Dermatological changes in a prospective cohort of acutely ill, hospitalised Malawian children, stratified according to nutritional status.

RATIONALE: Since the first documentation of skin changes in malnutrition in the early 18th century, various hair and skin changes have been reported in severely malnourished children globally. We aimed to describe the frequency and types of skin conditions in children admitted with acute illness to Queen Elizabeth Central Hospital, Blantyre, Malawi across a spectrum of nutritional status and validate an existing skin assessment tool. METHODS: Children between 1 week and 23 months of age with acute illness were enrolled and stratified by anthropometry. Standardised photographs were taken, and three dermatologists assessed skin changes and scored each child according to the SCORDoK tool. RESULTS: Among 103 children, median age of 12 months, 31 (30%) had severe wasting, 11 (11%) kwashiorkor (nutritional oedema), 20 (19%) had moderate wasting, 41 (40%) had no nutritional wasting and 18 (17%) a positive HIV antibody test. Six (5.8%) of the included patients died. 51 (50%) of children presented with at least one skin change. Pigmentary changes were the most common, observed in 35 (34%), with hair loss and bullae, erosions and desquamation the second most prevalent skin condition. Common diagnoses were congenital dermal melanocytosis, diaper dermatitis, eczema and postinflammatory hyperpigmentation. Severe skin changes like flaky paint dermatosis were rarely identified. Inter-rater variability calculations showed only fair agreement (overall Fleiss' kappa 0.25) while intrarater variability had a fair-moderate agreement (Cohen's kappa score of 0.47-0.58). DISCUSSION: Skin changes in hospitalised children with an acute illness and stratified according to nutritional status were not as prevalent as historically reported. Dermatological assessment by means of the SKORDoK tool using photographs is less reliable than expected.

Beyond wasted and stunted-a major shift to fight child undernutrition.

Child undernutrition refers broadly to the condition in which food intake is inadequate to meet a child's needs for physiological function, growth, and the capacity to respond to illness. Since the 1970s, nutritionists have categorised undernutrition in two major ways, either as wasted (ie, low weight for height, or small mid-upper arm circumference) or stunted (ie, low height for age). This approach, although useful for identifying populations at risk of undernutrition, creates several problems: the focus is on children who have already become undernourished, and this approach draws an artificial distinction between two idealised types of undernourished children that are widely interpreted as indicative of either acute or chronic undernutrition. This distinction in turn has led to the separation of programmatic approaches to prevent and treat child undernutrition. In the past 3 years, research has shown that individual children are at risk of both conditions, might be born with both, pass from one state to the other over time, and accumulate risks to their health and life through their combined effects. The current emphasis on identifying children who are already wasted or stunted detracts attention from the larger number of children undergoing the process of becoming undernourished. We call for a major shift in thinking regarding how we assess child undernutrition, and how prevention and treatment programmes can best address the diverse causes and dynamic biological processes that underlie undernutrition.