Characterization and scoring of skin changes in severe acute malnutrition in children between 6 months and 5 years of age.

BACKGROUND: Severe acute malnutrition is a life-threatening condition. It can be associated with severe skin changes, first properly described by Williams in 1933. The aetiology of these skin changes is still unknown and their character has never been systematically described in dermatological terms. The skin changes have been shown to be a predictor of mortality in hospital care. Systematic investigations on the character of the skin changes that have effect on prognosis, are needed to investigate which of the skin changes that are relevant to improve treatment. OBJECTIVES: Our main objective was to identify the skin changes characteristic of children with severe acute malnutrition and to develop a clinical score that describes the morphology and severity in dermatological terms. We also investigated if any of the different skin changes were connected to prognosis. MATERIALS AND METHODS: At Mulago Hospital, Mwanamugimu (Department of Paediatrics and Child Health), Uganda, 120 children were included over a period of six months and observed when treated for severe acute malnutrition. Skin changes were registered through clinical examination and photo documentation and associated to prognosis using Cox and logistic regression analysis. RESULTS: Skin manifestations were characterized by five objective skin signs: telogenic effluvium, pigmentary changes (hyper- and hypo-pigmentation), ichthyosiform skin changes, lichenoid skin changes and bullae-erosion-desquamation. The skin changes could be registered in a systematic manner using our simple clinical score. Lichenoid skin changes were a significant predictor of death and allowed improved accuracy of prediction of mortality. CONCLUSIONS: The clinical score is simple and practical. A standardized way to register and score the skin changes, will allow a more unified way of reporting results in future studies. The standardization of observations, obtained through the proposed scoring system, will enable comparison of study results in the future.

Proposed guidelines for the management of nodding syndrome.

Nodding Syndrome is a poorly understood neurologic disorder of unknown aetiology that affects children and adolescents in Africa. Recent studies have suggested that the head nods are due to atonic seizures and Nodding Syndrome may be classified as probably symptomatic generalised epilepsy. As part of the Ugandan Ministry of Health clinical management response, a multidisciplinary team developed a manual to guide the training of health workers with knowledge and skills to manage the patients. In the absence of a known cause, it was decided to offer symptomatic care. The objective is to relieve symptoms, offer primary and secondary prevention for disability and rehabilitation to improve function. Initial management focuses on the most urgent needs of the patient and the immediate family until 'stability' is achieved. The most important needs were considered as seizure control, management of behavioural and psychiatric difficulties, nursing care, nutritional and subsequently, physical and cognitive rehabilitation. This paper summarises the processes by which the proposed guidelines were developed and provides an outline of the specific treatments currently being provided for the patients.