Management of severe acute malnutrition in children – Authors' reply

Patrick Kolsteren and colleagues assertion that there is little evidence to support the scale-up of community-based therapeutic care is incorrect and disregards published studies on the topic and the recent experience of many humanitarian agencies and national ministries of health in Africa. Kolsteren and colleagues base their assertion largely on one article in a supplement to Food and Nutrition Bulletin which described three small trials in Malawi. They do not cite an article in the same supplement that presents data from 23 511 unselected cases of severe acute malnutrition treated in 21 community-based therapeutic care programmes implemented in Malawi Ethiopia and Sudan between 2001 and 2005. These programmes achieved recovery mortality and default rates of 79.4% 4.1% and 11.0% respectively. 76% of cases were treated solely as outpatients. These results far exceed international standards with mortality rates four to five times lower than the average in hospitals where severe acute malnutrition is treated exclusively on an inpatient basis. Furthermore evidence is now building that community-based therapeutic care can be effectively managed by national ministries of health with limited external support. This is in contrast to the repeated failure of many developing countries to implement the more resource-intensive 1998 WHO inpatient protocols. This integrated model has also enabled far higher numbers of patients to be treated than was previously possible using the exclusive inpatient approach. For example in Niger in 2005 Medecins Sans Frontieres treated 60 000 cases of severe acute malnutrition and achieved mortality rates of about 5% and cure rates of more than 80%. 70% of these children were treated exclusively as outpatients. (excerpt)