|Iron in ready to use therapeutic food (rutf)|
|iron in ready to use therapeutic food (rutf)||André Briend||19.10.2000|
|Re: iron in ready to use therapeutic food (rutf) the need for community therapeutic feeding||Steve Collins||27.10.2000|
|Hearth model||André Briend||27.10.2000|
|RE: Hearth model and community therapeutic feeding||Steve Collins||31.10.2000|
Date: Thu, 19 Oct 2000 16:49:55 +0100
From: "Andé Briend" <briendaatcnam.fr>
Subject: iron in ready to use therapeutic food (rutf)
Many ngo's now start using ready to use therapeutic food (RTUF) to facilitate feeding during rehabiliation phase and to treat severe malnutrition in places where implementation of the classical WHO protocol is not possible (to know more about rutf, see Lancet 1999; 353: 1767-8).
Some consider using this approach in other places to increase programme coverage / decrease duration of hospital treatment. Yet, questions are often raised regarding the iron content of these products (these questions apply to both products now in use / being tested). Maybe ngo nut is a good place to discuss this issue and have feedback from experts + all those involved.
RUTF contains iron because iron is added during the production process.
There is no more iron in RTUF ingredients than in F100. It was decided to add iron because these products are designed to be used in the catch up growth phase and may generate high weight gains. As a result, there is a real risk of anaemia if iron is not added. As far as I know, ACF in recent years, with the same rationale, has added routinely 20 mg iron per 1000 ml of F100. The same dose (in relation to energy) is used in RUTF. I did not hear addition of iron to F100 created any problem. This dose is not far from the 3 mg/kg/day iron recommended in the 1999 WHO manual (p 22) in the rehabilitation phase for 'nearly all children' (ie those with moderate anaemia). Unless there is strong evidence against this rationale, I would be in favour of keeping iron in RUTF used in phase 2.
This leads to a problem for those who want to use RUTF in phase 1.
My first reaction to this is that RUTF is NOT designed to be used in phase 1, at least for children in poor general condition. To me, F75 or diluted F100 should be given preference whenever this is possible for malnourished children in poor condition during the initial phase of treatment.
I understand that some ngo do not have much choice and consider using RTUF in some situations as an alternative to unadapted blended flour, or nothing or water. This leads to to several choices:
1) Have a iron free (and by the way low Na, low protein, groundnut free RUTF) RUTF for phase 1. Possible. This may create confusion between different types of products.
2) Have iron free RUTF only for everybody. Not very satisfactory with the problem of anaemia for most children in phase 2 .
3) Use phase 2 rutf with iron in phase 1.
If the alternative is clearly not adapted, then rutf with iron in phase 1 may be a good choice. Please note that the increase in mortality reported previously in severely malnourished children receiving iron was observed in children receiving iron from tablets. (see Smith at al, Plant protein rehabilitation diets... Eur J Clin Nutr 1989; 43: 763-768). Iron from food is likely to be less toxic. First it is not so well absorbed during feeds.
In the WHO manual it is advised to give iron between feeds to improve absorption. Second, iron is likely to be emptied from the stomach much more slowly with high energy rutf than with a tablet. Finally iron doses in RUTF (10 mg/100g) is much less than in a standard iron tablet (60 mg in a standard iron sulfate tablet).
4) Use different forms of iron with less secondary effects
An attractive option would be to add a different form of iron which has less secondary effects. A good candidate for this is polymaltose iron which seems well absorbed despite being in Fe+++ form. Its toxicity is decreased compared to ferrous iron and similar forms of iron can even be used in injectable form (not in malnourished children of course). Apparently, it leads to less oxidative stress than ferrous iron (see: Tuomainen et al.
Oral supplementation with ferrous sulfate but not with non ionic iron polymaltose complex increases the susceptibility of plasma lipoproteins to oxidation Nutr Res 1999; 19: 1121-32). Incorporation of this form of iron in RTUF could be considered. The problem with this form of iron, however, is that it is approved only as a drug and not as a food ingredient. Using this form of iron would be possible only if ngos are ready to regard RTUF as a drug and accept in RTUF an ingredient not in the Codex Alimentarius list.
I think at this stage it would help to have a consensus view about this issue. Feedback /other suggestions welcome.
André Briend, MD, PhD
CNAM - ISTNA, 5 rue du Vertbois, 75003 Paris, France
tel : 33-1-53 01 80 36, fax : 33-1-53 01 80 05
From: "steve collins" <steveatvalidinternational.org>
Subject: Re: iron in ready to use therapeutic food (rutf) the need for community therapeutic feeding
Date: Thu, 26 Oct 2000 15:33:25 +0100
Thanks for your recent thoughts on Fe and therapeutic foods - I found them very useful.
I have recommended recently that Oxfam and Concern use RUTF in some of their community based therapeutic programmes in Ethiopia. This was for several reasons.
1. Either the numbers of children were to high to make usual TFCs feasible 2. Children and communities were too spread out to allow for easy referral to TFCs
3. With my fairly limited understanding of the toxic effects of iron I reckoned that if a person has appetite, that means they have reasonable hepatic function. Hence a reasonable ability to detoxify Fe induced free radicals. Appetite also probably means that they are not that badly infected and so increasing the iron saturation of transferring probably has less critical effects on decreasing immunity. As you say, the quantity of iron is only 10mg / 500Kcal - and this doesn't seem too much. So in Ethiopia, if there was one TFC to which we could refer children with poor appetite / complications / persistent diarrhoea, many more relatively uncomplicated cases could be treated in the community.
4. The more I see TFCs in large scale emergencies, the more I think that we must work on alternatives to TFCs for the majority of severely malnourished - certainly for those in phase 3. The opportunity costs to mothers are often so high, (do we ever look at the negative impacts on siblings) ; the model usually requires very high expatriate input and leaves almost nothing behind when they leave; and in the recurrent/ chronic emergencies (that make up most of what we see) conventional TFCs offer no viable exit strategies. I also see that the 50 - 100 person TFC with good hygiene, measures to reduce cross infection, etc is somewhat of a dream - certainly in the initial phases when most of the severely malnourished present - and I feel increasing unhappy about congregating immunosupressed children together.
On balance, although there are of course many problems with decentralised therapeutic care I think we should make more effort to try it as a complimentary intervention to the standard TFC / SFC / GRD. What I was aiming for was an adaptation of the Hearth model that has been tried in Vietnam and Haiti. Using this model we could promote community therapeutic feeding via mother's groups supported by CHWs etc To my knowledge this hasn't been tried too much in emergencies, but if anybody has some experiences I'd be grateful if you could share them cheers
Dr Steve Collins
Oleuffynon, Llanidloes, Powys SDY18 6PJ
Date: Fri, 27 Oct 2000 09:24:05 +0100
From: "André Briend" <briendaatcnam.fr>
Subject: Hearth model
Thanks for your useful comments about ready to use therapeutic food.
"What I was aiming for was an adaptation of the Hearth model that has been tried in Vietnam and Haiti. Using this model we could promote community therapeutic feeding via mother's groups supported by CHWs etc"
Can you say a little more about this Hearth model ? Never heard of it, I am afraid, and would be glad to know more about it.
André Briend, MD, PhD
CNAM - ISTNA, 5 rue du Vertbois, 75003 Paris, France
tel : 33-1-53 01 80 36, fax : 33-1-53 01 80 05
From: "steve collins" <steveatvalidinternational.org>
Subject: RE: Hearth model and community therapeutic feeding
Date: Tue, 31 Oct 2000 19:59:43 -0000
Dear Andre and other NGOnuts
Here's a few thoughts around the concept of community therapeutic feeding and some copies of earlier NGOnut notes on the hearth model (sorry it's a bit long but I think that the subject is very important and worth a few extra bytes) (see here)
I see community therapeutic feeding as an important progression and compliment to what we do now. In Ethiopia Oxfam are developing an integrated intervention with fortnightly dry supplementary, weekly intensive dry supplementary, CTF and TFC services. Having this range of 4 selected feeding interventions allows us to better tailor nutritional support to suit the needs of the individual children and their carers. The intensive supplementary and CTF are very important in allowing us to increase our coverage of severely malnourished children (the Regional government are understandably not keen to have loads of TFCs and have limited Oxfam to only one small one).
I envisage that the CTF will gradually emerge out of the Dry supplementary programme. It will require several different elements: 1. Selection of suitable patients; 2. The grouping together of patients who can attend local community groups and 3. The arranging a schedule for community groups facilitated by local health care workers / programme outreach workers.
The selection will have to choose severely malnourished children who do not have major complications. Initially workers and other CHWs attending dry supplementary will identify severely malnourished children according to standard anthropometric and clinical criteria. Note The CHWs are there because we get the local CHW for each area to attend distributions with their community and deliver education sessions to the mothers and children whilst they wait for the ration.)
In addition, workers must assess whether the severely malnourished person has complications that require TFC care or whether they can be treated in the community. This differentiation is tricky and requires some clinical input. As there will probably not be a clinician with each supplementary team this might require that at risk cases be screened using a simple clinical scoring system. This could be adapted from the CHANCES system that we proposed recently as a clinical scoring system for assessing adult malnutrition. ( see Short term prognosis in severe adult and adolescent malnutrition during famine, JAMA Aug 2, 2000 Vol. 284 #5 pp621 - 626) Obviously markers of serious infection such as pneumonia (increased RR, chest in-drawing etc) and septicaemia (hypothermia, high pyrexia, decreased tone etc.) would be absolute indications for referral into a TFC. These can be included as such in the model by scoring them above the threshold for referral. Other more relative indications would be dehydration, persistent diarrhoea and appetite.
I reckon that appetite will be one of the most important factors, but assessing this in a meaningful way will require plenty of thought and different approaches in different cultures, together with some trial and error. During this initial phase when the programme is evolving, the screening threshold for referral to the TFC should be set at a level that is more sensitive and less specific. This will minimise the negative impacts of misclassification on individuals, with misclassification tending to be unnecessary referral to the TFC rather than vice a versa. Usually all such children would be referred to a TFC so there is no loss. Gradually as the form of the malnutrition and common complications and their clinical relevance for that area becomes better known, the screening threshold and criteria can be adjusted to increase specificity, thereby referring more children to the CTF.
Those that are selected for the CTF attend the SFP every week and receive an intensive dry supplementary ration. This is a basic premix (c.f. the UNIMIX of the normal SFP) plus a RUTF ( in Ethiopia we are using plumpy nut). The children will also receive usual systematic TFC treatments (Vit A, mebendazole, etc). The choice of antibiotic is still problematic and I have not been able to find an ideal candidate yet. What is needed is a long acting antibiotic that can be given once, preferably orally ( in Ethiopia there are great problems with compliance with any take home drugs). I was wondering is Azithromycin might not be a suitable drug as it has a relatively broad action and can be given as a single oral dose in the case of trachoma and genital Chlamydia. If not maybe Chloramphenicol in oil?, penadur? I posted a question to the group a couple of months ago and received no replies - if there are any thoughts now I'd be grateful). If there are no suitable single dose antibiotics then cotrimox, two days at a time with further doses given by the outreach workers / CHWs might be the most practical alternative
The programme itself will consist of frequent community group meeting with the mother, children and local CHWs / programme outreach workers. The model here will be based on the hearth model (see notes attached at the end of this e-mail). In essence the workers will demonstrate to the mothers a basic assessment of the MUAC, low weight, baggy pants and any other signs of malnutrition etc. This will enable the mothers to understand what the signs are and so that when the child begins to improve they will have a clearer idea of the improvements. During the next week, CHWs/outreach workers will work intensively with these people, every other day or every three days.
Initially they would create and reinforce appropriate feeding schedules, reinforce the correct use of the RUTF, create suitable recipes of local foods and where necessary supplementing these with oil +/- CMV etc. The children can also be screened for response and where appropriate referred to the TFC. The large amount of contact would also give time to reinforce hygiene and rehydration and if necessary follow up with the basic antibiotics. At the end of the first week the children would all attend the intensive supplementary distribution where they could be reassessed by programme workers and referrals made.
After the first week, the community meeting and outreach visits could be less frequent, twice a week or so to reinforce the concept of very regular feeding hygiene and correct recipes etc. At this stage the best motivated mothers could then start to be used as resources to spread the message to other families with malnourished.
Although this basic idea will require a lot of refinement in practice, I think that it forms the basis for an intervention that is much less resource intensive and has more potential to be reactivate in future times of acute food insecurity. It is also a relatively low risk strategy, as by keeping the children in the community they will be exposed to fewer unfamiliar pathogens, not congregated together with other immuno-compromised children to swap diseases. Importantly, their carers will not be removed from the rest of the family (so hopefully siblings will not suffer so much). So long as the follow up is regular and well structured and supervised, it should be possible to spot those who are not responding quickly and refer them to the TFC.
A major attraction is that the community in general will develop its capacity to treat malnutrition, and be better placed to cope with future lean years with less need to resort to loads of expats and landcruisers.
Bellow are some articles on the Hearth model that appeared in NGOnut a couple of years ago
Oleuffynon, Old Hall, Llanidloes
Powys SY18 6PJ
Wales - UK
Tel: +44 1686 413989, Fax + 44 87016 41364
Notes on the Hearth Program at the Hospital Albert Schweitzer in Haiti Barton R. Burkhalter and Robert S. Northrup
The Hearth program of the Hospital Albert Schweitzer (HAS) in Haiti is a result of evolutionary modifications of earlier feeding and education programs to combat childhood malnutrition.
The involvement of volunteer mothers (animatrices) and the location of the feeding at the hearths of these mothers rather than in special centers are the critical differences from earlier approaches.
A group of animatrices (10-20) from a single community are trained and motivated in a week-long educational program held in their own community.
They learn about basic principles of child feeding, the growth monitoring program, growth curves, the importance of micronutrient supplementation and then do a 24-hour recall dietary study on a single child from their 15 households who has been growing well (a "positive deviant"). Their trainers (monitrices) then combine the one-family information from the animatrices in the group to define a nutritious meal that is clearly available locally and is affordable. The animatrices-in-training prove to themselves and the community the economic feasibility of the diet by purchasing food (with money provided by the program) for such a meal at the local market. Then they practice preparing that meal early the next morning in one of their own kitchens and feeding it to any available local children.
At the end of the training week all the children aged 1 to 5 years from the selected households are weighed as well as dewormed and those with significant malnutrition identified. The mothers of these malnourished children are then convinced to have the children participate in the two-week feeding program beginning the following week.
The two weeks of feeding are sufficient to bring about a dramatic improvement in the appetite, general demeanour and activity level of the participating children. They are transformed before the eyes of the animatrices, mothers and neighbours from listless, apathetic children who do not want to eat to energetic children who seemingly cannot get enough to eat. This change appears to convince the animatrices of the effectiveness of the diet and the importance of their role in working with the children and mothers as motivators and neighbourhood leaders, even without pay. It is also believed to influence the mothers to continue giving their children the new diet after the Hearth feedings are completed, and to use the new feeding approach with younger siblings as well. The mothers learn by watching, participating and by talking with the animatrices and perhaps other mothers.
The program follows up with weighings at four and eight weeks after the feedings. Children with no weight gain are referred to the hospital for medical diagnosis and treatment. The animatrices are expected to continue to interact with their 15 mothers after the cycle is over. The monitrices then use monthly meetings to involve animatrices from a particular locality in a broader range of public health activities (such as breastfeeding promotion and AIDS and STD prevention).
A retrospective impact evaluation used a longitudinal sample of 192 program participants and a comparison group of 185 children to determine program impact after one year. The two samples were similar, with one exception. The comparison sample participated in a Growth Monitoring and Promotion (GMP) program but not in the Hearth program, while the program sample all participated in the Hearth program but only about one-third participated in the GMP program.
The results showed that the Hearth program prevented deterioration in the nutritional status of mildly underweight children relative to the comparison group, but did worse than the comparison group with respect to severely underweight children. The finding about the mildly underweight children was highly significant (p<.01) with the gain over the comparison group being substantial (about 30% of a standard deviation on the reference weight-for-age distribution), while the negative finding about the severely underweight was not statistically significant. This result suggests that a combination of Hearth and GMP may be the most effective solution to the malnutrition problem.
The Hearth program appears to be successful in recruiting community volunteers and motivating them to remain active. It has thus established the cadre of animatrices as a valuable force for reaching the community with other primary health care activities. Other findings are: (1) the use of "positive-deviant" mothers was more important as a psychological device to convince the other mothers that the menu was effective and affordable, than as a strategy for discovering best local foods; (2) the animatrices were selected on the basis of personality and interest; (3) the animatrices themselves decided which families they would work with. This approach tapped into the mobile dynamics of the Haitian countryside and is probably a key factor in program success; (4) surprisingly, the age of the participating children did not correlate with nutritional status or gain in nutritional status over the course of the program.
The cost of the program is relatively small, about $7 (U.S.) per program participant-about $3 for food per child ($.25 per meal), and $4 per child for other costs (salaries, transportation and documentation).
Several methodological issues threatened the validity of the evaluation's conclusions, e.g., selection bias and community effect. While the potential effects of these issues remain uncertain, most of the unresolved issues will tend to understate the real effects of the program. Future evaluations should be done prospectively with representative population samples rather than samples of program participants only. Further study is needed of the contribution to program impact made by the individual program components, including deworming, feeding, hospital referral and monitrice and animatrice characteristics and the interactive impact of GMP and Hearth on nutritional status.
Extra stuff plus where to get the report:
A) HEARTH NUTRITION MODEL: APPLICATIONS IN HAITI, VIETNAM, AND BANGLADESH
This new report published by BASICS and the World Relief Organization provides up-to-date information on the Hearth Nutrition Model, what it is and how it has worked thus far. The Hearth Nutrition Model was introduced in Haiti, Vietnam, and Bangladesh in the early 1990s. The model has evolved from earlier community-based approaches to alleviating childhood malnutrition. The focus is on energizing volunteer mothers to rehabilitate malnourished children using local, affordable, nutritious foods for two weeks in the context of a growth monitoring and counseling program. The visible change in the children is a powerful motivator for mothers to continue good feeding practices acquired through adult learning practices in the Hearth feeding sessions. Hearth programs are meant to be supported by other programs such as deworming, growth monitoring, income generation, and micronutrient supplementation.
Findings indicate that the Hearth Nutrition Model can make a significant contribution in reducing malnutrition.
For complimentary copies of either report mentioned above or for more information on BASICS, please contact:
Director of Information
BASICS Information Center
1600 Wilson Boulevard; Suite 300 Arlington
Phone: 703-312-6800; Fax: 703-312-6900
Notes from Mike Golden / NGOnut
Fellow Ngonuts, There seem to be a lot of us who do not know about the Hearth program. Basics and WorldRelief (USAID funded) have published a report of this program: "Wollinka O, Keeley E, Burkhalter BR, Bashir N. (eds) 1997; Hearth Nutrition Model: Applications in Haiti, Vietnam and Bangladesh", which I believe is available from the Basics office (infoctratbasics.org). CSS, WRC, HAS, SCF and PANP are all involved in these programs. I have had a chance to review this report. It is exciting and I recommend that all interested in community treatment of malnutriton should read it. The program arose out of the Berggren's experiences in Haiti. In essence, local volunteers are trained to run the program, then typical local mothers who have children who have grown well and yet have the same resources and use the same markets as the mothers of malnourished children are used to agree upon a diet.
Malnourished children are then brought to these mothers houses for two weeks where they are given a meal prepared by the positivly devient mother from local ingredients. Children are then followed up at 4 and 8 weeks. Those that do not respond are referred for investigation of an underlying pathology. There are modifications to the program in the three countries. However the results are quite consistant: there is a steady decline in the prevalence of malnutrition in the villages, over one or two yars, where the program has been implemented. In Haiti this seems to be due to prevention in deterioration of moderately malnourished children, whereas in Vietnam and Bangladesh even severely malnourished children respond. The criteria of malnutrition are based upon weight-for-age, which will predominantly represent stunting -chronic undernutriton. It would be very interesting to monitor some of these childrens gain in length by knemometry to see if stunting was indeed being reversed. These results open a new door the management of chronic malnutrition; although there is a tremendous amount of work to still be done, the biological (nutritional) reasons for the responses determined, and the differences between the program results explained.
Nevertheless, this is a landmark. Perhaps Bart Burkhalter will respond to any questions that you have about the details of the programs or the results that have been obtained.
Dear Emilia Fernandez
World relief Corporation and the BASICS project looked at the costs of rehabilitating children in Haiti in connection with a study of the hearth nutrition model . The results and relevant references can be found in two publications available at no cost from the BASICS Project: "Hearth Nutrition Model: Applications in Haiti, Vietnam and Bangladesh" and "Innovative Approaches to Child Survival." Contact Mathew Brown at the BASICS Information Center (MBrownatbasics.org). Further analysis of the data will become available in a chapter by Berggren et al in a volume scheduled for publication this year by Gordon & Breach on scaling up and scaling down nutrition programs edited by Tom Marchione.