Failure to respond to treatment in supplementary feeding programmes

By Prof Mike Golden and Yvonne Grellety

As highlighted in the recent large-scale retrospective review of emergency supplementary feeding programmes conducted by the ENN and SC UK, a significant number of children in these programmes fail to respond to treatment. Professor Mike Golden and Yvonne Grellety have developed an algorithm for the management of such cases. This approach has already been inserted into a number of national protocols (Ed).

A child with moderate malnutrition under treatment in a supplementary feeding programme (SFP) who is not responding as expected should not be allowed to remain in the standard programme, being given supplementary food month after month, until the child is eventually discharged as a "non-responder". This is unacceptable. Children who do not respond should be identified, investigated according to this protocol, and individual discharge determined by clinical or more specialist staff than normally operate a SFP.

Typical criteria for failure to respond to treatment are:

• Failure to reach discharge criteria after 4 months in the programme
• No weight gain after 6 weeks in the programme
• Weight loss over 4 weeks in the programme
• Weight loss exceeding 5% of body weight at any time.

The reasons for failure to respond can be classified as:

1. Problems with the application of the protocol
2. Nutritional deficiencies that are not being corrected by the diet supplied in the SFP
3. Home/social circumstances of the patient
4. An underlying physical condition/illness
5. Other causes

To address failure to respond, the following step-by-step procedure should be followed (outlined in Figure 1). Each step should be taken one at a time in the sequence shown and not omitting any step (see table 1).

1. Protocol problems
   Where a substantial proportion of children fail to respond to treatment, the proper application of the protocol and the training of the staff at field level should be systematically reviewed - if necessary by an external evaluation. Any shortcomings should be rectified.
2. Uncorrected nutritional deficiencies
   

   The diets normally used for supplementary feeding of moderately malnourished children are not designed to promote rapid catch-up weight gain, even if taken exclusively; the nutrient density does not compensate for the very low levels of some essential nutrients in the remainder of the diet. The diets often have low concentrations of several essential nutrients, the availability of these nutrients is often low and there are high concentrations of anti-nutrients. Furthermore, some products, such as UNIMIX and Corn Soya Blend (CSB) contain very high concentrations of iron that destroy other essential nutrients, such as vitamin C, during food preparation. Experience shows that about 25% of children lose weight or fail to grow, or that carers abandon SFPs because they see that their children are not recovering.

   An uncorrected nutritional deficiency can be investigated by changing the diet given in the SFP to one of higher quality. These diets are not given routinely as they are more expensive and less available than the standard diets. The possibilities are to give a diet with the specifications of a Ready to Use Therapeutic Food (RUTF) designed for the severely malnourished to promote rapid weight gain or, if not available, to give another higher quality diet (e.g. SP450). The quantity that needs to be given to achieve a response in this particularly group of children has not been investigated. Some agencies have given 200g of RUTF per day and reported a good response.

3. Social problems
   

   There are often problems with intra-family distribution, sibling rivalry and very occasionally, rejection of a child (e.g. paternity problems), parental psychopathology (e.g. depression, post-violation, schizophrenia, etc), parental illness (e.g. HIV/AIDS), or use of the child's state to access food and services for the whole family. Child headed families/communities, abject poverty and social rejection by the community are other causes that may be found.

   To address this, if possible, a home visit is made to evaluate the home circumstances. However, most of these causes may not be clear even with a home visit. If the cause is not determined or a home visit is difficult to arrange within a reasonable time, then the child is admitted (day care) and fed under careful supervision for about 3 days. If the child gains weight well with directly observed feeding, yet fails to gain weight at home, then there is a major social problem. This is then investigated with an in-depth interview with the parents who have seen the child gain under supervised feeding and possibly a further home visit.

4. Underlying medical conditions
   If the child does not respond to supervised feeding, then there is probably an underlying medical problem. A careful history and examination should be performed by a clinician and a search made for the common underlying conditions; in particular, TB, HIV, Leishmaniasis, schistosomiasis, other infections commonly found in the geographic area. Almost any condition in the paediatric textbook can present with malnutrition - cirrhosis, inborn errors of metabolism, chromosomal abnormalities, etc.
5. Other conditions
   If an underlying condition is not found, then the child should be referred to a paediatric facility with special expertise and diagnostic facilities. This facility may be able to exclude cirrhosis, neurological disease, malabsorption syndromes, inborn errors of metabolism, chromosomal abnormality, developmental syndromes, etc. The main reason why a malnourished child should be referred to a specialist facility is for diagnosis of underlying conditions in children that do not respond to treatment. There will be a residue of children with untreatable underlying conditions. The further management of all the children with underlying conditions should be determined by the clinical facility and not the staff of the SFP.

For more information, contact Mike Golden, email: mike@pollgorm.net