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: firstname.lastname@example.org
More like this
en-net: Multiple treatment failure in TFP - what to do?
In our program we have a girl age 18 months who has entered the therapeutic feeding program twice (most recently her MUAC was 10.5, WFH Z-score unavailable). The first time she...
en-net: Do we have "SAM Cure Rate" in health facilities running CMAM program
In a health facility where there is both SAM and MAM services (CMAM). Admitted SAM cases who reached to MAM criteria by anthropometric measurements, What are we going to...
en-net: Non-responder rate
Is there any acceptable level of Non responder rate and ideal way to manage in CMAM Program? Non-response can be seen as a species of program failure along with death and...
FEX: Managing at risk mothers and infants under six months in India – no time to waste
View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Sila Deb, Arjan de Wagt, Piyush Gupta, Nita Bhandari, Neha Sareen and Satinder...
en-net: Exit criteria and length of stay
1. What is exit criteria for severely acute malnourished child if it is recruited in a study/research on basis of MUAC (11.5 for two consecutive visit weight gain and clinical...
FEX: Constraints to achieving Sphere minimum standards for SFPs in West Darfur: a comparative analysis
A view of Mornei camp The current conflict in Sudan's westernmost state of Darfur began in early 2003, although most humanitarian agencies only gained access to the area and...
FEX: en-net update
By Tamsin Walters, en-net moderator Over the past three months, 37 questions have been posted on en-net, generating 59 responses. The forum areas for Prevention and management...
FEX: WHO consultation on management of moderate malnutrition in U5s
The WHO, in collaboration with UNICEF, WFP and UNHCR, hosted a second consultation to discuss the programmatic aspects of the management of moderate malnutrition in children...
en-net: monitoring MUAC change - use for decision making in follow-up visits
Monitoring weight change of children with SAM in outpatient care has been recommended: static weight or weight loss for 2 consecutive visits alerts the need for a home visit or...
en-net: Target weight based minimum weight during treatment at OTP sites
Hello every one During treatment of SAM children in OTP we often find some drop in weight for new enrolled children in initial couple of weeks. Pakistan CMAM guideline...
en-net: How long to continue RUTF for SAM children enrolled in OTP?
Dear all, I would like to know for how long RUTF should be continued in SAM children in the absence of SFP? Protocol says that the discharge criteria for SAM is W/H - W/L...
FEX: Follow-up of post-discharge growth and mortality after treatment for SAM in Malawi
Summary of research1 Location: Malawi What we know: There are limited data on long term outcomes following discharge from SAM treatment; what exists is largely pre-HIV....
FEX: Community-based Approaches to Managing Severe Malnutrition
One nutrition worker's solution to childcare at a busy feeding distribution! A three day meeting was held in Dublin hosted by Concern and Valid International between 8-10th of...
FEX: Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India
Summary of research1 Location: India What we know: The caseload of severe acute malnutrition in India is significant. Access to treatment is challenging in rural settings;...
en-net: The implication of the New 12.5cm MUAC OTP discharge criteria
As per my information from colleague, NUGAG has recommended the 12.5cm discharge criteria as opposed to weight gain. The panel of expert agreed that % weight gain was incorrect...
en-net: We are Working Against "Default Definition, Aren't we?
With some health workers we may notice high number of defaulters in the CMAM program. Without consultation and follow up, this issue continues for months and years and may be...
FEX: Managing at risk mothers and infants under six months in India – no time to waste
This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by...
FEX: Home Based Treatment of Severe Malnutrition in Kabul
By Muriele Therry Muriele Therry studied ethnology at Masters level. After two missions with ACF, one year in Sakhalin as food security officer and 6 months in Afghanistan as...
FEX: Continuity of information in nutrition interventions in India: Experiences from Jharkhand
View this article as a pdf Lisez cet article en français ici By Ipsha Chaand Ipsha Chaand is pursuing a PhD at the Centre of Social Medicine and Community Health,...
en-net: How to manage a Marasmic Child
If you were to manage a child aged months weighing 3kg with a MUAC 6.8, has never breastfed. Complementary food started at 2 wks. Currently Started F100 but the child has good...
Reference this page
Prof Mike Golden and Yvonne Grellety (). Failure to respond to treatment in supplementary feeding programmes. Field Exchange 34, October 2008. p23. www.ennonline.net/fex/34/failure