Treatment of severe malnutrition in Tanzania - a problem with ‘scoops’

By Chloe Angood

Chloe Angood has an MSc in Public Health Nutrition and a BA and MA in International Development Studies. She works for the International Malnutrition Task Force, at the Institute of Human Nutrition at the University of Southampton. In the past she has worked for various NGOs, including Viva Network, with whom she spent several years working in Sub-Saharan Africa. Chloe has also worked for ENN on the Infant Feeding in Emergencies programme.

The author would like to acknowledge the hard work of local staff at Muhimbili National Hospital, Morogoro Regional Hospital and Amana District Hospital reflected here. In particular, the author would like to mention Dr Mary Azayo, Dr Jesse Kitundu and the nurses at Makuti B, Makuti A and the general paediatric complex at Muhmbili National Hospital. The author would like to acknowledge the Tanzania Food and Nutrition Centre and WHO Tanzania Child Health Team who are spearheading the work in Tanzania. The author would also like to acknowledge the supervision and support of Professor Ann Ashworth, of the London School of Hygiene and Tropical Medicine and Professor Alan Jackson and Dr Penny Nestel, of the Institute of Human Nutrition at the University of Southampton.

A group of nurses learning how to make F75 and F100

This article describes practical problems in preparing therapeutic milk in a hospital-based setting and makes some suggestions to resolve them.

It is estimated that 3% of children under 5 years are severely wasted in Tanzania¹. Severe malnutrition with complications requires inpatient management². As adequate structures do not yet exist in Tanzania to provide community-based care, uncomplicated cases are also currently treated as inpatients. Significant efforts have been made in recent years by UNICEF, the World Health Organisation (WHO), the Tanzania Food and Nutrition Centre (TFNC) and the Paediatric Association of Tanzania (PAT) to build the capacity of inpatient facilities in Tanzania to manage severe malnutrition. These efforts have included training of selected health staff by WHO and UNICEF and the supply of F75, F100, Plumpy'nut®, weighing scales and length boards to 11 inpatient facilities by UNICEF since October 2006.

In April 2007, a follow-up visit was made on behalf of the International Malnutrition Task Force (IMTF), in association with WHO/UNICEF and the Royal College of Paediatrics and Child Health, to assess progress, particularly at Muhimbili National Hospital (MNH). It was found that although the WHO and UNICEF training had improved doctors' knowledge and prescribing practices at MNH, training had not been adequately transferred to nurses delivering care and the quality of care remained unsatisfactory. The case fatality rate at MNH for October 2006 to April 2007 was 33%.

Programme to improve the inpatient treatment of severe malnutrition in Tanzania

Training in Action

The author, working with University of Southampton and IMTF, was subsequently invited to Tanzania for 6 months to help improve the treatment of severe malnutrition and to support MNH staff through a programme of task-oriented training and supervised practice. This activity was conducted in collaboration with the Child Health Team of WHO Tanzania. Working closely with a paediatrician from MNH, a fourphase programme was developed, described in Figure 1. Input and advice was also received by other staff members of MNH, PAT, WHO, the IMTF and University of Southampton. Parts of the programme were subsequently tested at the regional level, at Morogoro Regional Hospital, where the case fatality rate for February to March 2007 was 50%, and at the district level at Amana District Hospital, with an estimated case-fatality rate of 36%. The knowledge and skills of nurses greatly improved following the training and there were many positive changes in practice at each of the three hospitals.

Preparation of F75 and F100 on the wards

In all three hospitals, UNICEF Tanzania provides boxes of Nutriset-produced F75 and F100 sachets. The sachets are a considerable advantage to staff, as they make feeds easy to prepare and provide children with micronutrients that are otherwise difficult to obtain in Tanzania. To make up one sachet of either F75 or F100, 2 litres of water should be added, to make 2.4 litres of feed. However, in most wards visited, only a few cases of severe malnutrition are treated at any one time, usually two to four children. Furthermore, there is usually no refrigerator, so fresh feeds must be made up every 3 to 4 hours. Therefore making up one whole sachet of F75/F100 (2.4 litres) each time leads to considerable wastage. With a limited country supply of F75 and F100 sachets available, this system is unsustainable.

Feed preparation instructions on the wall in one hospital before the training - these are copied from the Nutriset instructions

To avoid wastage, nurses prefer to make up only the volume of feed required on the ward every 3 hours. In the absence of dietary weighing scales, scoops are a practical way of measuring the right amount of F75/ F100 powder to make up feeds. Nutriset provides a packet of small red scoops inside each box of F75 and F100 to help with exactly this problem. These scoops measure approximately 4g of F100/ F75 powder. The instructions that come with the scoops instruct users to add 20ml water to one scoop of F75 and 18ml water to one scoop of F100. This is potentially a very helpful solution for nurses. However, in practice, the use of these scoops throws up problems.

Problems with the Nutriset 'red scoop'

The following problems were observed in the application of these instructions in Tanzania:

1. Children are commonly overfed F75. The final volume of 'made up' F75 or F100 is not stated. Nurses commonly assume that the final volume is the same as the volume of water added (e.g. 20ml when making F75, when, in fact, the final volume is 20% higher, i.e. 24ml). If a child is prescribed 100ml F75, nurses using this system will commonly feed the child 120ml. This puts the child at risk of fluid overload.
2. Nurses find it difficult to calculate the number of scoops to use for different feed volumes. For example, if a child requires 80ml of F75, the nurse must divide 80ml by 24ml to find the number of scoops of powder to use. The answer is 3.3, which must be rounded to 4 scoops. The nurse must then calculate how much water to add by multiplying 4 by 20ml (which is 80ml water). The maths skills of the nurses encountered were generally quite low and all found this calculation to be very complex. Calculations were frequently wrong, leading to risk of either fluid over load (if too much F75 is given) or hypogly caemia (if too little F75 is given). To avoid this calculation, a table is needed showing the volume of water to add to 1, 2 3 scoops etc., and the final volume of reconstituted F75 or F100. But Nutriset does not indicate this final volume per scoop, and so the table is difficult to create.
3. Miscounting of scoops: When making up feeds, it is very easy to miscount the number of scoops when the number required is above 5. This happens when feed volumes are in excess of 100ml, which is very common. This means that it is all too easy to reconstitute feeds incorrectly.
4. Difficulties of making up feed for several children: The red scoop is too small when there are more than 10 severely malnourished children, all feeding 2 or 3 hourly. Larger quantities need to be prepared which requires a larger scoop. The big challenge with this method is finding an accurate measure of one quarter/one half of a sachet.

Possible solution to the problem of 'scoops'

The reorganised feeding station with new, clear instructions, after the training

A meeting of the partners was held in October 2007, including representatives from Muhimbili National Hospital, Morogoro Regional Hospital, Amana District Hospital, TFNC, WHO Tanzania, Muhimbili National Hospital, the IMTF and University of Southampton. The above issue of scoops was discussed. It is very difficult to source ready-made, calibrated scoops in Tanzania. Much research was done during the 6 months and no satisfactory solution was found. The possibility of sourcing or making better scoops in Tanzania was considered by the partners, but quickly dismissed due to technical and resource constraints. Instead it was felt by the group that Nutriset should consider adapting the existing red scoop to something more useful that could have international applicability. Specifically, the group would like to request the following from Nutriset:

1. Much clearer instructions that avoid confusion and miscalculations and that explain how much water to add to each red scoop and the resulting volume of feed. Instructions could include a chart of precalculations for 1, 2, 3 scoops, etc.
2. A scoop that accurately measures one quarter of a sachet (perhaps a blue scoop for F100 sachets and an orange scoop for F75 sachets to co-ordinate with respective box and sachet colours) with clear instructions that explain how many scoops to use, how much water to add and the resulting volume of feed (instructions should detail how to make one quarter and one half of a sachet).

For more information, contact: Chloe Angood, Institute of Human Nutrition, University of Southampton, email:c.angood@soton.ac.uk

¹United Republic of Tanzania, Ministry of Health and Social Welfare (2006). National Nutrition Strategic Plan 2006/7 - 2009/10. Dar es Salaam: MoH.

²WHO (2003). Guidelines for the inpatient treatment of severely malnourished children. Geneva: World Health Organisation.