Failure to respond to treatment in supplementary feeding programmes
By Prof Mike Golden and Yvonne Grellety
As highlighted in the recent large-scale retrospective review of emergency supplementary feeding programmes conducted by the ENN and SC UK, a significant number of children in these programmes fail to respond to treatment. Professor Mike Golden and Yvonne Grellety have developed an algorithm for the management of such cases. This approach has already been inserted into a number of national protocols (Ed).
A child with moderate malnutrition under treatment in a supplementary feeding programme (SFP) who is not responding as expected should not be allowed to remain in the standard programme, being given supplementary food month after month, until the child is eventually discharged as a "non-responder". This is unacceptable. Children who do not respond should be identified, investigated according to this protocol, and individual discharge determined by clinical or more specialist staff than normally operate a SFP.
Typical criteria for failure to respond to treatment are:
- Failure to reach discharge criteria after 4 months in the programme
- No weight gain after 6 weeks in the programme
- Weight loss over 4 weeks in the programme
- Weight loss exceeding 5% of body weight at any time.
The reasons for failure to respond can be classified as:
- Problems with the application of the protocol
- Nutritional deficiencies that are not being corrected by the diet supplied in the SFP
- Home/social circumstances of the patient
- An underlying physical condition/illness
- Other causes
To address failure to respond, the following step-by-step procedure should be followed (outlined in Figure 1). Each step should be taken one at a time in the sequence shown and not omitting any step (see table 1).
- Protocol problems
Where a substantial proportion of children fail to respond to treatment, the proper application of the protocol and the training of the staff at field level should be systematically reviewed - if necessary by an external evaluation. Any shortcomings should be rectified.
- Uncorrected nutritional deficiencies
The diets normally used for supplementary feeding of moderately malnourished children are not designed to promote rapid catch-up weight gain, even if taken exclusively; the nutrient density does not compensate for the very low levels of some essential nutrients in the remainder of the diet. The diets often have low concentrations of several essential nutrients, the availability of these nutrients is often low and there are high concentrations of anti-nutrients. Furthermore, some products, such as UNIMIX and Corn Soya Blend (CSB) contain very high concentrations of iron that destroy other essential nutrients, such as vitamin C, during food preparation. Experience shows that about 25% of children lose weight or fail to grow, or that carers abandon SFPs because they see that their children are not recovering.
An uncorrected nutritional deficiency can be investigated by changing the diet given in the SFP to one of higher quality. These diets are not given routinely as they are more expensive and less available than the standard diets. The possibilities are to give a diet with the specifications of a Ready to Use Therapeutic Food (RUTF) designed for the severely malnourished to promote rapid weight gain or, if not available, to give another higher quality diet (e.g. SP450). The quantity that needs to be given to achieve a response in this particularly group of children has not been investigated. Some agencies have given 200g of RUTF per day and reported a good response.
- Social problems
There are often problems with intra-family distribution, sibling rivalry and very occasionally, rejection of a child (e.g. paternity problems), parental psychopathology (e.g. depression, post-violation, schizophrenia, etc), parental illness (e.g. HIV/AIDS), or use of the child's state to access food and services for the whole family. Child headed families/communities, abject poverty and social rejection by the community are other causes that may be found.
To address this, if possible, a home visit is made to evaluate the home circumstances. However, most of these causes may not be clear even with a home visit. If the cause is not determined or a home visit is difficult to arrange within a reasonable time, then the child is admitted (day care) and fed under careful supervision for about 3 days. If the child gains weight well with directly observed feeding, yet fails to gain weight at home, then there is a major social problem. This is then investigated with an in-depth interview with the parents who have seen the child gain under supervised feeding and possibly a further home visit.
- Underlying medical conditions
If the child does not respond to supervised feeding, then there is probably an underlying medical problem. A careful history and examination should be performed by a clinician and a search made for the common underlying conditions; in particular, TB, HIV, Leishmaniasis, schistosomiasis, other infections commonly found in the geographic area. Almost any condition in the paediatric textbook can present with malnutrition - cirrhosis, inborn errors of metabolism, chromosomal abnormalities, etc.
- Other conditions
If an underlying condition is not found, then the child should be referred to a paediatric facility with special expertise and diagnostic facilities. This facility may be able to exclude cirrhosis, neurological disease, malabsorption syndromes, inborn errors of metabolism, chromosomal abnormality, developmental syndromes, etc. The main reason why a malnourished child should be referred to a specialist facility is for diagnosis of underlying conditions in children that do not respond to treatment. There will be a residue of children with untreatable underlying conditions. The further management of all the children with underlying conditions should be determined by the clinical facility and not the staff of the SFP.
|Table 1: Implementation of step-by-step approach|
Diagnosis of failure to respond to treatment
|Step 1||Improve nutritional intake|
|Give RUTF, 1000kcal per day for 15 days (2 sachets per day)||This is a diagnostic test! It is not treatment per se. We are giving a diet which we know will correct all known nutritional deficiencies and seeing if the child now responds. The test MUST involve the best diet available for recovery of a malnourished child.|
|After 15 days (next visit), if he/she has now res- ponded to treatment, this means that it was a nutritional problem (type 2)||Continue the treatment with 2 sachets of RUTF plus the SFP ration for a further month.||It is unclear whether 2 sachets per day is the correct amount. This is an area for operational research - should the amount be adjusted according to the weight of the child? Would one sachet per day be enough? It is best to start with what we think will definitely work. Small studies should be conducted with limited numbers of children to test step-by-step reduced amounts and see how well these work.|
|After 15 days (next visit), if he/she does not respond to treatment, this means that the dominant problem is NOT A NUTRITIONAL deficiency and that social or medical problems must be investigated. The next most likely reason is a social problem.||Progress to Step 3|
|Step 3||Investigate the home social circumstances; the home visit may pick up some social problems|
|A problem is identified during the home visit that can be alleviated or solved.||Deal with the problem, leave the child at home for follow up and further visits can be made in the following weeks.||It is very important to realise that many/ most social problems will NOT be found during a home visit (such as discrimination against the child, neglect, parental manipulation, carer illness, siblings' rivalry, etc.). This is because parents' and children's behaviour changes during a visit by an outsider.|
|A problem is identified during a home visit that cannot be alleviated or solved at home.||Take any steps necessary to alleviate the problem - such as admission of the child to a facility, putting more resources into the home, arranging for a different carer (relative), getting treatment for the carer (eg psychiatric/HIV, etc).|
|During the home visit, if no problem is identified to account for the failure to respond to treatment, it is still likely that there is a social problem that has not been identified.||Admit the child for a trial of feeding under supervision in a TFC for 3 days.|
|Step 4||Investigation of underlying pathology|
|If still the child is not responding to treatment, then he needs to be sent to a facility (hospital) where there are clinicians/paediatricians that are skilled in diagnostics and have the facilities to investigate the child.|
|If this facility does not find the cause, then the child should be referred to a national centre/ University for full investigation of unusual causes.|
|If the final referral centre does not find any cause for the failure of the child then there is no other choice but to label the child as idiopathic failure-to-respond. The cause of the malnutrition has not been found. Such children should perhaps be entered into a register, have specimens stored and be seen whenever there is a senior paediatrician with skill in severe malnutrition and in diagnostics visiting the country.|
For more information, contact Mike Golden, email: email@example.com
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Reference this page
Prof Mike Golden and Yvonne Grellety (2008). Failure to respond to treatment in supplementary feeding programmes. Field Exchange 34, October 2008. p23. www.ennonline.net/fex/34/failure