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 academic and scientific debate is indispensable to increasing the efficiency and professionalism of medical interventions. MSF agrees with the suggestion that severely malnourished individuals should receive night feeds and, wherever possible, we ensure that children are kept in feeding centres on a twenty-four hour basis. MSF also agrees that iron should not be administered to patients during the first two weeks of treatment.

We would like to respond to the commentary made about MSF's protocols for administering F100 during Phase I of nutritional treatment and for antibiotic treatment. Subsequent to thirty years of experience in the field, MSF believes that medical and nutritional protocols cannot be interpreted in black and white terms. Because every field situation is unique and has its own operational constraints, field knowledge and experience are crucial to determining the hands-on decisions that save lives.

F75 and F100 are therapeutic milks designed for the treatment of severe malnutrition. In the previous issue it was alleged that MSF's use of F100 during Phase I for the treatment of severe malnutrition diverges from the "best practice" and, consequently causes unnecessary deaths. MSF believes that there is only circumstantial evidence to prove the superiority of F75 over F100 during Phase I treatment, and that there is no clear relationship between F75 and mortality rates.

MSF agrees that F75 has several theoretical advantages over F100. F75 has a lower energy content and osmolarity than F100; it is high in carbohydrates and has little fat and protein. As a consequence, F75 causes reduced metabolic stress on kidneys, the vascular system and liver. This being said, MSF feels that it is too simplistic to assume that the use of F75 makes a difference between life and death under field conditions. Mortality in Therapeutic Feeding Centres is always caused by a multitude of factors (e.g. poor patient management, low capacity of staff, slow decision-making, limitations imposed by insecurity and in the cases of Angola and Wau mentioned in the letter, being a referral centre for other feeding programmes). Throughout its experience in nutritional interventions, MSF has found that ultimately there is no clear correlation between F75 and low mortality rates. We have worked in several emergency contexts where the use of F100 has contributed to low mortality rates, even in situations with high incidences of kwashiorkor and marasmus (Burundi 2001, Congo Brazzaville 2000); conversely, we have also seen situations where our use of F75 did not affect mortality rates (South Sudan 1998 - see page 11). During a mission in Ethiopia 2000, MSF witnessed low mortality rates among patients receiving F100, and high rates among those receiving F75. This comparison, made possible by different organisations working amongst the same population, calls into questions the superiority of F75.

MSF believes that the use of one type of therapeutic milk is more efficient during nutritional emergencies, because it simplifies health care management on all levels. It eliminates the possibility of confusion (e.g. mistaking one milk for the other during preparation, prescription and handout). F75 complicates nutritional interventions since it requires additional storage facilities, planning and ordering procedures, and complicates emergency preparedness (e.g. product expiration). Although scientific study helps inform 'best practice', ultimately field staff must determine the most feasible practice by weighing the benefits of a more simple protocol against benefits of a more complicated one. In the case of F75 the theoretical advantage is clear, but the extent of its impact is not clear at all. There is a need for research in emergency contexts.

Malnutrition and infection often occur simultaneously. MSF provides systematic antibiotic treatment to all children during emergency situations for greater efficiency and coverage. MSF prefers an individual approach to antibiotic administration for adults (i.e. one that includes individual clinical examination, diagnosis and treatment). Adults are able to better articulate their physical complaints; therefore, antibiotic treatment can be adopted accordingly.

Retrospective investigations and evaluations have enabled field workers to analyse lessons learnt, and identify new ideas and future directions.

MSF appreciates constructive criticism and scientific debate, and looks forward to hearing operational conclusions.

Saskia van der Kam: MSF Holland
Aranka Anema: MSF Holland
Sophie Baquet: MSF Belgium
Marc Gastellu: MSF France