Severe acute malnutrition remains a major cause of childhood mortality worldwide, with 19 million preschool children affected each year. While treatment guidelines have incorporated ready-to-use therapeutic foods and antibiotics in outpatient settings, some children still fail to recover. A 2013 study found that adding amoxicillin or cefdinir to outpatient treatment significantly improved recovery rates. However, a 2016 study found no clear benefit of routine antibiotic use and raised concerns about increasing antibiotic resistance, calling for further research before changing treatment guidelines.

1. ANTIBIOTICSANDSEVERE
MALNUTRITION
Dr. AllenCherer

2. Childhood undernutrition is a major global health
problem and severe acute malnutrition remains a
major cause of childhood mortality. It is estimated
that 19 million preschool age children, mostly from
the World Health Organization African and South-
East Asia Regions, suffer from severe acute
malnutrition, contributing to major childhood
morbidity, mortality, intellectual impairment, and
disease susceptibility.

3. Of the 7.6 million deaths annually among
children who are under 5 years of age,
approximately 35% are nutrition related and
4.4% of deaths are specifically attributable to
severe wasting. Children with severe acute
malnutrition suffer severe wasting that may
(kwashiorkor) or may not (marasmus) be
accompanied by swelling of the body from
fluid retention.

4. It occurs when infants and children do not have
adequate energy, protein, and micronutrients in
their diet, and at times is combined with recurrent
infections.Diagnostically, it is defined as a mid-
upper arm circumference less than 115 mm or a
weight for height that is severely reduced. There is
strong epidemiological evidence that low weight-
for-height, weight-for-length, or mid-upper arm
circumference are highly associated with a 5-20
fold increased risk of mortality.

5. For decades, the primary management for severe
acute malnutrition comprised inpatient
rehabilitation with fortified milk formulas.
Management guidelines then transitioned to
incorporate the use of ready-to-use therapeutic food
(RUTF), usually a fortified spread of peanut paste,
milk powder, oil, sugar, and a micronutrient
supplement, in outpatient settings in those cases of
severe acute malnutrition where appetite was
preserved and there were no evident complicating
medical clinical signs.

7. Nevertheless, a significant number of children failed
to recover. Since many studies had demonstrated a
high percentage of clinically significant infections
among children with severe malnutrition, treatment
guidelines recommending the use of routine
antibiotics were developed. In 2013, a double-blind,
randomized, placebo-controlled clinical trial in rural
Malawi conducted by Trehan and colleagues was
reported in the New England Journal of Medicine.

8. The study found that the routine addition of
a seven day course of amoxicillin or cefdinir
to the outpatient management of severe
acute malnutrition was associated with
marked improvement in recovery and
mortality rates and significant increases in
weight and mid-upper arm circumferences.

9. Subsequently, the 2013 WHO guidelines
(previously updated in 1999) for treatment
of children with severe acute malnutrition
without health complications requiring
hospitalization called for high energy food
and routine antibiotics.

10. The new guidelines were considered superior
to previous ones in that they reflected new
opportunities and technologies in caring for
greater numbers of children in the outpatient
setting. In addition, the guidelines specifically
addressed children with severe acute
malnutrition who were less than 6 months of
age or were infected with HIV.

11. Most recently, a study from the Harvard T. H.
Chan School of Public Health and published
in the New England Journal of Medicine in
2016 calls into question the routine use of
antibiotics in the management of severe
acute malnutrition.

12. The double-blind, randomized trial of amoxicillin
vs. placebo in a population of children in Niger
between October 2012 and November 2013
demonstrated no superiority in terms of recovery
rate among children treated with amoxicillin and
no differences in overall mortality.

13. The implication is that in an era of increasing
antibiotic resistance, routine antibiotic
administration may pose a greater risk to child
health. Nevertheless, the study did demonstrate on
secondary analysis a faster rate of recovery (28 days
vs 30 days) among children treated with amoxicillin,
decreased risk of death in children over 24 months of
age, and decreased risk of transfer for clinical
complications.

14. Since the study population too was not
comparable to that of Trehan and colleagues
in Malawi and the level of ancillary care and
follow up was not the same, further studies
are indicated prior to recommending a
change in current treatment guidelines.