Brewster D R, Manary M J, Graham S M
College of Medicine, University of Malawi, Blantyre, Malawi.
Eur J Clin Nutr. 1997 Mar;51(3):139-47. doi: 10.1038/sj.ejcn.1600367.
(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).
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.
NRCs located at two central hospitals, two district hospitals and three rural clinics in southern Malawi.
1625 consecutive kwashiorkor admissions from January-December 1995.
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.
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.
（1）通过每周2 - 4次的儿科督导访视，改善7个营养康复中心（NRCs）对夸希奥科病的病例管理。（2）评估使用常规管饲法和微量营养素补充剂（Nutriset）的影响。
一项带有描述性临床数据的干预项目，在项目进行到一半时引入Nutriset，并将一个营养康复中心的常规管饲法与另一个类似中心不进行管饲法的情况进行比较。
位于马拉维南部两家中心医院、两家地区医院和三家农村诊所的营养康复中心。
1995年1月至12月连续收治的1625例夸希奥科病患者。
总体病死率为24.2%（393/1625），因机构级别而异（中心医院为30.5%，地区医院为25.8%，农村诊所为7.5%），反映出病例严重程度不同。通过酶联免疫吸附测定（ELISA）检测和临床方案，我们估计这些夸希奥科病病例中有21.7%（353/1625）感染了艾滋病毒，其中包括121名母乳喂养儿童。在中心营养康复中心，常规管饲法与未进行管饲法相比，体重增加情况更好（8.24克/千克/天 vs 4.51克/千克/天），但死亡率没有降低（31.4% vs 30.3%）。引入Nutriset与体重增加改善（6.06 vs 4.66克/千克/天）和较低的死亡率（20.8% vs 25.8%）相关，但受到季节因素的干扰。
从临床角度来看，艾滋病毒感染改变了非洲这一地区的夸希奥科病情况。常规管饲法在夸希奥科病治疗中与体重增加改善相关。儿科督导的益处受到访视频率低、卫生工作者积极性受限、资源缺乏以及疾病严重程度的限制。需要做出努力——不仅要关注病例管理方案——还要关注如何在这种情况下切实改善临床实践。
