To TFC or to CBTF

Summary of published letter^*

The last issue of Field Exchange carried a summary of a published article by Steve Collins on community based therapeutic feeding (CBTF). The Lancet subsequently published two letters in response to the original article and Collins' response to one of these letters. Below is a summary of these exchanges.

In one of the letters (Navarro-Colorado, et al) it was argued that therapeutic feeding has played a major role over the past 20 years in saving children's lives and that recognition of severe malnutrition as a medical emergency has contributed to a reduction in mortality from 20% to 5%. The authors however acknowledge that TFCs, especially in open situations, can have harmful effects on the food economy of patients' families, encourage population concentration and create dependence. They nevertheless caution that before designing the features of, and criteria for, CBTF in emergencies, we need broader debate, including more research and scientifically supervised experiences in the field. The identification of children who can qualify for at home treatment is the key issue. For example, the numbers of children too young for home treatment (cannot eat ready-to-use therapeutic foods) and who have complications or associated disease may be high and need to be treated in specialised centres. Also, a proper follow up system would be needed to supervise quality of recovery, educate mothers and help to relieve them from the burden imposed by treatment of the child. A final cautionary comment of the authors is that the 'Hearth' model (mother to mother education) proposed by Collins assumes that the main cause of malnutrition is lack of education and that this might not apply in an emergency situation.

Collins' response to this letter was that there seemed to be agreement with many of the points raised in his article but that he fundamentally disagreed with the authors suggestions on 'how to introduce community based strategies, i.e. that these should evolve out of existing TFC programmes' Collins believes that the approach should be tailored to field circumstances and that one cannot know what the most appropriate intervention is in advance. Circumstances and constraints vary. For example, where TFCs are already functioning it may make sense to develop community based strategies from them. Where the emergency intervention is starting from scratch it might make more sense to develop community strategies and smaller in-patient stabilisation centres simultaneously. In some situations TFCs cannot be established so that community-based programmes will need to be 'attempted' on their own.

Collins insists that viewing CBTF as a 'bolt-on' addition to existing therapeutic feeding centres is unlikely to stimulate the profound changes in staff recruitment, training and institutional guidelines that are needed.

A final letter (Van Dame, W and Boelaert, M) in the same issue of the Lancet is more supportive of Collins' advocacy for CBTF. Like Collins, the authors are also concerned about the low coverage and effects of classic TFCs. They cite analysis of the results of a refugee assistance programme in Forest Region of Guinea where coverage of TFCs was only 3.4%. One of the main reasons for the low coverage was that mothers judged the cost of living for several weeks in a TFC with their malnourished child as too high. Furthermore, despite the limited coverage running the TFC was very labour intensive and consumed a large proportion of programme resources. The authors therefore welcomed Collins' proposal stating that care at home might help strengthen family ties, rather than further weaken them.

^*Correspondence section in the Lancet (2002), vol 359, January 19th, pp 259-261