Nutritional and Health-Related Environmental Studies (NAHRES)

Management of severe acute malnutrition during early life; addressing nutritional requirements by stable isotope techniques

Background

Although accurate statistics is lacking, the World Health Organization (WHO) estimates that nearly 20 million children under 5 years of age suffer from severe acute malnutrition (SAM), defined as a very low weight for height, by visible severe wasting or by the presence of nutritional oedema (1). In children 6-59 months old, an arm circumference less than 110 mm is also indicative of severe acute malnutrition. Children with SAM are at considerably higher risk of dying compared to well nourished children, either as a direct cause of SAM or as an indirect cause as SAM dramatically increases case fatality rate in children suffering from common illnesses such as diarrhoea and pneumonia. Estimates suggest that SAM contributes to about 1 million child deaths every year - one child death every thirty seconds. However, considerably higher estimates (1.7 million deaths or more) have been proposed (2-3). The large majority of children with SAM live in south Asia and sub-Saharan Africa and although children with SAM appear in news coverage of humanitarian emergencies, the silent suffering of most of these children remains largely unnoticed.

In hospitals in many developing countries, children with SAM represent a significant proportion of paediatric deaths - not because there are more admissions for SAM than for other conditions but because a higher proportion of these children die (3). Case fatality rates of 25-30 % are commonly found and in some hospitals 50-70 % of children with SAM die. However, with specialized care, as outlined in the WHO treatment manual, "Management of severe malnutrition: a manual for physicians and other senior health workers" (4), low case fatality rates, about 5 %, can be achieved. A recent review of published studies showed that implementation of the guidelines reduced case fatality rate by 55 % (5). Good nutrition is obviously an essential component of the overall management of SAM together with appropriate use of antibiotics and micronutrient supplements. Until recently, treatment has been restricted to facility based approaches, greatly limiting its coverage due to limited resources and lack of specialized malnutrition wards. Recent data suggest that a large proportion of children with SAM can be treated in the community with ready-to-use therapeutic foods or other nutrient dense foods (1). The development of a community based approach for management of SAM is supported by the recommendation to actively search and treat malnourished infants and children in the Global Strategy for Infant and Young Child Feeding (6) and could prevent the deaths of hundreds of thousands of children.

Based on priority areas recently identified in the Lancet's Series on Maternal and Child Undernutrition (7) and discussions during a Consultants' Meeting, this CRP will address the urgent need for operational research to improve management of severe acute malnutrition during early life. The overall goal of the proposed CRP is to contribute new information to re-examine and improve dietary recommendations for treatment of children with SAM. Stable isotope techniques provide powerful tools to provide much needed information on energy and nutrient kinetics in vulnerable population groups but the application of these techniques has been limited. However, the usefulness of these techniques is clearly highlighted by recent studies in Malawi and Jamaica (8-13).

The second priority area for this CRP is to evaluate the potential usefulness of body composition assessment to predict outcome in children with SAM as virtually no information is available on this topic. In particular, a comparison of different techniques (stable isotope technique and multifrequency bioelectrical impedance analysis (BIA) would be of major importance..

Objective
Overall objective
  • To contribute new information to re-examine and improve dietary recommendations for treatment of children with SAM.
Specific objectives
  • To assess energy expenditure and macronutrient kinetics by stable isotope techniques in children with SAM
  • To evaluate the potential usefulness of body composition assessment as a predictor of outcome in children with SAM, based on stable isotope technique and/or multifrequency bioelectrical impedance analysis (BIA)
Expected research outputs
  • New data on energy expenditure and macronutrient kinetics in children with SAM.
  • New data on the potential usefulness of body composition assessment as a predictor of outcome in children with SAM
  • Publications in the form of scientific reports and peer-reviewed papers..
Expected Research Outcomes

To contribute to improved management of severe acute malnutrition in infants and young children..

Proposal submission forms

esearch institutions in Member States interested in participating in this CRP are invited to submit proposals directly to the Research Contracts Administration Section (NACA) of the International Atomic Energy Agency: Official.Mail@iaea.org or to Ms Lena Davidsson: L.Davidsson@iaea.org The forms can be downloaded from http://www-crp.iaea.org/html/forms.html. For more information about research contracts and research agreements, please visit our web-site: http://www-crp.iaea.org/html/faqs.html .

Deadline for submission of proposals

Proposals must be received no later than 1 September 2008. Transmission via E-mail is acceptable if all required signatures are scanned.
For additional information, please contact:
Lena Davidsson
Section Head
Nutritional and Health Related Environmental Studies Section
Division of Human Health
International Atomic Energy Agency (IAEA)
Wagramer Strasse 5
A-1400 Vienna Austria
Phone: + 43 1 2600 21657 or 21674
Fax: + 43 1 26007
L.Davidsson@iaea.org

References
  1. World Health Organization /World Food Programme/UNICEF/United Nations System Standing Committee on Nutrition. Community based management off severe acute malnutrition. A joint statement by WHO/WFP/UN SCN/UNICEF, 2007
  2. http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html
  3. Collins S, Dent N, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children. The Lancet 2006;368:1992-2000
  4. Jackson AA, Ashworth A, Khanum S. Improving child survival: Malnutrition Task Force and the paediatrician’s responsibility. Arch Did Chil d 2006;91:706-10
  5. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers, WHO, 1999
  6. http://www.who.int/nutrition/publications/en/manage_severe_malnutrition_eng.pdf
  7. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS, Shekar M. What works? Interventions for maternal and child undernutrition and survival. The Lancet 2008; 371:417-40
  8. World Health Organization/UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization, 2003
  9. The Lancet’s Series on Maternal and Child Undernutrition. The Lancet 2008. Executive Summary. http://www-tc.iaea.org/tcweb/abouttc/tcseminar/Sem6-ExeSum.pdf
  10. Jahoor F, Badaloo A, Reid M, Forrester T. Protein kinetic differences between children with edematous and nonedematous severe childhood undernutrition in the fec and postabsorptive states. Am J Clin Nutr 2005;82:792-800
  11. Badaloo AV, Forrester T, Reid M, Jahoor F. Lipid kinetic differences between children with kwashiorkor and those with marasmus. Am J Clin Nutr 2006;83:1283-8
  12. Jahoor F, Badaloo A, Reid M, Forrester T. Sulfur amino acid metabolism in children with severe childhood undernutrition: methionine kinetics. Am J Clin Nutr 2006;84:1400-5
  13. Manary MJ, Yarasheski KE, Berger R, Broadhead RL: CO2 production during acute infection in malnourished Malawian children. Eur J Clin Nutr 2004;58:116-20
  14. Manary MJ, Yarasheski KE, Berger R, Abrams ET, Hart CH, Broadhead RL: Whole body leucine kinetics and the acute phase response during acute infection in marasmic Malawian children. Pediatr Res 2004;55:940-6
  15. Manary MJ, Yarasheski KE, Smith S, Abrams ET, Hart CA. Protein quantity, not protein quality, accelerates whole-body leucine kinetics and the acute phase response during acute infection in marasmic Malawaian children. Brit J Nutr 2004;92:589-95