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:
- Lack of care in the ward: adults had no caretaker and there was limited staff capacity to provide the needed care, i.e. feeding, washing, helping the many who could not walk to the latrines.
- Only the most severely malnourished were admitted. The admission criteria were restricted to BMI < 12 kg/m2 or the very weak, i.e. not able to walk. Most patients were too weak to sit straight and patients were often brought in unconscious.
- Late referral: Other feeding programs and outreach teams only referred very sick (and often collapsed) patients to the adult TFC
- Patients often had multiple severe medical complications, e.g. malaria, diarrhoea, TB, respiratory tract infections and possibly HIV infection
- Protocols for feeding severely malnourished adults were not developed yet so that the diet was not appropriately adapted from the start
- Unrestricted use of RESOMAL increased the risk of heart failure
- On feeling slightly better (usually after 2-3 days) patients often would not accept a diet exclusively of milk: they tried to get into the second phase as quickly as possible to get porridge and were often fed by family members with a home-prepared meal
- Organisational difficulties
The organisational difficulties were:
- Supply constraints of F100 and F75 (due to importation restrictions, transportation difficulties and reliance on other agencies)
- Limited expatriate staff capacity (due to visa restrictions)
- Limited national staff capacity/commitment (due to low educational and language levels, mistrust of staff belonging to tribes opposed to the Dinka)
- Poor communication (no email, no radio, and limited ability to provide technical support)
- Poor co-ordination between UN and NGOs (absence of referral systems and lack of joint statements)
- Overwhelming scale of emergency resulting in a low expatriate staff : patient ratio
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:
- 24 hour care in 3 phases using 2 types of milk (F100 and F75)
- 24 hour care in 2 phases using 1 type of milk (F100)
- Day-care only in 2 phases (with provision of a nutritious snack for use at night)
- Phase one treatment in a specialist centre and phase two at home (in the community)
- Provision of weekly supplementation (SFP)
- Entirely at home (community treatment)
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: email@example.com
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: 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...
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...
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...
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...
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...
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...
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...
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...
Glossary ACF Action Contre la Faim CHA Community Health Assistant CHAM Christian Health Association of Malawi CNW Community Nutrition Worker CTC Community Therapeutic...
By Josephine Querubin, ACF-USA Josephine Querubin is a medical doctor who has been working in humanitarian work for the past 12 years. Beginning in her home country, the...
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....
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...
Summary of presentation1 Supplementary suckling (SS) has revolutionised management of young, malnourished infants Water balance in young, malnourished infants Water is an...
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...
FEX: Issue 15 Editorial
Two of the field articles in this issue of Field Exchange address to varying degrees the subject of advocacy. The dictionary definition of the word is 'recommendation' or...
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....
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...
FEX: The application of minimum standards during crisis - A practitioner ’s perspective, southern Sudan 1998/9
By Stephanie Maxwell Stephanie Maxwell worked as the medical co-ordinator for Medicines Sans Frontiers Holland (MSFH) between May '97 and March '99, and as programme manager...
Reference this page
Saskia van der Kam (). 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