Diets for malnutrition treatment    
local foods for malnutrition Benjamin Torun 10.01.98
local foods for malnutrition Michael Golden 13.01.98
Local foods for malnutrition treatment Andy Seal 14.01.98
local foods for malnutrition George Fuchs 14.01.98
therapeutic centres Katherine Hilderbrand 15.01.98
antibiotics for severe malnutrition Michael Golden 15.01.98
Diets to treat malnutirition Benjamin Torun 15.01.98
Diets for malnutrition Peter Sullivan 15.01.98
Local foods for treatment of maln Ann Burgess 16.01.98
local vs imported food Andre Briend 16.01.98
local vs imported food Benjamin Torun 16.01.98
antibiotics for severe malnutrition-yes George Fuchs 16.01.98
prophylactic antibiotics Michael Golden 16.01.98
Treatment of Severe Malnutrition David Brewster 17.01.98
treatment of malnutrition Rachel Pinniger 20.01.98


Date: Sat, 10 Jan 1998 11:09:03 +0600

From: George Fuchs gfuchsatcitechco.net

Subject: local foods for malnutrition

 

Dear Ben,

I have just returned to Dhaka and have been reviewing the discussion about

UNICEF, Haiti, etc. and was very interested in your comments. We too are

very interested in developing a database of sorts of PEM rehabilitation

diets using locally available foods. Any ideas on how we might pursure

this further in a coordinated way? I would be happy to work with you on

this if this would be of interest to you. At the very least I can share

our findings with you as the collection proceeds. All the best,

George

 

George Fuchs, MD, ICDDR,B: Centre for Health and Population Research

GPO 128, Mohakhali, Dhaka 1000, Bangladesh

Tel: 880 (2) 988-2399; Fax: 880 (2) 883-116, email: gfuchsatcitechco.net


Date: Tue, 13 Jan 1998 14:59:42 +0000

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: local foods for malnutrition

 

Dear Ngonuts, Benny and George,

I also am very interested in local foods for malnutrition and would love

to include an annex in the manual we are now writing on examples that have

been documented to work well. This is critical to many programs.

However, we should be careful to differentiate the phases of treatment -

and this seems to be part of the problem with the interpretation of Steve's

message. From his comments, he is clearly addressing the acute phase

before the child gets back its appetite (where there is almost no weight

gain), whereas you seem to be addressing the longer, but later, phases of

catch-up/rehabilitation. From experience, during the catch-up phase, many

diets made from locally made foods will work to a greater or lesser extent

- the differences being the degree and rate of functional recovery (there

can be good weight gain without recovery of immune function, or even normal

body composition etc), the rate of weight gain itself and the length of

time the mother has to concentrate on the child with severe malnutrition

(often, I suspect, a prolonged recovery is to the detriment of her other

children and difficulty in performing functions necessary for household

food security and care). At this stage we should not be dealing with a

significant mortality. Unfortunately, the functional recovery and body

composition on the one hand and the cost to the family of prolonged

recovery on the other are not usually assessed in studies using local foods.

However, the catch-up phase, where local food is properly used, is quite

different from having to decide how to get the appropriate energy and

nutrients into an acutely ill, infected, oedematous apathetic and anorexic,

often profoundly anorexic, child; it is very difficult to get appropriate

formulations and presentations of locally available foods that are taken by

such children and digested and absorbed. Very few local products will go

down an NG tube. Nearly all physiological and balance studies have, of

necessity, been made after the child has got over this initial acute

life-threatening phase, so that the absorption from any local food for this

purpose, is not known; clinically, many foods at this early stage lead to

severe diarrhoea and are mainly malabsorbed. Here we are dealing with the

life-threatening stage, the mortality for which is very high and has not

improved for many years. I am sure that many children, particularly

marasmics, and those with initial good appetites can be managed with local

foods: but the decision cannot be based upon anthropometric severity.

Surely, there is a middle ground. Special products have a vital place in

the initial acute medical management, and the cost can be kept reasonable

if these products are reserved for the initial phases only (say an average

of 4 days per child rather than 34 days). In complex emergency, acute

relief and special circumstances the use of these products is often

appropriately prolonged to cover some or most of the needs during

rehabilitation, whereas in stable situations, local-product based diets can

be used extensively or exclusively for rehabilitation. In this regard, Ed

Cooper's and Tom Heiken's studies on discharge as soon as appetite returns

and Sultana Khanum's study of home based management for selected children

(about half), are very encouraging.

( Cooper, E.S., Headden, G., & Lawrance, C. (1980). Caribbean children,

thriving and failing, in and out of hospital. Journal of Tropical

Pediatrics, 26, 232-238.

Heikens, G.T., Schofield, W.N., Dawson, S.M., & Waterlow, J.C. (1994).

Long-stay versus short-stay hospital treatment of children suffering from

severe protein-energy malnutrition. European Journal of Clinical Nutrition,

48, 873-882.

Khanum, S., Ashworth, A., & Huttly, S.R. (1994). Controlled trial of three

approaches to the treatment of severe malnutrition. Lancet, 344, 1728-1732.)

Thus, I do not see any real conflict between the points put by Steve

Collins and Benny Torun.

Best wishes,

 

Prof. Michael H.N.Golden

Dept of Medicine and Therapeutics, Univ of Aberdeen, Foresterhill

AB9 2ZD. Scotland, (UK)

Tel +44 (1224) 681 818 ext 52793/53014, Tel(direct) +44 (1224) 663 123 527 93

Fax +44 (1224) 699 884, INTERNET m.goldenatabdn.ac.uk


Date: Wed, 14 Jan 1998 14:36:18 GMT

From: Andy Seal <A.Sealatich.ucl.ac.uk>

Subject: Local foods for malnutrition treatment

 

Dear Ngonuts

During a recent visit to a government hospital in east Africa I encountered

a situation where neither locally produced or manufactured therapeutic feeds

were provided by the hospital in the treatment of malnutrition. The

responsibility for food provision was exclusively that of the patient or

relatives. Finance for drug provision faced similar, but not quite as

severe, constraints. It appeared extremely unlikely that any resources would

be made available for therapeutic feeds in the near future.

In this and similar situations, in the absence of external funding, it would

appear that the only option to try and improve all phases of malnutrition

treatment would be to advocate the best possible use of local food stuffs.

In this context, the proposed appendix to the malnutrition manual would be

especially crucial.

Nevertheless, it would be extremly interesting to know if there are any

studies looking at the cost-effectiveness of F-100 and local food stuffs in

the different phases of "non-emergency" malnutrition treatment, especially

in east Africa?

Thanks

Incidentally, I would suggest that it is important for us to continue to use

the term F-100 rathers than refer to 'Nutriset' as it is important not to

become oriented to one particular commercial source unless there are good

and explicit reasons for this.

 

Dr. Andy Seal

Centre for International Child Health, Institute of Child Health

30 Guilford Street, London WC1 1EH


Date: Wed, 14 Jan 1998 08:42:53 +0600

From: George Fuchs gfuchsatcitechco.net

Subject: Local foods for malnutrition

 

Dear Mike,

Your point regarding the distinction between phases of rehabilitation when considering food-based rehabilitation diets is certainly important. Our initial focus here in Dhaka in this regard has been the acute phase. All the best,

George


From: "Katherine Hilderbrand" <khildatnutrition.itg.be>

Date: Thu, 15 Jan 1998 12:10:09 +0000

Subject: therapeutic centres

 

Dear NGOnuts,

The exchange on local versus specialised foods is very interesting.

I agree with Prof Golden that a clear distinction should be made between the acute and the rehabilitation phases. The context is equally important. Even outside of emergency situations, i.e in the large grey zone of post-conflict or rehabilitation foods available are often limited and/or only seasonally available.

The acute phase of severely malnourished children is a medical emergency, and specialised imported formulas and drugs are unfortuanetly in many cases unavoidable.Specialised formulas shopuld be kept for severely malnourished children and not used outside of hospitals or therapeutic centres.

A second problem is that in many African hospitals there is no food for patients, and relatives take care of food. Setting up a kitchen for only one "ward" the therapeutic centre is unacceptable.

If anyone can give suggestions on the following, it would be very appreciated. In october, I was asked to carry out a consultancy in Angola. A therapeutic centre in a provincial hospital which has been running for 3 years with a very high delayed mortality (+/- 30 % after 8 days). More than 70 % of the children have oedema, and they are all very ill when they arrive.

The centre is relatively well organised and children are fed at night. My first hypothesis was a lack of potassium, as children were fed HEM (2 phases 100 kcal/kg and then 200 kcal + porridges) multi vits, standard treatment protocols etc..., but with no potassium. CMV was introduced and after one month the mortality has not changed at all.

My second hypothsis is linked to the treatment - children are not given antibiotics at admission, but the personnel waits until symptoms appear.

I would like to propose they try giving large spectrum antibiotics to all the children, at admission and not wait until symptoms appear.

Does this sound reasonable and which Ab should be suggested ?

Thanking you in advance for any suggestions.


Date: Thu, 15 Jan 1998 13:18:35 +0000

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: antibiotics for severe malnutrition

 

Dear Katherine,

The question of antibiotics frequently arises, and many clinicians think that they can reliably diagnose infection in the severely malnourished child: they are wrong. After 20 years of experience I certainly cannot do this and I've never been with a clinician who can. I've done many autopsies on children that died form malnutrition without any signs of infection - they were all infected without demonstrating the signs!

Hypothermia and hypoglycaemia are the common manifestations of infection - but these are late signs and you may have missed the boat if you wait this long.

Here is the relevant paragraph from the forthcoming WHO manual on the management of severe malnutrition:

---------------------

4.6.1 Bacterial infections

Nearly all severely malnourished children have bacterial infections when first admitted to hospital. Many have several infections caused by different organisms. Infection of the lower respiratory tract is especially common. Although signs of infection should be carefully sought when the child is evaluated, they are often subtle or absent. Unlike well nourished children with infection, who react with fever and inflammation, malnourished children with serious infections may only become apathetic or drowsy.

Early treatment of bacterial infections with effective antimicrobials improves the nutritional response to feeding, prevents shock and reduces mortality. Because infections are so common and also difficult to detect, all children with severe malnutrition should routinely receive broad-spectrum antimicrobial treatment when first admitted for care. Each institution should have a policy on which antimicrobials to use. These are divided into first-line treatment, given routinely to all severely malnourished children, and second-line treatment, used when a child is not improving or a specific infection is diagnosed. Although local conditions of bacterial resistance patterns, antimicrobial availability and cost will determine the policy, a suggested scheme is given below.

-----------------------

The question of which antibiotics to use is much more contentious: the usual pattern is to have a mixed infection with several bacteria, candida and frequently viruses and also small bowel bacterial overgrowth.

This requires agents active against both gram positive and negative organisms.

For example, when Wilkinson et al started to give ampicillin and gentamicin routinely and monitored blood glucose the mortality fell from 20% (32/162; 6 months before change) to 6% (8/132: 6 months after change). [Wilkinson D. Scrace M. Boyd N. Reduction in in-hospital mortality of children with malnutrition. Journal of Tropical Pediatrics. 42(2):114-5, 1996 Apr.]

The message sent earlier to NGONUT by George Fuchs, showing a dramatic reduction in mortality from "protocolisation" of the treatment, instead of allowing clinicians to decide management on their clinical judgement may also be partly due to the routine use of antibiotics at admission.

In Jamaica, we found that when highly-trained paediatricians came to the unit and tried to manage these children, making decisions on the basis of their experience in well-nourished children, the mortality rate increased.

In one ACF mission with a "reasonable" mortality rate whenever the nurses ran the centre according to the standard ACF protocols, the mortality rate doubled when we sent a doctor, reduced again whenever the doctor left and then again doubled whenever a second doctor was sent. This is NOT at all a criticism of the doctors - it is simply a statement that very few doctors are sufficiently experienced or trained to look after severe malnutrition, that the children do not behave or respond like a normal child that gets an illness, and that clinical judgement is very very unreliable in this condition.

I know that one of the MSF divisions disagrees with this and maintains that doctors are essential in running a TFC and that antibiotics should be given selectively. (Other MSF divisions do not agree).

However, I have no doubt that ALL severely malnourished children, particularly those with oedema, should be given antibiotics from the time of admission and that failure to do so is part of the reason (but only part) for the continuing high mortality.

Best wishes,

Prof. Michael H.N.Golden

 

Dept of Medicine and Therapeutics, Univ of Aberdeen, Foresterhill

AB9 2ZD. Scotland, (UK)

Tel +44 (1224) 681 818 ext 52793/53014, Tel(direct) +44 (1224) 663 123 527 93

Fax +44 (1224) 699 884, INTERNET m.goldenatabdn.ac.uk

AB9 2ZD. Scotland, (UK) | Fax +44 (1224) 699 884


Date: Wed, 14 Jan 1998 11:27:26 -0600

From: Benjamin Torun <btorunatnsem.incap.org.gt>

Subject: Diets to treat malnutirition

 

Dear NGOnuts,

It is important to bear in mind the distinction made by Mike Golden between the initial ("acute") and rehabilitation ("catch-up") phases of dietary management in severe, life-threatening malnutrition.

There are successful experiences, including our own, with the use of locally available products --either of animal or plant origin-- for the dietary management of both the acute and catch-up phases of treatment. Although many of those experiences may not have undergone the scientific rigor of controlled clinical trials, they have given good clinical results and were readily acccepted by the patients, their mothers and health staff.

As I mentioned in an earlier comment on this topic, "optimal" diets can --and have been-- formulated to give the best possible results, taking into account the needs for macro- and micronutrients of the malnourished child or adult. But the purpose of my comment coincides with Andy Seal's observations in East Africa: in the absence of those optimal diets or their ingredients, and in the absence of funding to buy "better" or "ideal" foods, options must be given to make the best possible use of whatever may be available, for all phases of dietary management.

With this in mind, George Fuchs and I are willing to compile and make available to all interested, a list of locally available and culturally accepted foods that have been used successfully to treat malnourished patients in different parts of the world. We will greatly appreciate the contributions that NGOnuts can make for inclusion in this database. We will also welcome participation of others in this endeavor.

To organize this task, George and I will prepare an outline of the information that will be needed for the diet database, and we will send it to all of you through this e-mail network.

Once again, my thanks to Mike Golden for his brillliant idea and great effort to provide us with this wonderful means of communication and exchange of opinions.

Ben

Benjamin Torun, M.D., Ph.D., Head, Human Nutrition Unit

Institute of Nutrition of Central America and Panama INCAP -- Apartado Postal 1188

Guatemala, Guatemala

Tel: [502] 471-9913, 471-5655, 472-3762, Fax: [502] 473-6529

e-mail: btorunatincap.org.gt, INCAP WWW site: http://www.incap.org.gt/


Date: Thu, 15 Jan 1998 11:54:05 +0000

From: peter.sullivanatpaediatrics.oxford.ac.uk (Peter Sullivan)

Subject: Diets for malnutrition

 

Dera ngonuts,

I greatly welcome the initiative to compile information on diets made from locally available and low-cost materials for the treatment of malnutrition.

I would make a plea, however, that when this is done we should also include diets that are used for children who not only have severe malnutrition but also persistent diarrhoea (PD). The management of persistent diarrhoea and malnutrition (PDM) is still far from ideal with a very high failure rate in many places and reliance on dietary regimes (based for example solely on skimmed milk sugar and oil) known to be ineffective particularly at restoring intestinal function (1).

A number of reports have indicated that diets formulated from traditional foods can be effective in the management of PD (2- 8). None of these diets, however, has been completely successful. Furthermore, in few of these studies was the effect of the diet on the restitution of intestinal integrity and function demonstrated. It is generally agreed that a more optimal dietary formulation yielding a higher success rate should be sought.

In Bangladesh, children treated for PD are given rice suji (rice powder, glucose, soya oil and egg-white) and it is said to have an 81% cure rate (9). In Pakistan, Zulfiqar Bhutta and colleagues compared soy formula with a traditional diet composed of rice, lentils and yoghurt ("Khitchri") and found a higher weight gain and lower stool output during the first week of therapy in those fed the traditional diet (10). Again, however, there was a 20% treatment failure rate particularly in younger children. Bhutta and colleagues concluded that further studies would be needed to determine the optimal composition of a traditional diet for use in severely malnourished children with PD (5).

Further debate on the composition of diets suitable for children with persistent diarrhoea as well as malnutrition would be welcome. This does also raise the issue of whether or not it is possible to use local foods in this context or whether one needs to rely on an "engineered" product such as F100. For my part, I would like to see a long-term follow-up of such children treated with F100.

 

1. Sullivan P B, Mascie-Taylor CGN, Lunn P G, Northrop-Clewes C A, Neale G.

The treatment of persistent diarrhoea and malnutrition : Long term effects of in-patient management. Acta Paediatr Scand 1991;80:1025-1030

2. Akbar MS, Roy SK, Banu N. Persistent diarrhoea: management in algorithmic approach using a low cost rice based diet in severely malnourished Bangladeshi children. J Trop Pediatr 1993; 39:332 337.

3. Roy SK, Haider R, Akbar MS, Alam AN, Khatun M, Eeckels R. Persistent diarrhoea: clinical efficacy and nutrient absorption with a rice based diet.

Arch Dis Child 1990; 65:294 297.

4. Brown KH, Lopez de Romana G, Graham GG, MacLean WC. Experience with a mixture of wheat noodles and casein in the initial dietary therapy of infants and young children with protein energy malnutrition or acute diarrhea. Hum Nutr Appl Nutr 1982; 36:354 366.

5. Bhutta ZA, Molla AM, Issani Z, Badruddin S, Hendricks K, Snyder JD.

Nutrient absorption and weight gain in persistent diarrhea: comparison of a traditional rice lentil/yogurt/milk diet with soy formula. J Pediatr Gastroenterol Nutr 1994; 18:45 52.

6. Olukoya DK, Ebigwei SI, Olasupo NA, Ogunjimi AA. Production of DogiK: an improved Ogi (Nigerian fermented weaning food) with potentials for use in diarrhoea control. J Trop Pediatr 1994; 40:108 113.

7. Rahman MM, Islam MA, Mahalanabis D, Biswas E, Majid N, Wahed MA. Intake from an energy dense porridge liquefied by amylase of germinated wheat: a controlled trial in severely malnourished children during convalescence from diarrhoea. Eur J Clin Nutr 1994; 48:46 53.

8. Roy SK, Akramuzzaman SM, Haider R, Khatun M, Akbar MS, Eeckels R.

Persistent diarrhoea: efficacy of a rice based diet and role of nutritional status in recovery and nutrient absorption. Br J Nutr 1994; 71:123 134.

9. Roy SK, Alam AN, Majid N, Khan AM, Hamadani J, Shome GP. Persistent diarrhoea: a preliminary report on clinical features and dietary therapy in Bangladeshi children. J Trop Pediatr 1989; 35:55 59.

10. Bhutta ZA, Molla AM, Issani Z, Badruddin S, Hendricks K, Snyder JD.

Dietary management of persistent diarrhea: comparison of a traditional rice lentil based diet with soy formula. Pediatrics 1991; 88:1010 1018.

Best wishes to all

 

Peter

Dr Peter B Sullivan MA MD FRCP FRCPCH

University of Oxford, Department of Paediatrics, John Radcliffe Hospital

Oxford OX3 9DU, UK

Tel: Int-44-1865-220934, Fax: Int-44-1865-220479

Email: peter.sullivanatpaediatrics.ox.ac.uk


Date: Thu, 15 Jan 1998 19:26:26 -0800

From: Ann Burgess <annburgessatsol.co.uk>

Subject: Local foods for treatment of maln

 

Dear Ngonuts

I strongly support what Andy Seal said recently. The situation he describes is almost the same as I have seen about a year ago in a regional govt hospital in E Africa (I don't think it is the same one!).

The only milk for the treatment of severe maln was small irregular amounts of fresh milk supplied by a local charity - although the AIDS patients got some dried milk. I hope when the WHO manual does finally appear it will give recipes for the stabilization phase using fresh milk (as well as dried). Some families might be able to supply that for the few crucial days.

The hospital food was mainly poor quality maize, beans and cabbage and some very tough meat (even supplying a mincer did not help). One result, apart from a seemingly high death rate, was that the staff were disillusioned. In fact a senior nutritionist told me that poor staff motivation was one of her biggest problems.

Re using local foods. Once long ago in the days when we were worried about lactose intolerance, we tried treating kwash with raw eggs, sugar and oil! The mixture did go down an NG tube and, as far as I remember, the few children on which it was tried recovered (Trans Roy Soc trop Med & Hyg 65:680. 1971). However I'm sure few people would advocate the use of raw eggs nowadays!!

I look forward to catching up with this important subject when I return from Tanzania in March.

 

Best wishes

Ann

Ann Burgess, Nutrition Consultant

c/o PO Box 10132, Arusha, Tanzania


Date: Fri, 16 Jan 1998 11:56:10 +0100 (MET)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: local vs imported food

 

Dear NGO nuts,

The debates on local vs imported food has been going on for years, and is often complicated by non nutritional issues. Let's be pragmatic. What we want is cheap effective food. A major progress would be made if different foods (local and imported) were compared in terms of :

1) cost per Kg

2) cost per 1000 kcal

3) cost per 100 g proteins

4) cost for daily requirements of all nutrients for a malnourished child (K, Mg, Fe, Zn ...)

5) cost for 1 kg observed weight gain.

6) cost per death averted

(of course, the last one is the most important).

I believe it would be a mistake to prefer local food in whatever circumstances. I just come back from Mauritania where the cost of 1 Kg of K given by banana (grown is some parts of the country) is very much higher than K bought in powder form (KCl) on the international market. Should we advocate the use of bananas just because it is 'local' ?

Of course, these comparisons should not go too far. Local preference culture should be of primary concern, but I believe cost nutrient comparisons would sometimes help to clarify this issue.

Dr. Andre' Briend


Date: Fri, 16 Jan 1998 11:27:48 -0600

From: Benjamin Torun <btorunatnsem.incap.org.gt>

Subject: Local vs. imported foods

 

Dear NGO nuts,

I agree with the comments that several people have been sending in relation to the use (or "misuse") of local foods to feed malnourished children and adults, who otherwise will either die or continue in a state of malnutrition. But let's not lose perspective of the discussion.

What triggered these interesting exchanges were actual cases pointing out that when a specific food that was the only one prescribed to treat severe malnutrition was not available, people (including hospital doctors) used wrong and dangerous dietary approaches.

There is no doubt that severe malnutrition is a medical emergency that must be handled as such, and foods must be regarded as the life saving "medications".

There is no doubt that, as we must select the best antibiotic for a specific infection, we should also use the best foods to treat a malnourished patient.

There is no doubt that many industrially prepared foods can be prepared with high quality standards, and at a lower cost than local preparations.

There is no doubt that bananas as a source of potassium are more expensive than imported KCl salts.

There is no doubt that cost/efficiency must be an important consideration.

But the issue that some of us advocate is that options must be given to use other foods --in most instances locally prepared, with locally available ingredients--, when the "best", "most nutritious", "least expensive" or "most efficient" foods simply are not there.

Under conditions of disaster the international community tends to help the victims, and relief programs have saved innumerable lives. These programs should be, as many are, geared towards obtaining and distributing the best of everything, including food for malnourished persons.

But in many parts of the world severe malnutrition is an endemic problem, and not only in emergencies or disasters. Here is where we often face the absence of imported foods. It is ironic that in some such places there are local foods that could help solve the problem, but they are not used because "it is not the norm", or no one has bothered to instruct policy makers and health personnel that such foods may be used to prepare adequate diets.

Regards to all,

Ben

Benjamin Torun, M.D., Ph.D.

Jefe, Unidad de Nutrición Humana, Head, Human Nutrition Unit, Instituto de Nutrición de Institute of Nutrition of Centro América y Panamá. Central America and Panama.

INCAP -- Calzada Roosevelt, Zona 11, Apartado Postal 1188

Guatemala, Guatemala

Tel: [502] 471-9913, 471-5655, 472-3762 Fax: [502] 473-6529

e-mail: btorunatincap.org.gt, WWW: http://www.incap.org.gt


Date: Fri, 16 Jan 1998 09:33:20 +0600

From: George Fuchs gfuchsatcitechco.net

Subject: antibiotics for severe malnutrition-yes

 

Dear Katherine,

I fully agree with Michael's comments and recommendations. The standardized protocol we are now using and which calls for the near "prophylactic" use of antibiotics in these children undoubtedly made a major contribution to the marked reduction in mortality we observed with the standardized protocol. This issue has been extensively studied and documented in other populations of immunocompromised children which I have also had the opportunity to treat, neonates and children with cancer undergoing chemotherapy. Similar aggressive antimicrobial use as used in both the WHO protocol and ours at ICDDR,B is standard procedure and credited with the prevention of excessive mortality. As in children with severe malnutrition, these children usually do not manifest typical signs of sepsis until it is too late. While clinical criteria to indicate the need of antisepsis antibiotic regimens have been developed for all these groups, in our experience it is the almost rare exception that one or more of these are absent in the acutely severely malnourished child. In my opinion it is therefore not at all unreasonable to provide broadspectrum antibiotic coverage to these children as a matter of routine. All the best,

George

 

George Fuchs, MD

ICDDR,B: Centre for Health and Population Research GPO 128

Mohakhali, Dhaka 1000, Bangladesh

Tel: 880 (2) 988-2399; Fax: 880 (2) 883-116 email: gfuchsatcitechco.net


From: mmd319atabdn.ac.uk

Subject: prophylactic antibiotics

Date: Fri, 16 Jan 1998 09:54:24 +0000 (GMT)

 

There is a difference between "blind treatment" and "prophylaxis": I try to avoid the idea that we use antibiotics "prophylactically" because of the many negative connotations of this term (in Western medicine prophylactic administration to immunocompromised patients is frequent - as well as blind treatment - and it is not always clear from the published reports which is intended).

However, "blind treatment" is very respectable, totally appropriate and forms a critical part of management in conditions where the vast majority of presenting patients have infection in a life-threatening disease.

Indeed, when we searched for infection with cultures at numerous sites and treated the patients on the basis of the sensitivity of the cultured organisms (specific treatment), we got much worse results! We then started to do immediate autopsies (within 60 min of death) and we astonished at the range of different organisms, each with different sensitivities, that we recovered. I interpret this to mean that when we manage to "recover" an organism and treat it specifically with a narrow-spectrum antibiotic we fail to treat all the others that are their, but the microbiologists have failed to grow (usually because we have not sampled the correct site - such as the lower respiratory tract) and these other organisms remain hidden until the child dies - we are truely blind.

The message is - most infections are MIXED - there are usually multiple sites infected - and a microbiological service is of limited use (this is good news for those without lab support (smile))

Best wishes,

Prof. Michael H.N.Golden


From: David.BrewsteratCASRDH.HEALTH.nt.gov.au

Date: Sat, 17 Jan 1998 13:28:44 +0930

Subject: Treatment of Severe Malnutrition

 

David Brewster

Associate Professor of Paediatrics

Northern Territory Clinical School, Darwin, AUSTRALIA

 

It has been interesting to follow the deliberations on local foods in malnutrition. I would like to add a few considerations which have not been mentioned:

1. Local Foods:

The excellent work from Latin America on use of local diets in diarrhoea and malnutrition cannot be extrapolated to acute severe malnutrition in African countries. I studied the use of a maize-soya-egg diet (with micronutrient supplements and antibiotics) compared to milk following the standard WHO & Waterlow schedules of 2 phases in Malawi. The two-phase milk diets (of comparable energy, protein and micronutrient density to the maize diets) were clearly superior in terms of mortality, weight gain and intestinal recovery (measured as permeability changes). There was evidence in the milk group that lactose intolerance - not clinically a problem - significantly delayed intestinal mucosal recovery, so if a low lactose formula had been used initially (unavailable to us), the milk group would have have had even greater improvements over the maize-based diet. (If anyone wants reprints of these papers, email me at: "David.Brewsterathealth.nt.gov.au" but NOT by replying to the network). So I would favour a low lactose milk-based diet in the initial treatment of severe malnutrition. Donor Agencies should consider supplying this with micronutrient supplements to hospitals and nutrition centres treating such children.

On the other hand, local foods during the recovery or "feeding up" phase or in stunted children is entirely different, and do not seem to have the problems with acute rehabilitation provided they have adequate protein, energy and micronutrient densities. We also found, not unexpectedly, that tube-feeding significantly increased weight gain but did not decrease mortality.

2. Antibiotics:

In response to Michael Golden's comments, the increasing pattern of antibiotic resistance complicates his advice. Chloramphenicol can no longer be counted on to cover the multiple organisms infecting malnourished children, yet Cefotaxime is too expensive and its widespread use has led to rapid emergence of resistance in areas with a high burden of disease (e.g.northwestern Australia) or high usage wards (nutrition, burns, ICU).

Wilkinson's (South Africa) cited drop in mortality with use of gentamicin may not be sustainable, and may also have been related to better nursing care.

In many poor African countries, doctors and male medical assistants admit severely malnourished children, but rarely review them - especially not at night. So sudden deterioration with sepsis requiring antibiotics (or a change if commenced on admission) will occur too late. I have tried to get nurses on nutrition wards to start antibiotics on their own initiative as soon as a child deteriorates, but District Medical Officers and Hospital Administrators usually veto this arrangement. The truth is that doctors are expected to do surgery in Africa (especially at mission hospitals) and kids are left to the nurses. I have found it very difficult to motivate male health workers and doctors (who are not based on a ward like nurses) to take a real interest in childhood malnutrition - particularly now that most have AIDS.

Having said that, I do not believe that the mortality of severe non-AIDS malnutrition (particularly kwashiorkor) can be decreased by simple feasible improvements in clinical care. In Malawi, we admitted new cases into an ICU with highly-paid expert research nurses for a short period with good paediatrician and laboratory access, but had little impact on mortality.

The workload on doctors and nurses in this ICU context increased several-fold, so it is hardly sustainable. We did discover that some of the kwashiorkor children who suddenly deteriorated developed heart failure rather than sepsis, and this was despite standard low volume fluid regimes.

This responded to furosemide, but not to antibiotics.

But the obvious conclusion is that the emphasis must be on preventive programs, but they are still too expensive and hard to administer for many African countries.

3. Regional Variations in Severity of Disease:

Although everyone pays lip service to the importance of local differences, they often end up ignored in global discussions and WHO manuals. Having looked after malnourished children from a paediatric perspective (hospitals and nutrition centres) in St Lucia, Samoa, Papua New Guinea, Zimbabwe, Solomon Islands, The Gambia, Malawi and now Aboriginal children in the Northern Territory (yes, who have severe nutritional problems), I would like to underline the differences. For example, even within Africa the mortality for kwashiorkor was 30% in Malawi and 12% in The Gambia with the same protocols and similar levels of nursing care, but the staple diet is different. I conclude that the severity of disease was much greater in Malawi with a maize diet (and lower per capita income). So international comparisons are NOT straightforward, and expert reviewers usually ignore this and generalise from their site. So protocols and manuals need to call upon local knowledge, and health workers need to be better supervised on site (not just trained).


From: pinnigeratumn.mos.com.np

Date: Tue, 20 Jan 1998 20:30:21

Subject: treatment of malnutrition

 

Interesting discussions!

1. We used to get good results with a shot of thiamine in these kids who developed heart failure suddenly especially if they were predominantly maize eaters. Has anyone looked at that recently or am I behind the times??

2. Ive also found most have mixed infections and broad spectrum antibiotics give the best chance.

3. We are currently updating a Standard Treatment Guide for auxiliary health workers (and perhaps doctors?) and need a simple relatively comprehensive protocol for different grades of malnutrition and use at 3 levels taking into account concurrent diarrhoea, infections, worms etc. We've had one in use elsewhere for >8 years but Id be interested in any that other people have devloped that they do not mind sharing. Many thanks

Rachel Pinniger

Assoc Prof, Community Medicine and Family Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal email: pinnigeratumn.mos.com.np

Postal address: Box 126, Kathmandu, Nepal