Since then, similar community- based therapeutic care (CTC) projects, treating more than 3000 severely malnourished children in Sudan,. Malawi, and Ethiopia ...
CORRESPONDENCE
The need to update the classification of acute malnutrition Sir—In August, 2002, we reported positive results from treating severe acute malnutrition on an outpatient basis.1 Since then, similar communitybased therapeutic care (CTC) projects, treating more than 3000 severely malnourished children in Sudan, Malawi, and Ethiopia, have replicated these findings. CTC projects include three modes of treatment: dry takehome supplementary care for people with moderate malnutrition uncomplicated by anorexia or life-threatening illness; outpatient therapeutic care for those with severe malnutrition uncomplicated by anorexia or lifethreatening illness; and phase one inpatient care for severe or moderate malnutrition complicated by anorexia or concurrent life-threatening illness. These CTC projects have shown that when people have good access to the services provided and sufficient information to understand what is on offer, they present early. Since the clinical course of malnutrition is one of a gradual decline in nutritional status and increasing medical complications, people who present early are usually easier to treat. In the CTC projects, most severely malnourished individuals have presented with appetite and without serious concurrent illness. Such people can be treated effectively as outpatients. In Sudan, 2001,2 external assessors used the Prudhon index to assess the CTC project. They estimated that the mortality rate in the 807 severely malnourished children treated (including 63 oedematous patients) was
54% of that expected in a well-run therapeutic feeding centre (3·2% in the project vs 6% expected). In this project, only 2% (17) of severely malnourished patients received any inpatient care. These positive results from the new CTC model of intervention call for a change in the way that we classify acute malnutrition. The WHO classification consists of moderate and severe categories, defined according to anthropometry and the presence of This bilateral pitting oedema.3 classification was appropriate and operationally relevant when the modes of treatment involved inpatient therapeutic feeding centres for severe acute malnutrition, and outpatient supplementary feeding for moderate acute malnutrition. This new era of community-based care, however, has three treatment modes. To be operationally relevant, a new system of classification must, therefore, include complicated malnutrition as well as severe and moderate malnutrition (figure). Complicated malnutrition can arise in either severely or moderately malnourished people. In practice, the assessment of whether malnutrition is complicated dictates whether patients are admitted for inpatient stabilisation or treated only as outpatients. Several negative consequences for both patients and nutritional projects might arise if the category of complicated malnutrition is not used. For example, admission of patients with severe uncomplicated malnutrition into therapeutic feeding centres needlessly exposes them to additional risks of nosocomial infections and needlessly forces the carer, usually the mother, to spend time away from her family and other children. Such a
Acute malnutrition
Complicated malnutrition
Severe uncomplicated malnutrition
Moderate uncomplicated malnutrition
