London School of Hygiene & Tropical Medicine

Eight out of ten children who die from malnutrition in hospital in the developing world are doing so unnecessarily, and as the result of errors on the part of doctors and nurses, a study in the medical journal the Lancet reveals today.

About 11 million children aged 0-4 die worldwide every year, and 99% of these are in the developing world. Malnutrition is associated with more than 60% of these deaths. Of those admitted to hospital, up to half die, and eight out of ten of these deaths can be attributed to poor hospital care.

The World Health Organisation (WHO) introduced guidelines in 2000 aimed at improving the quality of hospital care for malnourished children, and their implementation is one of the goals of the WHO strategy of Integrated Management of Childhood Illness. This study, carried out by staff at the London School of Hygiene & Tropical Medicine's Public Health Nutrition Unit with colleagues at the School of Public Health, University of Western Cape, South Africa and the Health Systems Trust, Cape Town, South Africa aimed to determine whether these guidelines were feasible and effective in under-resourced hospitals in developing countries.

Researchers studied all children admitted with a diagnosis of severe malnutrition to two rural hospitals in the Eastern Cape Province of South Africa between April 2000 and April 2001. Case fatality rates were compared with rates in a period before guidelines were implemented (March 1997 to February 1998).

At one location, the number of deaths more than halved, dropping from 46% before the implementation of the guidelines to 21% afterwards, while in the other rates fell from 25% to 18%, only to rise again to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. For the two hospitals combined, 50% of deaths in 2000-1 were due to doctor error and 28% to nurse error - in other words, weaknesses in the training, supervision and support of doctors and nurses contribute to eight out of ten deaths in children suffering from severe malnutrition.

The most frequent cause of death was sepsis (43%), and most deaths from sepsis were judged to be avoidable, and mainly caused by doctors failing to prescribe appropriate antibiotics. Deaths by dehydration and overhydration caused by poor fluid management were the next most common cause of death, and all were avoidable, with more than half judged to be the result of nurse error. 'Most were late deaths associated with failure to prevent dehydration in continuing or new episodes of diarrhoea or vomiting', explain the authors.

'Management of dehydration involves careful monitoring and reassessment of a child's condition', they continue, 'which requires not only clinical competence but also patience, attentiveness, and commitment. Understaffing, stress, and low morale in the workplace can undermine the motivation and commitment of staff, which in turn leads to poor performance and we believe these factors contributed to suboptimum care in the two hospitals'. Electrolyte imbalance was also identified as a common cause of avoidable death, with newly-qualified doctors failing to prescribe oral potassium because of a mistaken belief that it was dangerous.

The researchers identify several key changes to hospital policy which facilitated implementation of the guidelines, even in hospitals with scarce resources. These include ensuring that nurses were not rotated from the paediatric ward to other wards, and allowing mothers to stay overnight with their sick children and help with feeding. They also recommend triage training for outpatient staff, the training and motivation of clinic staff and community health workers to facilitate more effective community follow-up, and greater efforts to encourage carers to play and interact more with the children, which is known to improve mental development.

'The main failures were not because of problems inherent in the guidelines, but because of clinical errors and weaknesses in the health system, which could be remedied', explain the authors. 'For example, the high proportion of deaths attributed to doctor error highlights the need to improve medical training to equip young doctors to treat the conditions that they will encounter in their professional lives. In Africa, the WHO guidelines for inpatient management of severe malnutrition should be part of the medical and nursing curricula'.

The authors conclude that substantial improvements in the quality of care for children with severe malnutrition can be achieved with quite low levels of investment, but concede that weaknesses in the health system infrastructure in developing countries, combined with lack of leadership and supportive supervision and inadequate undergraduate training, make improvements difficult.

'Our findings are a timely reminder that a clinical approach to improving quality of care needs to be accompanied by broader initiatives in health systems and management to ensure the optimum translation of clinical guidelines into sustained good practice and improved health outcomes', they say. 'Furthermore, such initiatives would benefit the quality of care of other patients, not only severely malnourished children'.

To interview Ann Ashworth Hill, lead author of the study, please contact the London School of Hygiene & Tropical Medicine's Press Office in 020 7927 2073.

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