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 be en attributed to faulty case-management. We developed a standardised protoc ol for acute-phase treatment of children with severe malnutrition and diarr hoea, 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 admi tted 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 pr otocol 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 mor e children on standardised protocol had oedema, acidosis, and Vibrio choler ae isolated from stools. 199 (59.9%) of children on standardised protocol w ere successfully rehydrated with oral rehydration solution, compared with 8 5 (29%) in the nonprotocol group (p < 0.0001). Use of expensive antibiotics was less frequent in children on standardised protocol than in the other g roup (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 pro tocol resulted in fewer episodes of hypoglycaemia, less need for intravenou s fluids, and a 47% reduction in mortality. This standardised protocol shou ld be considered in all children with diarrhoea and severe malnutrition.