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 (Issue 12, April 2001). We appreciate that some practices have to be simplified in emergency settings, especially initially when there is a sudden influx of large numbers of patients, and staff are newly recruited. We are concerned, however, that the proposed divergence from 'best practice' will result in unnecessary deaths.

1. Standard diet (one vs two formulas). There are very considerable risks in simplifying feeding to just one formula (F-100) and failing to give F-75 in the initial phase of treatment (particularly for patients with oedematous malnutrition). For example, two of us (MG, YG) recently visited two therapeutic feeding centres in Africa where kwashiorkor is common. The first centre used the MSF protocol with only F-100 and about 20% of the children died during treatment. In contrast, in a neighbouring centre which used F-75 as the initial treatment, only 5% died. We examined some of the newly admitted children receiving F-100. The first four children we saw were all in heart failure, which MSF correctly emphasise is a risk when F-100 is fed too early. We have had this experience several times-usually the heart failure is misdiagnosed as pneumonia. A 3-times higher mortality was also found among severely malnourished adults fed a single high protein formula from admission (Collins et al, 1998).
   F-100 has too much sodium and protein for the very ill malnourished patient, and too high an osmolarity. F-75 was specifically designed to reduce deaths during treatment by taking into account the damaging effect that malnutrition has on cells and organs. With prepackaged products, it is not difficult to provide both F-75 and F-100. Thus to make F-75: open one red package and empty into 2 litres of water in a red bucket, stir and give according to instructions. For F- 100: open one blue package, empty into 2 litres of water in a blue bucket, stir and give according to instructions.
   Many NGOs (including ACF, CONCERN, GVC, IMC and ICRC) are already using F-75 and F-100, without encountering the difficulties or the confusion that MSF fears.
2. Feeding frequency. MSF makes no mention of feeding very ill children at night in 24 hour care units. Experience has shown that deaths often occur at night or early morning conventionally ascribed to hypoglycaemia and hypothermia. These deaths can be prevented by night feeding and such a practice should be included in treatment recommendations.
3. Routine treatment with iron MSF advises: 'Iron with malaria testing'. The meaning of this is not clear, but if it means that iron should be given routinely, this is contrary to WHO advice which is based on evidence of higher mortality when iron is given in the initial phase (Phase 1). In severe malnutrition, reduction in ironbinding transferrin means children are less able to bind all the iron given to them. Any 'free' iron is harmful because it promotes production of highly damaging free radicals. Free iron also promotes the growth of some pathogens, making some infections worse. Thus, iron should never be given during the initial phase of treatment until the child has re-synthesised sufficient iron-binding proteins. It should be given only during the rehabilitation phase.
4. Antibiotics. MSF advises that antibiotic treatment for adults should be given only if there are signs of infection. This advice conflicts with WHO recommendations. In severe malnutrition the usual signs of infection, such as fever, are often absent and infections remain hidden. Antibiotics should always be given straightaway to all severely malnourished patients, regardless of age.

For the reasons set out above, we do not think that such compromised recommendations should be included in a treatment manual that has previously had a high reputation and been widely used. We encourage MSF to reconsider their guidelines.

Yours sincerely

E. C. Schofield and Ann Ashworth, London School of Hygiene and Tropical Medicine
Professor M. H. N. Golden,
Dr Y. Grellety.

Reference

Collins S, Myatt M, Golden B. Dietary treatment of severe malnutrition in adults. Am J Clin Nutr 1998; 68: 193-9.