Postscript on local capacity building for treatment of severe malnutrition

Ann Ashworth Hill,

Professor of Community Nutrition Public Health Nutrition Unit, London School Hygiene and Tropical Medicine

International NGOs usually provide better treatment for children with severe malnutrition in their feeding centres than is provided by local hospitals. Unfortunately the opportunity for local capacity building by transferring NGO knowledge and skills to hospital staff in the host country is often overlooked. Dr Grabosch provides two examples of capacity building in Malawi and Guinea where she set about the task of improving hospital treatment with tenacity and resourcefulness. She describes several key components for success:

1. involvement of hospital administrators - once the administrators were persuaded that feeding is essential for recovery, they agreed to important changes in how malnourished children were fed, including a change in policy to provide food. When planning how to improve treatment, others who need to be involved include pharmacy and kitchen staff, as well as doctors and nurses. Getting people together to identify and resolve problems is more likely to lead to feasible actions, co-operation and implementation. Developing an action plan serves as a useful reminder of what was agreed, and shows who accepted responsibility for the various actions and the expected time frame.
2. staff motivation - once staff saw that the new treatment was successful, they became more motivated. Getting started can be rather overwhelming when many changes are needed. Starting with just one or two children can be less daunting for busy staff and also increases the chance of success. Very dramatic transformations are achieved when malnourished children are correctly managed, and working with malnourished children can be one of the most satisfying and rewarding jobs. Using just one or two children as an initial 'demonstration' can be a powerful way to motivate staff. Once they have seen children dramatically transformed, they are likely to want to improve treatment for all malnourished children in their care.
3. staff education - it is now widely acknowledged that poor knowledge of doctors and nurses about treatment of severe malnutrition leads to inadequate and even harmful treatment practices. Dr Grabosch found on-the-job training to be more effective than theoretical sessions. The Chinese proverb comes to mind: I hear and I forget; I see and I remember; I do and I understand. Training needs to be on-going, as new staff also need to be trained.
4. adaptability - it is unlikely that all resources will be available and innovative approaches such as described by Dr Grabosch for peanut milk, may be needed. Compromises may also be needed. Innovations and compromises, however, require a sound knowledge of the principles of treatment and the physiological changes that occur in severe malnutrition, otherwise inappropriate decisions may be made.

Peanut milk: In Guinea, Dr Grabosch developed a liquid feed based on peanut paste, sugar and banana for the initial phase of treatment. The recipe is reported only in household measures so it is difficult to calculate the content, and its protein content is not given. Food Composition Tables and a dietary or pharmacy scale (perhaps borrowed temporarily) are invaluable in developing recipes from local ingredients. Severely malnourished children should not be given high intakes of sodium, and in the first few days of treatment they should not be given high protein intakes. When developing an alternative recipe for F75 for feeding at the start of treatment, the content per 100ml should be 75kcal and 0.9g protein, and the recipe should not contain more than 10g sugar/100ml. Peanut paste is high in protein so care needs to be taken not to exceed the recommended protein content. For F100 and catch-up meals, the aim is for a content of at least 100kcal and 3g protein/100ml. When developing recipes, start by getting the desired protein content; then use oil and sugar to make up any shortfall in energy. Peanut paste is excellent in catch-up meals as it is high in both energy and protein.

Potassium is essential and can be difficult to provide. Banana contains potassium but not in sufficient amounts to correct the deficit in severe malnutrition. Even if potassium chloride is not available, many adult wards have Slow K. Give malnourished children half a tablet/kg/day (crushed and preferably in divided doses).

Recording: Dr Grabosch successfully introduced feed intake charts. Often nurses do not understand the purpose of the tasks they do, and then do the tasks badly or not at all. Knowing how the information can be used for decision-making can help nurses understand the purpose of the task. Feed charts are a good example as decisions about tube feeding and when to move to the catch-up phase are based on this information.

For sustainable improvements in hospital treatment, Dr Grabosch's article gives helpful pointers and shows that treatment can succeed with few resources.

For readers interested in training nurses in hospitals with limited resources, Professor Ann Ashworth and colleagues have produced a training manual on CD Rom entitled 'Improving the Management of Severe Malnutrition: A Guide for Trainers'.

For further information, please contact her via email: ann.hill@lshtm.ac.uk

Recommended management of severe malnutrition

Where possible, a dehydrated child with severe malnutrition should be rehydrated orally. Intravenous infusions easily cause overhydration and heart failure. Since malnourished children are typically deficient in potassium and have abnormally high levels of sodium, adapted oral rehydration solutions (ORS) are recommended. Magnesium, zinc and copper should also be given to correct deficiencies. Resomal is a specially-adapted rehydration product available commercially. An acceptable solution can also be made by diluting 1 packet of standard WHO ORS solution in 2L of water (instead of 1L), and adding 50g sucrose (25g/L) and 40ml (20ml/L) of mineral mix solution.

All malnourished children are at risk of developing hypoglycaemia. To prevent this, children should be fed at least 2-3 hourly, day and night.

Two formula diets are recommended in the management of severe malnutrition. F75 (75 kcal/100ml) is used during the initial phase of treatment while F100 (100kcal/100ml) is used during the rehabilitation phase after appetite has returned. Both formulas are available commercially and are prepared by adding water. Alternatively these formulas can be prepared from basic ingredients (e.g. dried skimmed milk, sugar, cereal flour, oil, mineral mix and vitamin mix).

WHO recommended mixes of vitamins and minerals require accurate weighing of component ingredients. If only small amounts of feed are being prepared, a proprietary multivitamin supplement may be used. A combined mineral and vitamin mix for malnutrition is also available commercially.

Nearly all severely malnourished children are anaemic and should be supplemented with iron and folic acid. Iron should never be given in the first or initial phase of treatment, but in the rehabilitation phase. Iron should only be administered orally, never by injection.

Adapted from: Management of malnutrition: a manual for physicians and other senior health workers.WHO Geneva, 1999.

View the article that this postscript relates to