Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol

Background Severely malnourished children have high mortality rates. Death commonly occurs during the first 48 h after hospital admission, and has been attributed to faulty case-management. We developed a standardised protocol for acute-phase treatment of children with severe malnutrition and diarrhoea, with the aim of reducing mortality. Methods We compared severely malnourished children with diarrhoea aged 0–5 years managed by non-protocol conventional treatment, and those treated by our standardised protocol that included slow rehydration with an emphasis on oral rehydration. The standardised-protocol group included children admitted to the ICDDR, B Hospital, Dhaka between Jan 1, 1997, and June 30, 1997, while those admitted between Jan 1, 1996, and June 30, 1996, before the protocol was implemented, were the non-protocol group. Findings Characteristics on admission of children on standardised protocol (n=334) and non-protocol children (n=293) were similar except that more children on standardised protocol had oedema, acidosis, and Vibrio cholerae isolated from stools. 199 (59·9%) of children on standardised protocol were successfully rehydrated with oral rehydration solution, compared with 85 (29%) in the nonprotocol group (p<0·0001). Use of expensive antibiotics was less frequent in children on standardised protocol than in the other group (p<0·0001). Children on standardised protocol had fewer episodes of hypoglycaemia than non-protocol children (15 vs 30, p=0·005). 49 (17%) of children on nonprotocol treatment died, compared with 30 (9%) children on standardised protocol (odds ratio for mortality, 0·49, 95% CI 0·3–0·8, p=0·003). Interpretation Compared with non-protocol management, our standardised protocol resulted in fewer episodes of hypoglycaemia, less need for intravenous fluids, and a 47% reduction in mortality. This standardised protocol should be considered in all children with diarrhoea and severe malnutrition.