Assessment Tool for Treatment of Severely Malnourished Children
Assessment Tool for Treatment of Severely Malnourished Children Tom Davis 28.06.99
Re: Assessment Tool for Treatment of Severely Malnourished Children References Penelope Nestel 28.06.99
Assessment Tool for Treatment of Severely Mal Mercedes de Onis 29.06.99
Manual on Management of Severe Malnutrition Mercedes de Onis 02.07.99
treatment of malnutrition Patrick Kolsteren 07.07.99
treatment of malnutrition Michael Golden 21.07.99


From: "Tom Davis, MPH" <tdavisatm-y.net>

Subject: Assessment Tool for Treatment of Severely Malnourished Children

Date: Mon, 28 Jun 1999 12:32:19 -0000

 

After reading some of the posts a while ago about treatment of children with severe malnutrition (especially the use of iron)(cf. Nutrition assessment of adolescents), I was convinced that we should begin assessing the treatment protocols used for treating severe malnutrition in the clinics that work in our project area (with an eye towards improving their skills). Do any of you know of a tool that can be used to assess if clinic/hospital workers are properly treating severe malnutrition?

Thanks,

 

Tom Davis, MPH, Consultant & Senior Program Specialist

Andean Rural Health Care


Date: Mon, 28 Jun 1999 17:33:01 -0700

From: Penelope Nestel <pnestelaterols.com>

Subject: Re: Assessment Tool for Treatment of Severely Malnourished Children References

 

It is my understanding that the WHO had a module/guidelines for this under the ICMI. Jim Tullock, Director, program on Child Health and Dev, WHO, is the contact person (fax: 41-22-791-0746).


From: deonismatwho.ch

Date: Tue, 29 Jun 1999 09:22:11 +0100

Subject: Assessment Tool for Treatment of Severely Mal

 

Dear Tom:

WHO recently published (January 1999) a Manual for the Management of Severe Malnutrition. One possibility to assess current practices would be to compare them with "best practices" as set out in the Manual. On the basis of the assessment, an action plan could be developed to implement "best practices" as far as is feasible in that particular setting.

Best wishes,

 

Mercedes de Onis

Department of Nutrition, World Health Organization

Geneva, Switzerland


From: deonismatwho.ch

Date: Fri, 2 Jul 1999 12:23:53 +0100

Subject: Manual on Management of Severe Malnutrition

 

Dear colleagues:

I would like to let you know that the WHO Manual on the 'Management of Severe Malnutrition' is now available at the following Web address:

www.who.int/nut/Manageme.pdf

Kind regards,

 

Mercedes de Onis

Department of Nutrition, World Health Organization


Date: Wed, 07 Jul 1999 09:49:07 +0100

From: "Patrick Kolsteren" <pkolsterenatitg.be>

Subject: treatment of malnutrition

 

Dear ngonut,

The publication of the manual on the treatment of severe malnutrition is indeed an important improvement to decrease the case fatality rate of severely malnourished children. As the editorial in the Journal of Tropical Pediatrics underlines, there is an important improvement to be made.

I see here at the institute of tropical Medicine every year a large number of MD's who follow the Masters in Public health with whom I discuss the developments in treatment schedules for severe malnutrition. Sadly to say they are rather sceptical as to the implementation possibilities of the proposed treatment guidelines.

Most district health systems suffer from lack of resources. Drugs are not continuously available and the availability of drugs is limited due to distribution difficulties. In many countries milk is a not traditional food and is expensive to purchase, if it can be bought at all. It is therefore difficult to implement, for practical reasons, a scheme wich relies on purchased goods and mineral and vitamin preparations that also need to be ordered and distributed.

It would therefore be good to also develop alternatives to the F75 and F100 formulas with other food products.

Would it not be good to also describe the underlying principles of the treatment guidelines. Why milk? Why exactly these amounts? How where the vitamin and mineral dosages calculated etc. This way local alternatives can be developed.

When I was working in Nepal we treated many severely malnourished children with local available foods. We only rarely needed milk products which we had to purchase in the capital. the case fatality rate was 2%, so the results were not all that bad. We did however treat infections early, gave very frequent feeds, also at night and added potassium, vitamin a and a multivitamin preparation.

Particular care was given to hypothermia by keeping the children close to the mother on the same mattress.

It seems to me that the case fatality can be considerably reduced by practising a certain number of instructions without needing the F75 and F100 formulas if they are not available. It would be even better if alternatives can be proposed for situations where milk is hard to get and the health system has resourse and distribution problems.

 

Dr.P.Kolsteren

Nutrition and Child Health Unit, Institute of Tropical Medicine Antwerp

NAtionalestraat 155, 2000 Antwerpen, Belgium tel 32-3-2476389 Fax 32-3-2476543


Date: Wed, 21 Jul 1999 18:10:49 +0100

From: Michael Golden <refugeesatabdn.ac.uk>

Subject: treatment of malnutrition

 

Patrick Kolsteren raises a number of very important points in his letter of 7th July with respect to the implementation of the new treatment guidelines on severe malnutrition (wasting and oedema), that require discussion.

1) "It seems to me that the case fatality can be considerably reduced by practising a certain number of instructions without needing the F75 and F100 formulas if they are not available".

This statement is certainly true. The manual is not simply a presentation of formula, and introduction of the formulae alone will not reduce the fatality rate to reasonable levels. We have found that the organisation of the centers is absolutely critical, with the staff knowing what to do and following the whole protocol. Perhaps the most damaging practice is the frequent use standard quantities of intravenous fluids in these children and the misdiagnosis of "dehydration", failure to assume the presence of infection and give blind treatment, and failure to prevent hypoglycaemia/hypothermia by frequent feeds. Such measures have a major effect.

2) "Would it not be good to also describe the underlying principles of the treatment guidelines. Why exactly these amounts? How where the vitamin and mineral dosages calculated etc. This way local alternatives can be developed."

Many of the underlying principles are described in Golden MH. "Severe Malnutrition". In: Weatherall DJ, Ledington JGG, Warrell DA, eds. Oxford Textbook of Medicine. 3 ed. Oxford: Oxford University Press, 1996:1278-1296.

There have been many experiments to examine the need for individual nutrients and energy in the literature.

Most of these have reported the results in terms of the amount of nutrient per kilo body weight. This is not really a useful way of expressing the results, because it means that each child would have to have a diet individually prescribed, and the "additives" intake would not change with the intake of the whole diet. What I did was to translate these experimental results from per-kilo child to per-amount-of-diet, examining whether there would be sufficient if the child took 100kcal/kg and making sure that there would not be an excess if the child took over 200kcal/kg.

This change in philosophy to designing a diet rather than prescribing nutrients takes into consideration, to some extent, the metabolic state of the child - in other words when the child is taking a amount and gaining weight rapidly there is an automatic increase in the intake of the nutrients required for that new tissue. This is in contrast to having a fixed amount given per kilo to the child whether that child is gaining or losing weight.

The calculations for protein have been published separately (Golden MH. Protein-energy interactions in the management of severe malnutrition. Clin.Nutr. 1997;16 (Supplement 1):19-23). For some of the mineral nutrients the underlying database is not at all strong. There has been very little work on the vitamins needs in severe malnutrition

3) "Why milk?" - the best answer to this is that it seems to work, and other diets that have been tried do not achieved the same rates of weight gain. It does have the major disadvantage of being a good medium for bacterial growth and because of this needs to be made up freshly and hygienically shortly before each feed. I am sure that there are alternatives that can be made that will in the future be as good as milk based diets. The main thing was to have a standard against which other diets can be fairly tested. When one centre uses another diet, and gets a weight gain of, say, 6g/kg/d - how do we interpret these data? The relatively poor gain in weight may indeed be due to the diet, alternatively it may be due to the regimen or the type of patients that are being treated. We are now at a stage when we can compare new diets with F100.

For example, in many of the centers we introduce a porridge as the children recover. If this is CSB or UNIMIX then the rate of weight gain of the children suddenly drops - in other words, these diets do not adequately substitute for F100. On the other hand, when we introduced a porridge (commercial name SP450) based upon the GBG formula (Golden MH, Briend A, Grellety Y. Supplementary feeding programmes with particular reference to refugee populations. Eur.J.Clin.Nutr. 1995;49:137-145) there was no diminution in the rate of weight gain - showing that this formula could substitute for F100 during rapid growth.

4) There are several important situations when F100 is not appropriate, and yet there is little in the way of an alterative that has been shown to work. F100 needs trained staff and residential facilities (it should be classified as a medicine). What about an emergency situation where it is not possible to establish residential facility, what about nights when staff cannot be there for security reasons, what about out-patient management, what about management from a health centre where there are few such patients and no kitchen and no staff at weekends. Most hospitals cannot keep the children residential for sufficiently long for them to recover until the bed is needed. Clearly, F100 is only the start!

Recently, we have completed a series of experiments using a solid paste like diet, based upon the F100 formula, but looking and tasting like peanut butter. It was successful (Briend et al "Ready-to-use therapeutic food for treatment of marasmus" Lancet 1999;353:1767-1768), and we are now going on to test whether children can have there whole recovery on this diet alone (it is made by Nutriset). Compact is also developing such a diet which is in a prototype phase for use in emergency situations.

The diet that has been developed, along the same principles, by the team in Bangladesh (ICDDRB) from local ingredients seems to work well.

So F100 is just the start of what I hope is a renaissance of work on trying to develop and properly evaluate a variety of diets formulated form different ingredients.

5) The cost is important. However, a rough calculation shows that it is not excessive. If the present regimen has a morality of 40% and the modern treatment has a mortality of 10% then by switching regimens for every 10 children treated 3 will be saved. The additional cost of the diets, purchased commercially, for one months treatment is about US$ 15. or about US$45 per death averted. It is much less if the ingredients are mixed on site - but then this requires more highly trained staff and much more vigilance (almost everywhere I've been there were mistakes being made in the mixing). However, the costs compare very favorably with public health measures such as measles vaccination and vitamin A distribution. Of course US$15 is not the total cost, only the additional cost - however, George Fuchs calculated that the new protocolised management was in fact cheaper than the old individual management, so that in many centers the additional costs of using the protocol.

If a child is gaining weight on the new diet at 15g/kg/d and he needs to go from 70% to 85% of body weight this will take 10 days (10x15g = 15% of body weight). If a child is gaining at 5g/kg/d on local produce it will take 30days to achieve the same weight gain. If non-diet the inpatient costs are US$ 2.00 per day then the total costs for the rapid growth phase is US$ 20 + 15 for the diet = US$35 for the F100 diet whereas it is US$ 60 + 0 for the local diet (assuming the local diet has no cost). Indeed, it is much cheaper to have the children recovering quickly on a slightly more expensive diet than more slowly on a more expensive diet - if they are to be kept in residential care until recovered! Indeed, in a TFC addition of porridge to the regimen increases the cost of treating a patient because it prolongs the stay.

At the moment many children are discharged before they are recovered to the same environment they came from, it is likely that many die because of this early discharge.

Clearly, the way forward is, for some patients, the outpatient management regimens developed by Sultana Khanum (Lancet) - but this was only deemed suitable for half the patients and there must be something for the others!

There are "middle ground" possibilities, such as out-patient and health-centre management, which would be much cheaper than residential care, but these could not use F100: as the new high quality formulations specifically designed for the severely malnourished, that are "take-home" or "ready to use" and bacteriologically safe, become available - then the efficiency, ease and cost of treatment should come within most countries ambit.

Thank you very much for raising these issues - there is still a lot of work to be done and a major research agenda to address many of these questions.

The Manual should be seen as just tool, with new editions needed quite frequently - and not as "tablets of stone", years in gestation and now immutable.

Mike Golden

 

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

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