Persistent diarrhea in Northeast Brazil: etiologies and interactions with malnutrition

With the improved control of acute diarrheal illness mortality with oral rehydration therapy, persistent diarrhea is now emerging as a major cause of childhood mortality in tropical developing areas like the impoverished populations in Brazil's Northeast. "Graveyard surveillance" in the rural community of Guaiuba in northeastern Brazil revealed fully half of the 70% diarrhea mortality was due to persistent diarrheal illnesses. Furthermore, 11% of 14 or more diarrheal illnesses per child per year in an urban slum in Fortaleza persisted beyond 14 days, a definition that clearly identified the high risk children for heavy diarrhea burdens. Not only did heavy diarrhea burdens ablate the key "catch-up" growth seen in severely malnourished children and in children following previous diarrheal illnesses, but malnutrition significantly predisposed children to a greater incidence and duration of diarrhea as well as a greater incidence of persistent diarrhea. Etiologic studies of 37 children presenting with persistent diarrhea to Hospital das Clinicas in Fortaleza revealed that Cryptosporidium (in 13%) and enteroadherent E. coli (36% with aggregative, 29% with diffuse and 13% with localized adherence to HEp-2 cells) were the predominant potential pathogens found in the stool or upper small bowel. These findings suggest that persistent diarrhea is emerging as an important health problem in Brazil's Northeast, that it identifies a high risk child for heavy diarrhea burdens, that important interactions occur with malnutrition and that Cryptosporidium and enteroadherent E. coli warrant further study as potential etiologies of this major cause of morbidity and mortality.     

Impact of a standardized management protocol on mortality of children with diarrhoea: an update of risk factors for childhood death

In the developing world, diarrhoeal disease is a significant cause of childhood morbidity especially amongst severely malnourished children. As a direct result of improved acute-phase management of this group of patients, there has been a 47 per cent reduction in the death rate among severely malnourished children hospitalized at the ICDDR,B in Bangladesh. The change in the risk factors for death among children aged under 5 years presenting with diarrhoea was reassessed. The charts of 366 children under 5 years of age who were hospitalized for diarrhoeal disease in the year 1998 were retrospectively analysed. One hundred and eighty-three of these patients died and 183 of those who survived acted as controls. Univariate analysis found 12 significant risk factors on admission that impacted outcome. Only two factors, female sex and positive blood culture, remained significant in the multivariate analysis with odds ratios (95 per cent CI) of 2.05 (1.1-4.0) and 4.6 (1.7-12.4), respectively. Prior to the change in the protocol involving the management of severely malnourished children, only severe malnutrition and non-breastfeeding were found to be significant predictors of mortality.     

Day-care management of children with severe malnutrition in an urban health clinic in Dhaka, Bangladesh

Management of severely malnourished children with associated complications relies on hospital-based treatment. Implementation of a standardized protocol at the Dhaka Hospital, ICDDR,B reduced case fatality approximately 50%. We developed and prospectively evaluated a day-care clinic approach that provided antibiotics, micronutrients and feeding during the day with continued care by parents at home at night as an alternative to hospitalization. Severely malnourished children aged 6-23 months denied admission to hospital were enrolled at Radda Clinic, Dhaka and received protocolized management with antibiotics, micronutrients and milk-based diet from 8:00 am to 5:00 pm each day, while mothers were educated on continuation of care at home. They were transitioned to the day-care nutrition rehabilitation (NR) unit of Radda Clinic following resolution of acute illness, received NR diet (Khichuri, halwa and milk-based) daily until children attained 80% weight-for-length. From February 2001 to November 2003, 264 children were enrolled; 52% were boys and 78%, 21% and 1% had marasmus, marasmus-kwashiorkor and kwashiorkor, respectively. Only 13% had severe malnutrition alone while 35% had pneumonia, 35% had diarrhea and 17% had both pneumonia and diarrhea. The mean (SD) duration of acute and NR phases were 8 (4) and 14 (13) days, respectively. Children gained weight [mean (SD) g/kg day] more rapidly during acute 10 (7) than NR phase 6 (5). Successful management was possible in 82% (95% CI 77-86%) children, 12% discontinued treatment and 6% referred to hospitals. Only one child died during NR phase. Severely malnourished children can be successfully managed at existing day-care clinics using a protocolized approach.     

Persistent diarrhea as a cause of childhood mortality in rural Bangladesh

To determine the importance of persistent diarrhea in childhood mortality a multiple-step verbal autopsy method was used to study 1934 deaths in Matlab, Bangladesh. We found that most of the deaths from acute watery diarrhea occurred in infancy, whereas the peak of non-watery diarrhea deaths was in children over 12 months of age. Children suffering from persistent diarrhea and malnutrition were at highest risk of dying during their third year of life. Children with infectious diseases have a two to four times higher risk of dying if they are malnourished, and for diarrhea the risk is 17 times as high. Forty-nine percent of the diarrheal deaths were in children with malnutrition associated with persistent diarrhea. These results imply that fluid and dietary management are key aspects in the treatment of diarrhea, particularly for those episodes which persist. We conclude that attempts to reduce diarrhoeal deaths with vertical ORT programmes will not have a major impact unless other interventions are directed to the persistent diarrhoea-malnutrition complex.     

Critical appraisal of the management of severe malnutrition: 3. Complications

Abstract:   The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20–40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.     

Management of Acute Diarrhea in Emergency Room

Acute diarrhea is the second leading cause of under-five mortality in India. It is defined as the passage of frequent watery stools (>3/24 h). Recent change in consistency of stools is more important than frequency. Acute diarrhea is caused by variety of viral, bacterial and parasitic agents. The common ones are: Rotavirus, E. coli, Shigella, Cholera, and Salmonella. Campylobacter jejuni, Giardia and E. histolytica are also not uncommon. The most important concern in management of acute diarrhea in Emergency room (ER) is fluid and electrolyte imbalances and treatment of underlying infection, wherever applicable. It includes, initial stabilization (identification and treatment of shock), assessment of hydration and rehydration therapy, recognition and treatment of electrolyte imbalance, and use of appropriate antimicrobials wherever indicated. For assessment of hydration clinical signs are generally reliable; however, in severely malnourished children sunken eyes and skin turgor are unreliable. Oral Rehydration Therapy is the cornerstone of management of dehydration. Intravenous fluids are not routinely recommended except in cases of persistent vomiting and/or shock. Majority of cases can be managed in ER and at home. Hospitalization is indicated in infants <3 mo, children with severe dehydration, severe malnutrition, toxic look, persistent vomiting and suspected surgical abdomen. Supplementations with zinc and probiotics have been shown to reduce severity and duration of diarrhea; however evidence does not support the use of antisecretary, antimotility and binding agents. Education of parents about hand hygiene, safe weaning and safe drinking water etc., can help in reducing incidence of this important health problem in the country.     

Cryptosporidium, malnutrition, and chronic diarrhea in children

Cryptosporidium was found in the stools of 13.5% of 221 children hospitalized with diarrhea. It was the single most prevalent pathogen isolated. Children with Cryptosporidium-positive stools were significantly more malnourished than children in whom Cryptosporidium was not detected. Children with more severe malnutrition (ie, less than 50% of their expected weight) and with Cryptosporidium in their stools had a significantly longer duration of diarrhea than similarly malnourished children without Cryptosporidium (63 vs 32 days, respectively). In 77 better-nourished outpatients with diarrhea, Cryptosporidium was found in only 5.2% of cases and was associated with less-severe illness. Our findings are consistent with the hypothesis that in less-developed areas, Cryptosporidium is a major pathogen, not only in acute but also in chronic childhood diarrhea, and may play an important role in the interaction between diarrhea and malnutrition.     

Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea

OBJECTIVES: Efficacy, development of overhydration, and correction of electrolyte disturbances of severely malnourished children with acute diarrhea using a modified oral rehydration solution for malnourished children (termed ReSoMaL and recommended by the World Health Organization [WHO]) were evaluated and compared with standard WHO-oral rehydration solution (ORS). STUDY DESIGN: Children age 6 to 36 months with severe malnutrition and acute watery diarrhea were randomized to ReSoMaL (n=65) or standard WHO-ORS (n=65). Major outcome measures included the number of children who developed overhydration and the number who corrected hypokalemia. RESULTS: The numbers of children who developed overhydration were not significantly different (ReSoMaL vs WHO-ORS, 5% vs 12%, P=.2). ReSoMaL corrected basal hypokalemia in a greater proportion of children by 24 hours (36% vs 5%, P=.0006) and 48 hours (46% vs 16%, P=.004) compared with WHO-ORS. More children on ReSoMaL than WHO-ORS remained hyponatremic at 48 hours (29% vs 10%, P=.017). Three children in the ReSoMaL group developed severe hyponatremia by 24 hours, with one experiencing hyponatremic convulsions (serum sodium, 108 mmol/L). CONCLUSIONS: ReSoMaL has a large beneficial effect on potassium status compared with standard ORS. However, ReSoMaL therapy may result in symptomatic hyponatremia and seizures in patients with severe diarrhea.     

Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome.

AIMS: To determine the prevalence, clinical characteristics, and outcome of hypoglycaemia on admission in children at a rural Kenyan district hospital. METHODS: Observational study of 3742 children (including 280 neonates) in Kilifi District Hospital, Kenya. Main outcome measures: hypoglycaemia (blood glucose <2.2 mmol/l) and hyperglycaemia (blood glucose >10.0 mmol/l). RESULTS: Non-neonates: the prevalence of hypoglycaemia on admission was 7.3%. Severe illness, malnutrition, last meal >12 hours ago, and a positive malaria slide were independently associated with hypoglycaemia. Overall, mortality in hypoglycaemic children was 20.2% compared to 3.8% in normoglycaemic children (p < 0.001). The brunt of mortality in hypoglycaemic children was borne by those who were severely ill or malnourished (31.8%) as opposed to those who were neither severely ill nor malnourished (9.0%). Neonates: 23.0% of neonates were hypoglycaemic on admission. Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Hyperglycaemia was present in 2.7% of children and was associated with a higher mortality than normoglycaemia, 14.0% versus 3.8% respectively (p < 0.001). CONCLUSIONS: Hypoglycaemia is common in children admitted to a rural Kenyan district hospital and is associated with an increased mortality. Apart from features of severe illness and poor feeding, clinical signs have a low sensitivity and specificity for hypoglycaemia. Where diagnostic facilities are lacking, presumptive treatment of severely ill children is recommended. For other children, the continuation of feeding (by nasogastric tube if necessary) should be part of standard management.     

An integrated community‐based outpatient therapeutic feeding programme for severe acute malnutrition in rural Southern Ethiopia: Recovery,fatality, and nutritional status after discharge

A scaled up and integrated outpatient therapeutic feeding programme (OTP) brings the treatment of severely malnourished children closer to the community. This study assessed recovery from severe acute malnutrition (SAM), fatality, and acute malnutrition up to 14 weeks after admission to a programme integrated in the primary health care system. In this cohort study, 1,048 children admitted to 94 OTPs in Southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits. Only 32.7% (248/759) of children with SAM on admission fulfilled the programme recovery criteria at the time of discharge (i.e., gained 15% in weight, or oedema, if present at admission, was resolved at discharge). Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely malnourished, and 37.5% (348/928) were moderately malnourished; thus, 72.1% were acutely malnourished. Of the children, 27/982 (2.7%) had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75). The median length of admission to the programme was 6.6 weeks (interquartile range: 5.3, 8.4 weeks). Despite children participating for the recommended duration of the programme, many children with SAM were discharged still acutely malnourished and without reaching programme criteria for recovery. For better outcome of OTP, constraints in service provision by the health system as well as challenges of service utilization by the beneficiaries should be identified and addressed.     

Malnutrition: a secular challenge to child nutrition

OBJECTIVE: To review current knowledge about child malnutrition, including the historical aspects of the problem, its dimension as a childhood public health problem, its natural history, physiopathology, clinical features, diagnosis and treatment, and strategies used by the health sector to control this disease. METHODS: Information was collected by researching the Medline system, the Bireme library, internet sites of interest, catalogues of publications produced by Brazilian governmental organizations and international institutions dealing with child nutrition. RESULTS: The review pointed out that despite recent world prevalence reduction, child malnutrition is a major public health problem in developing countries. Malnutrition, in any of its forms, contributes for more than 50% of deaths among children under 5 years in those countries. Mortality rates of severely malnourished children treated as in patients have been unchanged for the last five decades. Guidelines for improving the treatment and reducing mortality rates of severely malnourished children treated in hospitals were recently defined by the World Health Organization. Even though some positive results have been achieved by the health sector in reducing child malnutrition prevalence, the effectivity of the interventions is often low. Lack of food might limit the success in treating and preventing malnutrition. Factors that may contribute to the effectiveness of interventions against malnutrition include approaches which reassure the confidence of health professionals about achieving positive results with the proper treatment of malnourished children, establishment of an effective relationship between health professionals and mothers, as well as practical support to mothers in recognizing them as valuable active agents for their children nutrition rehabilitation at the household level. CONCLUSIONS: Throughout the centuries, malnutrition has been the biggest challenge faced by developing countries in order to guarantee to children under five years of age their right of being well nourished and healthy. The current challenge is the proper use of the available scientific knowledge on child nutrition to further reduce the figures for all the types of child malnutrition.     

Pneumococcal bacteraemia--a study of 75 black children

Seventy-five black children from 0 to ten years old with pneumococcal bacteraemia, who were hospitalized during a one-year period, were studied retrospectively from case records. Half the children were under one year and 68% under two years of age. Sixty-seven per cent were malnourished, 34% severely so. The overall case-fatality-rate was 26.7% being highest in children presenting in autumn (52.4%) and in those with meningitis (54.5%), severe protein-calorie malnutrition (42.8%) or associated infections (61.5%). Host defences against the pneumococcus are discussed, especially in relation to their deficiencies in malnourished and young children. Special mention is made of early-onset neonatal sepsis due to the pneumococcus and of the association between pneumococcal bacteraemia and acute post-streptococcal glomerulonephritis. This study indicates that pneumococcal bacteraemia is a serious infection in children, especially in those with malnutrition and other infections. In view of the emergence of penicillin-resistant strains, its treatment may become more difficult in the future.     

Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome

Aims: To determine the prevalence, clinical characteristics, and outcome of hypoglycaemia on admission in children at a rural Kenyan district hospital. Methods: Observational study of 3742 children (including 280 neonates) in Kilifi District Hospital, Kenya. Main outcome measures: hypoglycaemia (blood glucose <2.2 mmol/l) and hyperglycaemia (blood glucose >10.0 mmol/l). Results: Non-neonates: the prevalence of hypoglycaemia on admission was 7.3%. Severe illness, malnutrition, last meal >12 hours ago, and a positive malaria slide were independently associated with hypoglycaemia. Overall, mortality in hypoglycaemic children was 20.2% compared to 3.8% in normoglycaemic children (p < 0.001). The brunt of mortality in hypoglycaemic children was borne by those who were severely ill or malnourished (31.8%) as opposed to those who were neither severely ill nor malnourished (9.0%). Neonates: 23.0% of neonates were hypoglycaemic on admission. Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Hyperglycaemia was present in 2.7% of children and was associated with a higher mortality than normoglycaemia, 14.0% versus 3.8% respectively (p < 0.001). Conclusions: Hypoglycaemia is common in children admitted to a rural Kenyan district hospital and is associated with an increased mortality. Apart from features of severe illness and poor feeding, clinical signs have a low sensitivity and specificity for hypoglycaemia. Where diagnostic facilities are lacking, presumptive treatment of severely ill children is recommended. For other children, the continuation of feeding (by nasogastric tube if necessary) should be part of standard management.     

A large-scale operational study of home-based therapy with ready-to-use therapeutic food in childhood malnutrition in Malawi

Home-based therapy with ready-to-use therapeutic food (RUTF) for the treatment of malnutrition has better outcomes in the research setting than standard therapy. This study examined outcomes of malnourished children aged 6-60 months enrolled in operational home-based therapy with RUTF. Children enrolled in 12 rural centres in southern Malawi were diagnosed with moderate or severe malnutrition according to the World Health Organization guidelines. They were treated with 733 kJ kg(-1) day(-1) of RUTF and followed fortnightly for up to 8 weeks. Staff at each centre followed one of three models: medical professionals administered treatment (5 centres), patients were referred by medical professionals and treated by community health aids (4 centres), or community health aids administered treatment (3 centres). The primary outcome of the study was clinical status, defined as recovered, failed, died or dropped out. Regression modelling was conducted to determine what aspects of the centre (formal training of staff, location along a main road) contributed to the outcome. Of 2131 severely malnourished children and 806 moderately malnourished, 89% and 85% recovered, respectively. Thirty-four (4%) of the moderately malnourished children failed, with 20 (2%) deaths, and 61 (3%) of the severely malnourished children failed, with 29 (1%) deaths. Centre location along a road was associated with a poor outcome. Outcomes for severely malnourished children were acceptable with respect to both the Sphere guidelines and the Prudhon case fatality index. Home-based therapy with RUTF yields acceptable results without requiring formally medically trained personnel; further implementation in comparable settings should be considered.     

Response to live attenuated measles vaccine in children with severe kwashiorkor

An impaired response to vaccination with live attenuated measles vaccine was found in severely malnourished children, when compared with well nourished controls. It is suggested that humoral immune response may fail in children with severe protein energy malnutrition due to diversion of available amino acids to other uses. The possibility of a delayed antibody response to measles vaccine in malnourished children was not excluded.     

The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi

A study was undertaken in a central nutritional rehabilitation unit in southern Malawi to assess the impact of HIV infection on clinical presentation and case fatality rate. HIV seroprevalence in 250 severely malnourished children over 1 year of age was 34.4% and overall mortality was 28%. HIV infection was associated significantly more frequently with marasmus (62.2%) than with kwashiorkor (21.7%) (p < 0.0001). Breastfed children presenting with severe malnutrition were significantly more likely to be HIV-seropositive (p < 0.001). Clinical and radiological features were generally not helpful in distinguishing HIV-seropositive from HIV-seronegative children. The case fatality rate was significantly higher for HIV-seropositive children (RR 1.6 [95% CI 1.14-2.24]). The increasing difficulties of managing the growing impact of HIV infection on severely malnourished children in Malawi are discussed in the context of reduced support for nutritional rehabilitation units.     

WHO guidelines for severe malnutrition: are they feasible in rural African hospitals?

AIMS: To assess the feasibility of implementing and sustaining the WHO guidelines for inpatient management of severe malnutrition in under-resourced rural South African hospitals, and to identify any constraints. INTERVENTION: Three 2-day training workshops were held in 1998, followed by monthly 1-day visits for 5 months, ending in March 1999, in two rural district hospitals with limited resources in Eastern Cape Province, South Africa. METHODS: A 12-month observational study was conducted from April 2000 to April 2001 in Mary Theresa and Sipetu hospitals (Eastern Cape Province, South Africa), including 1011 child-hours of observation on the wards, medical record reviews, interviews with carers and staff, and inventories of essential supplies. All admissions (n = 193) for severe malnutrition to the two hospitals were studied. The main outcomes were the extent to which the 10 steps for routine care of severely malnourished children were implemented, proficiency of performance and constraining factors. RESULTS: The hospitals made the changes required in clinical and dietary management, but the tasks were not always performed fully or with sufficient care. Play and stimulation and an effective system of follow-up were not implemented. Doctors' poor knowledge, nurses' inattentiveness and insufficient interaction with carers were constraints to optimal management. The underlying factors were inadequate undergraduate training, understaffing, high doctor turnover and low morale. CONCLUSIONS: Guidelines for severe malnutrition are largely feasible but training workshops are insufficient to achieve optimal management as staff turnover and an unsupportive health system erode the gains made and doctors treat cases without having being trained. Medical and nursing curricula in Africa must include treatment of severe malnutrition.     

Detection of severe protein-energy malnutrition by nurses in The Gambia.

AIM: To test whether nurses can use the WHO integrated management of childhood illness (IMCI) nutrition algorithm to identify reliably severe protein-energy malnutrition in children. METHODS: Nurses were trained to identify severe protein-energy malnutrition using IMCI training materials. They identified visible severe wasting and bipedal oedema, and categorised weight-for-age using a growth chart, in consecutive children attending outpatient clinics. Their findings were compared with weight for height Z (WHZ) score, bipedal oedema assessed by a trained observer, and weight-for-age Z score. RESULTS: A total of 352 children were recruited, of whom 34 (9.7%) were severely wasted (WHZ score <-3) and 18 (5.1%) had bipedal oedema. In the detection of severe wasting, the nurses' assessments showed 56% sensitivity, 95% specificity, and 56% positive predictive value (PPV), and for bipedal oedema 22%, 99%, and 57% respectively. Overall, the nurses identified only half of 50 children with severe wasting and/or bipedal oedema and wrongly identified a further 13 children as severely malnourished. Plotting weight for age by the nurses showed 62% sensitivity, 99% specificity, and 89% PPV for the detection of children with very low weight. CONCLUSIONS: Severe malnutrition was both under-diagnosed and wrongly diagnosed by nurses trained in the use of the IMCI nutrition algorithm in a clinic setting in The Gambia. These guidelines for health workers and the training materials, particularly with respect to calculation of age, need further development to improve the detection of malnourished children.     

Detection of severe protein-energy malnutrition by nurses in The Gambia

Aim: To test whether nurses can use the WHO integrated management of childhood illness (IMCI) nutrition algorithm to identify reliably severe protein-energy malnutrition in children. Methods: Nurses were trained to identify severe protein-energy malnutrition using IMCI training materials. They identified visible severe wasting and bipedal oedema, and categorised weight-for-age using a growth chart, in consecutive children attending outpatient clinics. Their findings were compared with weight for height Z (WHZ) score, bipedal oedema assessed by a trained observer, and weight-for-age Z score. Results: A total of 352 children were recruited, of whom 34 (9.7%) were severely wasted (WHZ score <-3) and 18 (5.1%) had bipedal oedema. In the detection of severe wasting, the nurses'' assessments showed 56% sensitivity, 95% specificity, and 56% positive predictive value (PPV), and for bipedal oedema 22%, 99%, and 57% respectively. Overall, the nurses identified only half of 50 children with severe wasting and/or bipedal oedema and wrongly identified a further 13 children as severely malnourished. Plotting weight for age by the nurses showed 62% sensitivity, 99% specificity, and 89% PPV for the detection of children with very low weight. Conclusions: Severe malnutrition was both under-diagnosed and wrongly diagnosed by nurses trained in the use of the IMCI nutrition algorithm in a clinic setting in The Gambia. These guidelines for health workers and the training materials, particularly with respect to calculation of age, need further development to improve the detection of malnourished children.     

Diagnosis and treatment of severely malnourished children with diarrhoea

Children with severe acute malnutrition complicated by diarrhoea require special care due to their unique physiological vulnerability and increased mortality risks. A systematic literature review (1950–2013) was conducted to identify the most effective diagnostic and therapeutic measures for the community‐based management of severely malnourished children with diarrhoea. No studies directly addressed this question, so the search was broadened to include inpatient care. Of the 129 studies identified, 32 were selected for full review and found to contain varying degrees of indirectness, inconsistency and bias. Evidence from diagnostic studies point to the use of both prolonged and persistent diarrhoea as morbidity markers, rapid hypoglycaemia diagnosis and the frequent aetiological role of Cryptosporidium. Therapeutic studies suggest benefits from routine antiparasitic medication and feeding regimens with ready‐to‐use‐therapeutic foods, lactose‐free diets and zinc supplementation. Existing rehydration treatment guidelines were affirmed, but the utility of glutamine and low osmolarity feeds were inconclusive.