title: Case management of kwashiorkor: an intervention project at seven nutrition rehabilitation centres in Malawi.
abstract: OBJECTIVE
  (1) To improve case management of kwashiorkor at seven Nutritional Rehabilitation Centres (NRCs) through 2-4 weekly paediatric supervisory visits. (2) To evaluate the impact of the use of routine tube-feeding and a micronutrient supplement (Nutriset).
  
  
  METHODS
  An intervention project with descriptive clinical data in which Nutriset was introduced halfway through the project, and routine tube-feeding at one NRC was compared to no tube-feeding at a similar one.
  
  
  METHODS
  NRCs located at two central hospitals, two district hospitals and three rural clinics in southern Malawi.
  
  
  METHODS
  1625 consecutive kwashiorkor admissions from January-December 1995.
  
  
  RESULTS
  The overall case-fatality rate was 24.2% (393/1625), varying by facility level (central 30.5%, district 25.8% and rural 7.5%), reflecting different severity of cases. From ELISA testing and a clinical protocol, we estimate that 21.7% (353/1625) of these kwashiorkor cases were HIV-infected, including 121 breastfed children. Routine tube-feeding was associated with better weight gain (8.24 g/kg/d) than no tube-feeding (4.51 g/kg/d) at central NRCs, but with no reduction in mortality (31.4% vs 30.3%). The introduction of Nutriset was associated with improved weight gain (6.06 vs 4.66 g/kg/d) and a lower mortality (20.8 vs 25.8%), but was confounded by seasonal factors.
  
  
  CONCLUSIONS
  From a clinical perspective, HIV infection has transformed kwashiorkor in this part of Africa. Routine tube-feeding was associated with improved body weight gain in the treatment of kwashiorkor. The benefit of paediatric supervision was limited by the infrequency of visits, by constraints of health worker motivation, by a lack of resources and by the severity of disease. Efforts need to focus-not just on case management protocols-but on how to actually improve clinical practice in this setting.
authors.affiliation: College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: D R
authors.initials: DR
authors.lastname: Brewster
authors.forename: M J
authors.initials: MJ
authors.lastname: Manary
authors.forename: S M
authors.initials: SM
authors.lastname: Graham
mesh_terms: D019090:Case Management; D002675:Child, Preschool; D004750:Enteral Nutrition; D005260:Female; D005527:Food, Fortified; D006801:Humans; D007732:Kwashiorkor / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008295:Malawi; D008297:Male; D012047:Rehabilitation Centers; D012307:Risk Factors; D012423:Rural Health; D012621:Seasons; D012720:Severity of Illness Index; D016896:Treatment Outcome; D015430:Weight Gain