Reply to correspondence letter by M. Das et al.: WHO Child Growth Standards

Abstract

Das and coworkers make two main points in their letter (ref). First, they argue that there is a need for a mixed clinical-anthropometrical classification system of proteinenergy malnutrition (PEM) as a tool for pediatricians and public health workers involved in nutritional interventions. Second, they implicitly suggest that the particular mixed classification system proposed by Bhattacharyya (1986) would be appropriate after some simplifications and adaptation by using the World Health Organization (WHO) 2006 Child Growth Standards. Mixed clinical-anthropometrical classifications of PEM all essentially combine one or more broad levels of anthropometric stunting, wasting, or underweight (variously defined) with clinical syndromes based on simple clinical signs, mostly edema, and sometimes also visible loss of subcutaneous fat, dermatosis, or other signs of PEM. The classification of Bhattacharyya (1986), in addition, brings in further distinctions such as between “current acute,” “current chronic,” and “past chronic” PEM. The clinical usefulness of such classifications as broadly described above (and indeed of all classifications) depends on whether they effectively support clinical decision making in terms of referral, diagnosis, choice of proper treatment, evaluation of treatment success, or advice to prevent both recurrence and occurrence in family members. If that is taken as the criterion, one way in which current mixed classifications achieve part of that goal is by distinguishing medical emergency situations made up by the presence of rare kwashiorkor syndromes or by the existence of extreme wasting. In resource-limited settings where PEM is frequent and mostly caused by undernutrition and infections rather than by underlying chronic diseases and in clinical settings with limited diagnostic and treatment resources, the mixed classifications may have further value, for example as screening tools for referral, as a basis for prioritization of treatment and nutritional rehabilitation efforts, or as tools to monitor nutritional rehabilitation progress. In many other contexts, however, they are likely to be insufficient as a basis for clinical decision making, especially as a basis for planning or monitoring of individualized intervention. In some contexts, PEM tends to be one of several complications of an underlying chronic disease process in a majority of cases. The implication is that more refined nutritional assessment and assessment of underlying diseases and of organ functioning will be needed to inform individualized treatment and the type and timing of nutritional rehabilitation. Nutritional assessment will tend to concern body composition, metabolic state, electrolyte balance, micronutrient status, and diet and requires putting the nutritional condition of the person in context of the entire medical condition and history. Recognition of catabolic states, acute infections, electrolyte imbalances, micronutrient deficiencies, and renal function, among others, dictate the modalities of the nutritional rehabilitation strategy. In addition, a proper longitudinal view on (recovery of) nutritional status requires assessments of weight velocities or increments and interpretation of the longitudinal trends of different anthropometric indices. J. Van den Broeck (*) Department of Epidemiology and Public Health, University College Cork, Cork, Ireland e-mail: Jvdbroeck1959@gmail.com