Letter on standards for severe malnutrition mangement, by Kiross Tefera, with response by Saskia van der Kam

Dear Field Exchange,

First my gratefulness goes to Professor Michael Golden and Yvonne Grellety for their detailed and scientific article based on the research outcome of about 8500 children comparing the observed to expected mortality rate done in different therapeutic feeding institutions (Field exchange, issue 15, April 15, pp. 12-13).

Second I would like to thank MSF for sharing their field experience on therapeutic milks (F-75 and F-100) with comments on using F-75 (Ibid. pp. 9-11).

My comment is on the MSF article, Van der Kam et al about their list of justification not to use F-75 always. I have listed their justifications below and tried to forward my opinion.

1. "MSF has found ultimately there is no clear correlation between F-75 and low mortality rate."
   Using F-75 only is not a guarantee to achieve low mortality rates unless you improve all your procedures. Let's say, if the appropriate re-hydration practice and correct use of ORS, RESOMAL, and IV fluids are not in place, you can't expect low mortality rate. In conclusion, whenever we accept a new approach we have to review the other procedures as well. Also it would be useful if MSF could present data on observed and expected mortality in the centres they refer to, using the Prudhon index. This allows valid comparison of death rates at various stages of treatment and between centres.
2. "MSF believes that the use of one type of therapeutic milk is more efficient during nutritional emergencies."
   In my opinion, we can't compare the cost of human life with the efficiency of a project (manpower, money, time.). MSF agreed the theoretical advantage of F-75 and recommend using when there is high number of kwashiorkor, many adults fail to improve, and mortality rate in a TFC is high. If the advantaged of F-75 is agreed in principle, why do wait until there is high mortality. We should respect the value of human being instead of calculating the simplicity or efficiency of using F-75 unless there is scientific evidence.
3. "It eliminates the possibility of confusion (e.g. mistaking one milk for the other during preparation, prescription, and handouts)".
   This is usually resulted due to poor training for the staff. If the staffs are properly trained, there will not be a question of confusion.
   To make it simple, we can use the following methods:

• Using different buckets - e.g. red bucket for F-75.
• Admitting in separate building/places - we can keep phase one in separate building if there are enough places, if there is only one room, we can classify based on bed number or mat number etc.
• Giving F-75 and F-100
  

There should be eight meals given in Phase 1 (meals should be given every three hours). For example, the timetable for F-75 is 6am, 9am, 12am, 3pm, 6pm, 9pm, 12pm and 3am.

The schedule for F-100 depends on the number of meals per 24 hours. Where five or six meals are given in a 24 period, to avoid overlapping with F-75, we can schedule meal times before or after F-75. For example, start F-100 one and a half hours after F-75. The timetable for F-100 would then be 7.30am, 11.30am, 3.30pm, 7.30pm, 11.30pm and 3.30am.

4. "It requires additional storage facilities, planning and ordering procedures, and complicates emergency preparedness (e.g. product expiration)"

From December 2000 to May 2001, I was working in one of Save the Children UK's TFCs in Wollo. We used both F-75 and F-100. There was no problem in storing both theraputic milks. There was no special recommendation to store F-75. For both products, the expiry duration was the same - May 2000 to November 2001.

MSF should consider the implications of their policies for other agencies. Their new recommendations are not consistent with WHO. Their protocols are widely adopted by other agencies - many with less experience than them as an agency. In an effort to promote best practice and support coordination and interagency consistency on standards, couldn't they reconsider their recommendations?

Kiross Tefera
Emergency Nutrition Programme (SCUK, Ethiopia)

Dear Kiross Terefa,

One of the biggest values MSF fosters is that the quality of care should be optimal as possible, taking into account the latest insights and best practices. However, in emergency situations one must often compromise between the best practices and feasible interventions.

One of the biggest dilemmas of the best practices is: do we wait with an intervention until all preconditions are available (F100, F75, sufficient expat and national staff available and trained, government agreement, cars arrived, structures in place, funding secured, etc.) or do we start an intervention with the means we have? For instance in Wau 1998 (Field Exchange 15, April 2002) we certainly considered using F75 in our intervention; F75 was ordered but the delivery in Wau took several months. The high mortality in this particular intervention in Wau (South Sudan) was mentioned by Schofield et al. (Field Exchange 14, November 2001) as evidence of the necessity of F75. However, we did not see any change when we finally used it, despite the fact that other operational aspects (access, staffing, logistics, etc.) had improved since the start of the intervention. Nevertheless MSF believes the F75 is a very appropriate food in the first phase and certainly MSF recommends the use of it, in order to optimise quality standards. However, we want to be flexible and adapt the therapeutic regimes according to emergency context and available resources, in order to intervene promptly, and to avoid inertia.

Saskia Van der Kam
(MDF Holland)