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.)

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: saskia_vd_kam@amsterdam.msf.org

View the postscript that this article relates to