Treatment of severe malnutrition Yvonne Greletty 23.10.97
RE: Treatment of severe malnutrition Djamil Benbouzid 24.10.97
ORS, PEM, etc. George Fuchs 27.10.97
RESOMAL and standard ORS André Briend 28.10.97
Re: ORS, PEM, etc. Benjamin Torun 28.10.97
more on PEM and ORS André Briend 29.10.97

Date: Thu, 23 Oct 1997 08:01:22 +0200

From: Yvonne Greletty <>

Subject: Treatment of severe malnutrition Content-Disposition: inline


Dear Ngonuts,

There is a major problem with the confusion and the difficulties encountered in implementing the protocol of rehydration for severely malnourished patients. There is no official documentation which says that the WHO protocol for rehydration, with the plan A, B and C, is not suitable for severely malnourished patients.

What can we do to change the practice of those who insist on using this standard WHO protocol for the management of rehydration of severely malnourished patients ?

Best wishes,


Yvonne Grellety

Subject: RE: Treatment of severe malnutrition

Date: Fri, 24 Oct 1997 13:59:09 +0200

From Djamil Benbouzid on Anna Verster's E.mail


The answer lies with the CDD Programme at HQ, in particular with Olivier Fontaine. I am once again very pleased to inform the NGONUT that the PEM Manual is being typeset now and definitely will be released soon.


From: George Fuchs


The correspondence regarding ORS and the severely malnourished child prompts me to ask if anyone as any data documenting the superiority of a reduced sodium, higher potassium ORS over the standard WHO ORS. We have not uncovered such data in the course of our literature searches. The few studies we found had some methodologic problems, but they seemed to indicate no great excess risk with standard ORS contrary to our intuition.

WHO's Olivier Fontaine and CDD are supporting a study which we have just started comparing a modified ORS with standard ORS, so perhaps we will know a bit more precisely.

On a related note, we developed a protocol to manage severe PEM here at ICDDR,B in parallel to and which is very similar to the soon-to-be released WHO protocol (kindly shared with us by Olivier Fontaine and Michael Golden). We developed the protocol because I suspected we could be doing a better job with this, even though the experience and knowledge of our physicians/scientists is quite good. The ICDDR,B protocol is conceptually the same as the WHO protocol with some of the differences being the choice of antibiotics which reflects our population of patients who predominantly have diarrhea, some dysentery, and our use of a designed rehabilitation diet made from locally available foods, among others. We also use standard ORS pending more conclusive information on the modified ORS. Attached is a draft of an abstract describing our initial experience with protocolized management. While in some ways it is not terribly surprising, it suggests to me that even experienced health care workers can improve the care of severely malnourished children through a protocolized approach.

Improvement in care might be predicted to be even greater when used by the less experienced.

George Fuchs




Ahmed T, Ali M, Salam M.A., Rabbani GH, and Fuchs GJ.

Clinical Sciences Division, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)

GPO Box 128, Dhaka, Bangladesh,


Severely malnourished hospitalized children have a high mortality rate. In order to reduce mortality, a standardized treatment protocol was developed and implemented at the ICDDR,B hospital in January, 1997. Key points of the protocol include standardized use of rehydration fluids, slower rehydration, aggressive but deliberate feeding, micronutrient supplementation, antibiotic therapy and timely management of complications.

Outcome and cost of treatment were compared among protocol and comparison groups of severely malnourished children with diarrhoea. The protocol group (PG) consisted of children admitted to the hospital from January 1 to June 30, 1997. Children admitted from January 1 to June 30, 1996 that received conventional, non-protocolized treatment formed the comparison group (CG). The same physicians treated both groups.

Admission characteristics of children in PG (n=334) and CG (n=293) were comparable except that more PG children had pedal edema, acidosis and Vibrio cholerae isolated from stools. 59.5% of children in the PG were successfully rehydrated with ORS rather than intravenous fluids compared to 29.3% in the CG (p=0.00001). Use of expensive antibiotics was reduced in the PG (p=0.001). PG children had fewer episodes of hypoglycemia (15 versus 26, p=0.02). Costs of laboratory tests, intravenous fluids and antibiotics were significantly less in the PG. Thirty children (9%) in the PG died compared to 49 (17%) in the CG (p=0.003; OR 0.49, 95% CI 0.3-0.08).

The results of the study indicate that standardized management under the protocol resulted in a 47% reduction in mortality among severely malnourished children with diarrhoea and reduced the risk of dying by 51%. It also resulted in fewer episodes of hypoglycemia. The use of intravenous fluids was less, thereby reducing the risk of sodium and fluid overload. In addition, the use of expensive antibiotics was also minimized as well as cost of laboratory tests, antibiotics and intravenous fluids. The use of a standardized approach to the management of malnourished children should be considered in the care of all severely malnourished ill children.

Date: Tue, 28 Oct 1997 09:44:26 +0100 (MET)

From: (Andre' BRIEND)

Subject: RESOMAL and standard ORS


Some comments to George mail.

1- RESOMAL formula is relatively new. It started circulating in NGO circles around 1993, but in a way may be regarded as not yet officially endorsed by WHO, untill the WHO manual on treatment of malnutrition is published (side remark: this manual has been to be published next month for the last 3 years. Hope this time Djamil is right). No wonder you don't find refs comparing the two solutions.

2- Although resomal formula is new, it is based on principle which have been known for years. If you look at previous versions of WHO manual on diarrheoa management (para on severe malnutrition), it says to give water between ORS feeds (which is equivalent to diluting ORS) and adding potassium supplement.

In a way, RESOMAL just reproduces in a glass the mixing which used to happen previously in the stomach of the child. The attraction of resomal is that it is much easier to handle, hence its great success in emergency situations. I suspect previous recommendations were to difficult to follow except in a few places with high supervision level by skilled physicians (which is a case of ICDDR,B, and may explain the absence of spectacular improvement with RESOMAL in your settings). Other differences between resomal and previous protocol are i) addition of sugar (which must be a plus to prevent hypoglycemia) and ii) addition of Mg Zn Cu. Again no major difference to be expected in children who are fed more or less +/- 6 hours after admission, with a properly balanced diet with all these minerals, but a major simplification of the management.

3- A group from Belgium working in Republique Democratique du Congo (former Zaire) has done a formal comparison of RESOMAL versus ORS. Despite all my comments above, they did find differences in the 2 rehydrations solutions.

By and large, I understand they found the group on resomal takes up less Na, and more K, which is in favour of resomal in this area which is a high kwk region. I'll ask this group whether they can get in touch with you and share their results.


Dr. André Briend

Date: Tue, 28 Oct 1997 13:03:32 -0600

From: Benjamin Torun <>

Subject: Re: ORS, PEM, etc.



Dear George:

The reduced sodium, higher potassium ORS is not available in our part of the world. Several colleagues and I have had excellent clinical results rehydrating malnourished children with standard WHO ORS. Serum electrolytes are not assessed routinely, but hypernatremia does not seem to be a major problem, at least from a clinical viewpoint.

In theory, the modified (less Na, more K) ORS should be better for severely malnourished, dehydrated patients. However, my concern, which is shared by others in Latin America with whom I have discussed this issue, is that advocating that the standard WHO ORS should NOT be used with malnourished patients, may have dangerous outcomes. We must also weigh carefully the risks of the confusion that may be caused when one type of salts is recommended for well nourished and another for malnourished children.

In many countries, acceptance of standard WHO ORS by health workers and the population at large has taken many years and much effort; we must be careful not to undermine those efforts. Part of the success has been due to the widespread availability of WHO ORS through local health services. Modified ORS must become as readily available before recommending that it substitute standard ORS.

My approach is recommending low Na, high K ORS, WHEN IT IS AVAILABLE; OTHERWISE, CONTINUE USING STANDARD WHO ORS. My plea is to avoid creating a negative image for standard ORS, unless it is withdrawn and effectively substituted by modified ORS in all health services and NGO operations.

On a different note, I was not able to read the protocol to manage severe PEM that you sent. Could you please send it again converted into WordPerfect 5.x or 6.x format? I will greatly appreciate it.



Benjamin Torun, M.D., Ph.D., Jefe, Unidad de Nutrición Humana, Head,

Human Nutrition Unit, Instituto de Nutrición de Institute of Nutrition of Centro América y Panamá. Central America and Panama.


INCAP -- Calzada Roosevelt, Zona 11

Apartado Postal 1188

Guatemala, Guatemala

Tel: [502] 471-9913, 471-5655, 472-3762 Fax: [502] 473-6529

e-mail:, WWW:

Date: Wed, 29 Oct 1997 08:28:03 +0100 (MET)

From: (Andre' BRIEND)

Subject: more on PEM and ORS


Dear Roberto,

Some comments to your mail.

The reason for advocating a low Na in severe malnutrition is to prevent heart failure. Hypernatraemia usually is not a problem in severely malnourished children who tend to be hyponatremic.

I think the problem of Na overload is real, especially in KWK patients. You must be aware of the following paper :

Wharton BA, Howels GR, McCance RA. Cardiac failure in kwashiorkor. Lancet 1967; ii: 384 7.

This paper shows that you can induce heart failure in kwk patients, even with relatively low Na intakes (I would say from memory above 7 mEq Na /kg) that you can reach easily by generously rehydrating a severely malnourished child with standard WHO ORS given at standard rates for well nousished children. Again, this comment applies to KWK patients, especially when they are with an increased risk of heart failure due to anaemia (see the original paper). This condition seems pretty common even now in central Africa. I even heard of problems of heart failures in places in Central Africa where RESOMAL was given too generously (maybe Yvonne or Mike can give details on that). This issue may not be so critical in marasmic children (and may be not so ciritical in Bangladesh or Central America).

When the idea of a special ORS for the severely malnourished child took off, precautions were taken to avoid confusion with standard ORS. Actually, the risk is low, since resomal is to be used only in hospital and therapeutic feeding centres. For this reason, when the industry started to produce RESOMAL, it was asked to package it in sachets for 10 L. Apparently NGO's now find this quantity too large, and ask sachets for 2 L for small treatment units. They do not think that confusion with standard ORS is a real problem.

RESOMAL should be used in hospitals only, and its introduction of course should not imply that it is any better than standard ors for well nourished children. There is absolutely no risk of inducing heart failure in moderately malnourished children with standard ORS, at whatever dose, and community programmes should continue to use standard ors as ever before.


Dr. André Briend