Community-based Therapeutic Care (CTC)

Malnourished Child being fed with ready-touse therapeutic food (RUTF)

Summary of published research¹

Bedawacho Woreda is a district in Ethiopia, 350 km south of Addis Ababa, which had suffered three years of drought. A nutritional survey by Concern Worldwide found that 17% of children aged 6-60 months were moderately malnourished (weight-for height less than -2 z scores) and 5% were severely malnourished (weight-for-height less than -3 z scores). In response, Concern Worldwide started a decentralised dry supplementary feeding programme (SFP) from ten distribution points, located at government-run primary health-care clinics or health centres.

During the first weeks of the feeding programme, 160 children were identified as severely malnourished. The children were dispersed across the Woreda district, much of which was inaccessible. Ideally, their treatment would have commenced with several days in a phase-1 unit. However inpatient care facilities were not available in the district, and the regional government did not want agencies to set up new therapeutic feeding centres. Consequently, patients were treated as outpatients attending only once-per-week at clinics or distribution sites.

Between October and January 2001, patients were enrolled at any one of the ten supplementary feeding programme (SFP) distribution points. Inclusion criteria were a weight-for-height ratio of 70% or less, or bilateral pitting oedema. One outpatient therapeutic feeding programme site was set up at each of the ten SFP sites. Each participant in the outpatient programme returned weekly to their closest site in order to receive food and a medical assessment. Every fortnight during the SFP distribution, the outpatient participants were examined and supplied with a two week ration of Farmix and a weekly supply of ready-to-usetherapeutic food (RUTF). On the weeks between the SFP, children were examined by local clinic staff and given a one week ration of RUTF. Outreach workers followed up patients at home once or twice a week. They checked children's progress and referred ill children back to the clinic.

On admission, patients were given an oral dose of vitamin A, mebendazole and folic acid. Patients received a 5-day course of cotrimoxazole. Dehydration was treated with ReSoMal. On alternate weeks, patients received folic acid orally. At admission, an educational message sheet was discussed with groups of patients' mothers. The message was reinforced by the community outreach team during home visits. Education focused on the feeding regimen and on reducing the risk of complications arising from severe malnutrition. Patients were discharged to the SFP if their weight-for-height was more than 75% for two consecutive weeks and they did not have infectious disease.

A retrospective cohort study was conducted on the outpatients between September 2000 and January 2001 involving clinical records for 170 children aged 6-120 months². The children had either marasmus, kwashiorkor or marasmic kwashiorkor. Outcomes were mortality, default from programme, discharge from programme, rate of weight gain and length of stay in programme.

The study found that 144 patients recovered, seven (4%) died, eleven (6%) were transferred and eight (5%) defaulted. Median time to discharge was 42 days, days to death (14) and days to default (14). Median rate of weight gain was 3.16 g/kg/day. Amongst patients who recovered, median rates of weight gain were 4.8 g/kg/day for marasmic patients, 4.03 g/kg/day for marasmic kwashiorkor patients and 2.7 g/kg/day for kwashiorkor patients.

Outpatient care exceeded internationally accepted minimum standards for recovery, default, and mortality rates. Time spent in the programme and rates of weight gain did not meet these standards. However, caution is required in interpretation of these data. For example, weight gain was calculated in relation to when oedema was first assessed as having disappeared and as there was weekly weighing, this may not have been accurate. Furthermore, as dangers of acquired infection were less (malnourished patients were not removed from home environments and congregated), length of time in programme is of less significance. Also, slow response was probably caused by sharing of food rations. However, it may also have reflected poor dietary composition of the ration, and formal controlled tests for effectiveness of RUTF in oedematous patients are needed. The default rate was low, indicating that outpatient care was acceptable to participants. No data for programme coverage were collected. which the authors of the study believe was a serious omission and should take place in subsequent evaluations of this type of programme.

Among the authors conclusions were the following:

• Outpatient care could provide a complementary treatment strategy to therapeutic feeding centres but further research is needed to compare the effectiveness of outpatient and centre based treatment of severe malnutrition in emergency nutritional interventions.
• Marasmic kwashiorkor patients are very vulnerable and have a high risk of death and complication. These patients require the intensive care, monitoring and cautious F75 based feeding regimens of phase one therapeutic care which are not possible in outpatient treatment. In the absence of a RUTF designed for phase one treatment, outpatient feeding should be run in conjunction with suitable inpatient facilities.
• The reasonable response to this type of treatment indicates that only severe cases (marasmic kwashiorkor or those with complications) require inpatient care, which need last only a few days. Phase one centres could, therefore, be smaller and more basic than conventional therapeutic feeding centres, easier to construct and less resource intensive.
• An advantage of combining outpatient feeding with phase one centres it that the outpatient element can be started immediately and begin rehabilitating people while the phase one centres are being built.
• Small centres, where patients stay for only a few days, have lower risks of nosocomial infections, decrease disruption to carers, and release emergency funding to strengthen local health infrastructures.

¹Outpatient care for severely malnourished children in emergency relief programmes; a retrospective cohort study. S. Collins and Kate Sadler. The Lancet, vol 360, Dec 7th, 2002

²Children aged 6 - 120 months were included in analysis since reasonable weight-for-height tables exist for this group and children in this age-group were treated in the programme (10%, n=16, were over 60 months of age). Personal communication. Dr Steve Collins, 30.05.03