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Zulfiqar Bhutta and colleagues (1)rightly focus attention on intervention strategies
for child undernutrition. However, they concentrate predominantly on stunting, and treatment of severe acute malnutrition is not a “key message” despite its huge potential to save lives. Kwashiorkor (nutritional oedema), the most lethal form of severe acute mal nutrition in central and southern Africa, is not mentioned in the entire undernutrition Series. Similarly, moderate forms of wasting receive no analysis at all.
WHO, UNICEF, and the World Food Programme recommend community-based
management of severe acute malnutrition by use of nutrient-dense ready-to-use foods(2), but Bhutta and colleagues, despite some positive comments, use only evidence from facility-based management in their recommendations. Such evidence comes from only about 1000 patients treated per the 1999 WHO guidelines.
Lack of robust, randomised studies is cited as a reason for not endorsing com munity-based care with ready-to-use foods, yet none of the five published studies cited in support of improved facility-based care used randomisation. Additionally, many of the interventions recommended in table 1—eg, hand-washing and behaviour change communication— are not supported by studies showing an effect on nutritional status, let alone mortality. It is unclear why diff -erent standards are used to recommend some interventions and not others.
Compared with resource-intensive,facility-based inpatient management, community-based outpatient care with ready-to-use food is a practical,
large-scale intervention (3–5)
Skewed analyses and conservative recommendations could set back the progress made in treating severe childhood undernutrition. Rather than calling for more studies, it is now time to scale-up community-based ready-to-use food for malnutrition.
We declare that we have no conflict of interest.
*Tido von Schoen-Angerer,
(1) Bhutta ZA, Ahmed T, Black RE, et al, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: 417–40.
(2) WHO, WFP, UNSCN, UNICEF. Community based management of severe acute
malnutrition. http://www.who.int/nutrition/ opics/statement_commbased_malnutrition/
en/index.html (accessed Jan 17, 2008).
(3) Defourny I, Seroux G, Abdelkader I, Harczi G. Management of moderate acute malnutrition with RUTF in Niger. Field Exchange 2007; 31: 2–4.
(4) Collins S, Sadler K, Dent N, et al. Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006; 27 (suppl 3): S49–82.
(5) Linneman Z, Matilsky D, Ndekha M, Manary MJ, Maleta K, Manary MJ. A large-scale operational study of home-based therapy with ready-to-use therapeutic food in childhood malnutrition in Malawi. Matern Child Nutr 2007; 3: 206–15.
Susan Shepherd, Kamalini Lokuge,
Clair Mills, Christophe Fournier
tido.von.schoenangerer(at)geneva.msf.org
Medecins Sans Frontieres, 1211 Geneva 21,
Switzerland
