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Correspondence
Therapeutic feeding Carlos Navarro-Colorado centres for severe malnutrition
, Anne-Sophie Fournier, Laurence Verdenal and Mija T Ververs
Action Contre la Faim, Paris 75014, France
Available online 21 January 2002.
Sir––Steve Collins (Aug 11, p 498)[1] reports on therapeutic feeding centres (TFCs) in treatment of severe malnutrition as a medical emergency.
TFCs for treatment of inpatients with severe malnutrition in emergencies have played a major part in saving children's lives in the past 20 years. Recognition of severe malnutrition as a medical emergency has contributed to reductions in mortality from 20% to 5%.[2] Nevertheless, as Collins notes, TFCs, especially in open situations (ie, resident populations or internally displaced persons not in refugee camps) can have harmful effects on the food economy of patients' families, encourage increased population concentrations around them, and create dependence from international agencies.
We agree with Collins that at-home curative programmes for severe malnutrition may be the most appropriate alternative. However, consideration needs to be given to the dangers for patients and the community, so they do not do more harm than good. Broader debate is urgently needed, including more research and scientifically supervised experiences in the field, before we can design the features of, and criteria for, community-based treatment in emergencies.
We believe that identification of children who can qualify for at-home treatment is a key issue. In Khanum and colleagues' study,[3] cited by Collins, 57% of children were ineligible because of severity of malnutrition or age. The number of children too young for home treatment (who cannot take ready-to-use therapeutic foods), or who have complications or associated disease that they report, corresponds with the situation in emergency settings. Such children need to be treated in specialised centres such as TFCs.
Patients should not be discharged to continue treatment at home until weight gain has started without complications, rather than at recovery of appetite or after a fixed number of days. Start of weight gain is associated with a disproportionate mortality from cardiac failure related to introduction of higher contents of salts and proteins. This event is likely to be more frequent and difficult to identify and treat at home.[4]
Finally, a proper follow-up system is needed to supervise the quality of recovery, educate mothers, and help to relieve them from the burden imposed by treatment of the child (four meals per day, which will compete with other duties). Outcomes of all children, including defaulters, must be monitored. Moreover, use of the Hearth model (mother-to-mother education) as the reference could be misleading, since it assumes that the main cause for malnutrition is lack of education, which might not apply in emergency situations.
Despite Collins' claim, community-based treatment is not necessarily faster to implement, because access to the populations can be limited by security, political constraints, or both. Community-based treatment might also not be more costeffective, since TFCs are still needed as referral centres, even though they will be smaller, and follow-up of patients in large areas requires additional funds.
Emergency strategies should be developed from the existing TFC model, with
gradual management of malnutrition at community level.
1. S. Collins , Changing the way we address severe malnutrition during famine. Lancet 358 (2001), pp. 498–501. SummaryPlus | Full Text + Links | PDF (75 K)
2. D. Wilkinson, M. Scrace and N. Boyd , Reduction in in-hospital mortality of children with malnutrition. J Trop Pediatr 42 (1996), pp. 114–115. Abstract-EMBASE | Abstract-MEDLINE
3. S. Khanum, A. Ashworth and S.R. Huttly , Controlled trial of three approaches to the treatment of severe malnutrition. Lancet 344 (1994), pp. 1728–1732. Abstract-EMBASE | Abstract-MEDLINE
4.
Y. Grellety Management of severe malnutrition in Africa, University of
Aberdeen, Aberdeen (2000).
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Volume 359, Issue 9302, 19 January 2002, Pages 259-260 |
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