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 before publication. Furthermore, it should be noted that certain important aspects of these draft guidelines do not conform with other currently employed guidelines (Eds).

This is the third in a series of pieces published in Field Exchange which summarises key sections of the newly revised MSF nutrition guidelines for use in emergencies (see Field Exchange 10 and 11). This third piece summarises key principles in the new guidelines for treatment of severe malnutrition.

Details on the treatment of severe malnutrition are described in various handbooks, of which " The Management of Severe malnutrition", WHO 1999, is the most well known. The MSF guide builds on this reference work, but develops new thinking on choice of approach and medical standards.

Key principles for the effective rehabilitation of severely malnourished individuals are outlined as follows:

1. Provide quality nutritional and medical care using standard protocols.
2. Use simple and efficient routine medical treatment for prevention and management of specific complications.
3. Employ standard dietary treatments divided into two phases, phase 1 and phase 2.
4. Principles of treatment are the same for all age groups - children, adolescents, adults and the elderly.
5. Food and drugs should be administered orally or by naso-gastric tube. The use of intra-venous fluids or transfusions, are not part of normal treatment.
6. Design the programme according to context.

Simple routine treatments

The MSF guidelines advocate the routine administration of vitamin A, antibiotics, antihelminths, measles vaccination, iron with malaria testing and treatment (in regions with malaria) regardless of the clinical state of the malnourished patient.

It must be noted that all medical treatments should be carried out under the supervision of a physician.

Simplicity is enhanced by:

1. having a focus on drugs which must be administered over a limited time period;
2. employing a limited number of weight categories for patients so that drug dosage calculations are made easier.

The protocols presented in the MSF guidelines strike a balance between cheap and accessible treatments and high quality of care. For example, in regions where malaria is prevalent, MSF advocates the use on admission of rapid malaria tests (blood smear or rapid field test) for all children and pregnant women. Where diagnosis is confirmed treatment with a combination of two drugs is necessary (e.g. artisunate and fansidar/mefloquine). The reasoning is that effective treatment at individual and public health level is in the end more efficient with adherence to optimal but more expensive protocols (routine testing and dual drug therapy). Furthermore, by employing these protocols while maintaining an on-going dialogue with the pharmaceutical companies about reducing prices of essential drugs, MSF hopes to eventually make these effective treatments accessible to other agencies and health institutes that cannot currently afford industry prices.

Simple Standard Diet

Standard dietary treatment provides for a gradual and balanced re-introduction of energy, proteins and other nutrients. Specialised food items (F-100, plumpynut, fortified blended food, CSB, WSB, UNIMIX, BP5 etc.) are used to provide a balanced diet.

In phase 1 of therapeutic feeding MSF advocates the use of F-100. This contrasts with some other guidelines which advocate the use of F-75. This is because the use of an even more specialised milk for the first phase (F-75) will be difficult to manage in many of the settings where MSF operates, e.g. in conflict situations where it may be difficult to find experienced staff. The benefits of using F-75 (lowered osmolarity) as well as F-100 may not outweigh the risk of mistakes. Patients in phase 1 could receive F100 in the amounts meant for F75 which leads to a risk of over-feeding. Similarly, if patients in phase 2 receive F75 in quantities meant for F100 then caloric intake will be reduced. The use of F-75 increases work load considerably for staff and competes with other vital activities in TFCs. The new MSF guidelines therefore advise that F-75 should only be used in therapeutic feeding centres if the centre is well organised so that the risk of mistakes are minimised.

Treatment phases

Treatment of severe malnutrition is divided into two phases - phase 1 and phase 2.

The division into phases indicates a change in diet and the intensity of monitoring of the individual patient. In phase 1 the metabolism of a severely malnourished individual has to be restored so they can then metabolise larger amounts of food in Phase 2. During Phase 1 the patient should be closely monitored for signs of complications. The transfer from phase 1 to phase 2 should be based on clinical assessment of the patient, (i.e. are they responsive, lively and interested?).

Additionally all of the following criteria should be met:

• Recovery of appetite (patient asks for more food, patient finishes the bowl).
• Absence of oedema or grossly decreased oedema after 7 days in phase 1.
• No severe medical complication (severe dehydration, severe anaemia, severe infection).
• Maximum stay in phase 1 is 7 days (exceptions can be made for individuals in rare cases).

The move from Phase 1 to Phase 2 should take place at mid-day, in order to achieve a gradual increase in the amount of food consumed. Some agencies have a separate phase for this transition with a total of three phases in the centre. However this may introduce a risk that patients stay longer than necessary 'in transition', and that the crucial individual monitoring of patients in transition is replaced by a standard nutritional protocol.

A premature transition from phase 1 to phase 2 can lead to over-feeding syndrome, congestive heart failure (see above) and increased oedema (or persistent oedema in phase 2).

The syndrome associated with over-feeding is caused by hypervolemia combined with electrolyte imbalances. This leads to kidney, heart and intestinal system overload, which can lead to a fatal congestive heart failure. Typical causes of over-feeding are:

• Excess volume of food (and liquid) during one meal (e.g. early transfer to phase 2; an adult patient eating more then prescribed)
• A high protein diet (> 16% of Kcal provided by protein)
• A diet high in sodium (either through the use of excess RESOMAL or ORS or from food offered by family members)

The signs of over-feeding syndrome include:

• an increase or the (re-)appearance of oedema
• in severe cases, the rapid development of congestive heart failure

All age groups

The principles of treatment (food and drug types) are applicable for all age groups - children, adolescents, adults and the elderly. Differences include:

• for adults treatment with antibiotics is not systematic but is carried out only on prescription, i.e. on demonstrating symptoms or having specific complaints for which treatment is prescribed by the designated medical person
• measles vaccination is not necessary for adults
• systematic malaria testing of adults is not necessary

Dosages of medical and nutritional regimes will differ depending on the weight and age of individuals. For dietary treatment adults should be placed in groups according to weight and phase of treatment in order to (as much as possible) give adults similar amounts of food. This is to reduce workload for staff and reduce risk of over/underfeeding of the patient.

IV and Naso-gastric tube

Food and drugs should be administered orally or by naso-gastric tube. A naso-gastric tube should be used when there is:

• complete anorexia
• severe dehydration
• inability to drink and eat (too weak, consciousness impaired)
• severe or painful mouth lesions (candidasis)
• repeated, very frequent vomiting

Patients with a naso-gastric tube should be placed in an area which facilitates close monitoring by medical staff.

The use of intra-venous fluids or transfusions is not part of the normal treatment. The only indication for infusion in severe malnutrition is when the risk of acute cardiac failure is high due to circulatory collapse (severe dehydration or septic shock) or a life-threatening anaemia.

In some cases, intramuscular (IM) injections are necessary. Care should be taken to carefully select the site of each IM injection.

Programme Issues

Setting up a TFC is justified when there is a food crisis or famine with large numbers of severely malnourished patients. The sole objective of the TFC is to reduce mortality due to malnutrition in the community. Outreach workers should actively search for patients in the community as well as trace defaulters. Additionally, efforts should be made with the community to identify and tackle the causes of the food crisis and malnutrition.

In non-emergency situations there may be a limited number of severely malnourished individuals (children, adolescents and adults). These individuals will often have a history of disease and social and economic marginalisation. These patients also need treatment which should be offered in existing hospitals. The principles that are outlined above for TFCs also apply to hospitals; however hospital staff will need thorough training in treatment of severe malnutrition. In addition discussions with individuals and their families should take place to identify the causes of malnutrition and possible solutions for that individual. It should be recognised that it may not be possible to have an active case finding, defaulter tracing nor a programme component aimed at reducing severe malnutrition in the community through hospital programmes. This may need to be negotiated with the Ministry of Health and Community Health Programmes (if these exist).

In situations where there are only a few cases of adult malnutrition, they can be treated in TFCs which target children or in a hospital.

Design of TFC

Ideally a TFC has a 24-hour care unit where cases in the first phase are treated and where patients in the second phase with medical complications are treated. However, when first opening a TFC, especially where there are large numbers of patients (e.g. in a famine situation), the TFC should at first set up day-care only. As soon as the situation stabilises and capacity is adequate, then 24-hour care can be started. When the number of patients is large, the nutritional component of the treatment can be standardised on the basis of individuals being placed in weight categories/groups and groups requiring intensive or less intensive monitoring. These simplifications make it easier to provide patients with adequate care at a time when resources may be stretched without compromising management or exhausting the staff.

Authors of the MSF nutritional guidelines: Sophie Baquet, Saskia van der Kam, Jane Little, Veronique Priem, Fabienne Vautier.