3.9). Very low weight-for-age (WFA) (Z-score of < -4.4) was not associated with an increased risk of mortality. Because first-level health facilities generally lack length-boards, bipedal oedema and visible severe wasting were chosen as indicators of severe malnutrition. To assess potential WFA thresholds for the very low weight classification, our primary source of data came from 1785 Kenyan outpatient children, but we also examined data from surveys in Nepal, Bolivia, and Togo. We examined the performance of WFA at various thresholds to identify children with low WFH and, for children aged < or = 2 years, low height-for-age (HFA). Use of a WFA threshold Z-score of < -2 identified a considerable proportion of children (from 13% in Bolivia to 68% in Nepal) which, in most settings, would pose an enormous burden on the health facility. Among ill children in Kenya, a threshold WFA Z-score of < -3 had a sensitivity of 89-100% to detect children with WFH Z-scores of < -3, and, with an identification rate of 9%, would avoid overburdening the clinics. Potential modifications include use of a more restrictive cut-off in countries with high rates of stunting, or the elimination of the WFA screen in order to concentrate efforts on intervention for all children below the 2-year age cut-off. Key issues in every country include the capacity to provide counselling for many children and linkage to nutritional improvement programmes in the community. Severe malnutrition and very low weight were assessed as potential indicators for the classification of protein-energy malnutrition in the guidelines for the integrated management of childhood illness. For severe malnutrition, the authors examined 1202 children under age 5 years admitted to a Kenyan hospital for any association of the indicators with mortality within 1 month. Bipedal oedema indicating kwashiorkor, and the marasmus indicators of visible severe wasting and a weight-for-height (WFH) Z score of less than -3 were associated with a significantly increased risk of mortality. Very low weight-for-age (WFA) was not associated with an increased risk of mortality. Bipedal edema and visible severe wasting were chosen as indicators of severe malnutrition since first-level health facilities typically lack length-boards. Data for 1785 Kenyan outpatient children as well as survey data from Nepal, Bolivia, and Togo were used in assessing potential WFA thresholds for the very low weight classification. Use of a WFA threshold Z-score of less than -2 identified from 13% of children in Bolivia to 68% in Nepal who would in most settings burden health facilities. Among sick children in Kenya, a threshold WFA Z-score of less than -3 was 89-100% sensitive in detecting children with WFH Z-scores of less than -3 and, with an identification rate of 9%, would not overburden health clinics. Potential modifications include the use of a more restrictive cutoff in countries with high rates of stunting or the elimination of the WFA screen in order to focus efforts upon intervention for all children under the 2-year age cutoff.
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