A pragmatic approach to treating severe malnutrition in emergencies: is F75 always beneficial?

By Saskia van der Kam

Saskia is the headquarters nutritionist in MSF Holland.

This article describes MSF's experience of implementing a therapeutic feeding programme for adults in Wau, southern Sudan in 1998. Current MSF guidelines advocate a pragmatic approach to the treatment of malnutrition and, depending on the circumstances, advise the use of a single formula regimen in order to simplify protocols (see letters section, page 9 and excerpt from current MSF guidelines below). Readers should note that this is contrary to WHO guidelines highlighted in the box below. MSF challenges current thinking on the use of only one standard strategy to treat severe malnutrition (e.g. 2 milks, 3 phases, 24 hour inpatient care) and calls for further research. (Eds.)


The following is an excerpt from current MSF guidelines on choosing a therapeutic milk.

  • F100 milk is recommended in emergency situations (preference)
  • When F100 milk is not (yet) available or affordable, high energy milk (HEM) can be prepared.

The use of F75 or F100 diluted can be considered when:

  • TFC is well organised
  • There are a high number of kwashiorkor admissions
  • Many adults fail to improve
  • Mortality rate in a TFC is high


Current WHO guidelines recommend the use of both F75 and F100 in the management of severe malnutrition. F75 is used in the initial phase of feeding and F100 in the rehabilitation phase, after appetite has returned. The initial phase using F75 may last from 2-7 days, the duration being determined by the child's appetite and general condition.

Management of severe malnutrition: A manual for Physicians and other senior health workers. WHO, Geneva, 1999


Mortality in an Adult Therapeutic Feeding Centre in Wau

Wau, an enclave in South Sudan controlled by the government in North Sudan, had about 80,000 inhabitants in the spring of 1998. During the famine of that year, 72,000 displaced Dinkas entered the town between May and September 1998. The peak of the influx was in July with 1000 per day arriving. The displaced were in a deplorable state. Rough estimates of the mortality rates in town were 15- 20/10,000/day (August 1998).

A survey of resident and displaced children under five found global and severe malnutrition rates of 43.3% and 18.6% respectively. In the internally displaced population (IDP) alone, the global and severe malnutrition rates were 71% and 41% respectively (UNICEF, August 1998). Amongst 329 adults (18-49 years) screened on first arrival, 56% of males and 45% of females had a BMI below 16 kg/m2 (ICRC, southern reception point, August 1998).

By July, some NGOs (CARE, SCF, ICRC) had begun operating supplementary feeding programmes and were distributing soups or porridge. Other NGOs were only able to start feeding interventions in September (ACF, Goal).

In July, MSF established a Therapeutic Feeding programme for children in the hospital. Later, MSF took over the adult ward in the hospital and began a feeding programme for adults. Both programs were closed in the third week of December since mortality and malnutrition rates in Wau had declined and other NGOs had established additional feeding programmes. By November the overall global and severe malnutrition rates in Wau had declined to 9.6% and 2.4% respectively.

The mortality rate (measured as % of exits) in the TFC for children was 5% in August and 1.7% in September despite admission criteria of < 60% weight for height. The mortality rates subsequently increased to 11% in October and 12% in November, eventually returning to 4.2% in December. This increase in mortality can mainly be explained by the fact that despite the increasing number of other NGO feeding programmes treating a greater number of children elsewhere, the most severe and sick cases remained within the MSF programme.

The results on the adult ward were disappointing. Although the mortality rate declined from nearly 100% at the time of MSF take over of the ward, the rate stabilised at 25% and improved no further.

Several reasons for the high mortality rate were identified:

The organisational difficulties were:

The feeding regime initially used was High Energy Milk (HEM) made from DSM, oil and sugar. In September this was replaced by F100, and F75 was introduced in October. This staggered introduction was necessary due to shipment delays to the field. An interim recommendation to decrease the osmolarity of the HEM by dilution was only received by the field at a relatively late stage (beginning September). At this time staff decided to 'wait' for shipment of F100 and F75 so that they would only have to introduce one change to the feeding protocol. With hind-sight this was probably not a good decision since F75 did not subsequently arrive until October. However, the introduction of F75 was not met by the anticipated reduction in the mortality rate (see graphs).

In the event of a similar scenario in the future, MSF will use F75 where available (see excerpt from MSF guidelines) and will take steps to dilute HEM milk as necessary. However, despite the theoretical basis supporting F75, this programme experienced no reduction in mortality following the introduction of F75. This case study serves to highlight uncertainty over the extent to which use of F75 is able to reduce mortality in severely malnourished adults in this type of situation.

Range of strategies

This case study illustrates how in emergencies, constraints such as population access, insecurity, poor supply lines, limited staff capacity, poor communications and overwhelming scale, limit the possibility of implementing the best programme in terms of technical practice. Field staff had to adopt pragmatic compromises in the face of numerous constraints. In general, complex protocols or complications in emergency circumstances may need to be avoided in order to achieve efficient and effective programme implementation. Currently there is a range of strategies for treating severe malnutrition that are under discussion. These vary from optimal 'scientific' practice in controlled environments to highly adapted protocols as a pragmatic response to practical constraints. Treatment of severe malnutrition has been organised as follows:

The alternatives to 24 hour care in specialised therapeutic feeding centres aim primarily to improve coverage of the feeding programmes and thus overall programme efficacy. These strategies rely on newly developed products that are suitable for consumption at home (cookie, bar or paste).

However we urgently need to evaluate these relatively new strategies and protocols in terms of impact (coverage, case fatality, efficiency), advantages and limitations. Only then will we be able to give guidance to field staff on which type of strategy is best suited to an emergency situation with a specific set of constraints and morbidity/malnutrition patterns. For those of us faced with decisions about programme design in emergencies, it will come as a relief to be able to make more informed choices out of a range of options for treating severe malnutrition.

For further information contact Saskia van der Kam at: saskia_vd_kam@amsterdam.msf.org

View the postscript that this article relates to

More like this

FEX: Letter on MSF guidelines on using F75, Saskia van der Kam, Aranka Anema, Sophie Baquet and Marc Gastellu

Dear Editor, MSF would like to thank Schofield et al for their constructive criticism in the letter section of the previous edition of Field Exchange. We believe that...

FEX: Adapted MSF nutrition guidelines on F75

Prompted by recent operational findings, MSF has decided to modify its Nutrition Guidelines to promote the use of F75 in Phase I treatment of severe malnutrition. Although...

FEX: Letter on standards for severe malnutrition mangement, by Kiross Tefera, with response by Saskia van der Kam

Dear Field Exchange, First my gratefulness goes to Professor Michael Golden and Yvonne Grellety for their detailed and scientific article based on the research outcome of...

FEX: Postscript to: 'A pragmatic approach to managing severe malnutrition: Is F75 always beneficial?'

Michael Golden,Yvonne Grellety It is quite wrong to consider the advantage of F75 as "theoretical". However, a decreased mortality will not be seen if other aspects of faulty...

FEX: Local versus industrially produced therapeutic milks in managing severe malnutrition

By A Ould Sidi Mohamed, M. Diagana, Federica Riccardi, Abimbola Lagunju, Jean-Pierre Papart and Rebecca Norton. A Ould Sidi Mohamed is a paediatrician and chief of the...

FEX: MSF Holland

Name MSF Holland Year formed Staff (2003) 1984 Address Plantage Middenlaan 14 PO Box 10014 1001 EA Amsterdam The Netherlands Overseas 795 Telephone 00 31 20 520...

FEX: Treatment of severe malnutrition in Tanzania - a problem with ‘scoops’

By Chloe Angood Chloe Angood has an MSc in Public Health Nutrition and a BA and MA in International Development Studies. She works for the International Malnutrition Task...

en-net: Use of half strength infant formula instead of F75 Formula

Hi All I am currently working as a Dietitian Advisor to the Samoan NHS. A current practice in the Paediatric ward for infants ranging from about 6 months to 2 years,...

FEX: Treating severe malnutrition in nonemergency situations: Experiences from Malawi and Guinea

By Dr. Eva Grabosch, M.Sc, CHDC Malnourished boy recovering in the nutrition unit of the Teresian Sisters Hospital, Alinafe, Malawi Dr. Eva Grabosch is a specialist in...

en-net: Converting F100 to F75 or making F75 from commercial milk powder

We have a problem of access to one area in Darfur and are asking for feedback on how to either convert F100 to be equivalent to F75 OR how to prepare F75 from locally available...

FEX: Revised MSF nutrition guidelines III

By Saskia van der Kam and Sophie Baquet, MSF The summary below is based upon a near final draft of the new MSF guidelines.1 The guidelines may therefore undergo some revision...

FEX: Nutrition in the DPRK - a field view

By Marie-France Bourgeois Marie-France Bourgeois spent four months at the end of 1997 monitoring and co-ordinating ECHO funded programmes in DPRK. In that time, she travelled...

FEX: Foods for the Treatment of Malnutrition

Summary of Conference Presentation At the Dublin conference on Emergency Supplementary Feeding (February 18 to 21, 1997), reported on in the last issue of Field Exchange, Prof....

FEX: Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria

By Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam Maartje Hoetjes is a Medical member of the MSF emergency team, currently working in South Sudan....

FEX: Locally produced RUTF in a hospital setting in Uganda

By Tina Krumbein, Veronika Scherbaum, and Hans Konrad Biesalski Tina Krumbein is a graduate nutritionist. This article forms part of her diploma thesis submitted to the...

FEX: Diet and renal function in malnutrition

Summary of presentation1 Supplementary suckling (SS) has revolutionised management of young, malnourished infants Water balance in young, malnourished infants Water is an...

FEX: Letter on revised MSF Nutrition Guidelines draft, by E.C. Schofield, Ann Ashworth, Mike Golden and Y. Grellety

Dear Field Exchange, Revised MSF nutrition guidelines We would like to comment on the draft of the newly revised MSF guidelines for the treatment of severe malnutrition...

FEX: Debate on the Management of Severe Malnutrition

by Marie McGrath, Fiona O'Reilly and Jeremy Shoham (ENN). Over the past six months, ENN has been a party to debate regarding technical aspects of the management of severe...

FEX: Clinical Trial of BP100 vs F100 Milk for Rehabilitation of Severe Malnutrition

Child eating BP100 in Freetown TFC. By Carlos Navarro-Colorado and Stéphanie Laquière Carlos Navarro-Colorado is a medical doctor, with a MSc Epidemiology. He has ten years...

en-net: Is volume-based preparation of HEM possible?

Are there recognized protocols for the preparation of HEM using volume (e.g. teaspoons, tablespoons) as opposed to weight? For health workers for whom calculating meal volume...


Reference this page

Saskia van der Kam (2002). A pragmatic approach to treating severe malnutrition in emergencies: is F75 always beneficial?. Field Exchange 15, April 2002. p10. www.ennonline.net/fex/15/pragmatic