D. Food and Nutrition
9. Therapeutic Feeding Programs
Therapeutic feeding reduces deaths among infants and young children with severe PEM. The main causes of death in severe PEM are dehydration, infection, hypothermia, hypoglycemia, cardiac arrest, and severe anemia. If severe PEM exists, therapeutic feeding will be one of the best ways to save lives. If the startup of an SFP is delayed (e.g., if resources, particularly trained personnel, are concentrated on a TFP), however, there may be a sudden deterioration in other less-malnourished children, with life-threatening consequences. Having a TFP that saves the lives of a few is less important than an adequately functioning SFP benefiting a larger population.
Food is the treatment for PEM. Unlike SFPs, TFPs are used solely for curative measures and should be administered only as short-term programs. The need for its continuation will depend on the effectiveness of general and supplementary feeding programs as well as the nutritional condition of new arrivals to TFP programs.
The usual criteria for admission to a TFP are if a child under the age of 5 years suffers from bilateral edema on the feet (kwashiorkor) or severe marasmus (WFH less than 70 percent or a Z-Score of less than - 3). If persons older than 5 years are to be admitted, their nutritional status should be assessed clinically because clear anthropometric criteria do not exist. Patients should remain on a TFP until they are free from illness, at least 80 percent of WFH, and without edema. On graduation from a TFP, patients should be discharged to an SFP.
Therapeutic feeding should take place on an inpatient basis whenever possible, as food must be given every 3 to 4 hours. Three products are available as "ready to use" sachets for the treatment of severe malnutrition: (1) a special oral rehydration solution for use for the malnourished, (2) a formula for the severely malnourished during the first few days (phase 1) of treatment called F75, and (3) a formula for rapid growth (phase 2) called F100. They are produced by companies such as Nutriset in France and Compact in Denmark. These products include not only the appropriate protein and caloric mix for safely feeding the severely malnourished, but also the essential vitamins and minerals that are often missing in feeding mixtures that use skim milk.
Infection and dehydration are the major causes of death. Patients must be closely watched for medical complications. If weight does not increase quickly at a properly run TFP, the individual is likely to also have an illness that must be treated. The immunization of children against measles is a priority because of the high mortality associated with this disease in a malnourished population. All children admitted to a TFP should be given a full course of vitamin A, with doses on days 1, 2, and 7 of admission.
TFPs must be run by experienced and qualified personnel. One center can usually handle about 50 children and will require two experienced supervisors working full time. Doctors and nurses with little training in nutrition or experience in treating severe PEM must be given necessary guidance. Displaced people and mothers of patients, in particular, should be involved in running the therapeutic feeding center.