Briend, André

Golden, M.H.N.

Horizon / Pleins textes

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CONFERENCE 
Treatment of malnutrition in refugee camps 
For severe childhood malnutrition i lactose intolerance. Such yoghurt has 
treatment ought to start with a low- i been successfully used in Senegal to 
protein diet because of hepatic insuffí- treat malnutrition for 10 years.z 
ciency. In the recovery phase, the diet i The presence of dehydration makes 
ought to be higher in protein and more i the management of malnourished 
energy-dense, to produce rapid weight i children especially diffícult. Malnour- 
gain. Such a protocol, though, is not i ished children already have a greatly 
practical enough for use in refugee : increased total-body-sodium and de- 
camps, where protocols have to be i creased total-body-potassium, which 
simple yet embody all the essential i contribute significantly to their ill- 
principles of the more complex regi- : ness. The potassium concentration of 
mens developed in metabolic wards of i WHO-ORS (20 mmol/L) is too low to 
research units. This issue and others, i match stool output or make good the 
such as the use of WHO oral rehy- i deficit, and the sodium concentration 
dration solution (ORS) for treating i (90 mmol/L) is sufficiently high to 
dehydration in severely malnourished 
children when close clinical super- 
vision is not possible, were discussed 
at a meeting hosted by Médicins sans 
Frontière, fipicentre, and INSERM 
in Paris in May. General agreement 
was reached on features of a formula 
suitable for all stages of treatment. 
A formula of 80 g dried skimmed 
i induce heart failureY3 particularly 
i in kwashiorkor and marasmic- 
! kwashiorkor. The deficiency of min- 
i erals such as magnesium, zinc, and 
i copper in malnourished children can 
i contribute to the diarrhoea, and these 
i minerals are not present in W O -  
i ORS. Magnesium, in particular, is 
j essential for the retention ofpotassium 
milk, 50 g sugar, 60 g oil, minerals, and i and is usually lacking in refugees' 
vitamins per litre of feed' (energy i  ration^.^ If one WHO-ORS packet is 
density; 1 kcallrd,) is sufficient for i diluted in 2 L of water (instead of 1 L), 
catch-up growthz when fed to appe- i and the same mineral sachets used to 
tite. The same formula may also be supplement the diet (1 sachet/L) and 
given orally or by nasogastric tube, in i 50 g sugar (25 g/L) are added, then an 
the early stages of treatment, if diluted i isotonic (290 mosmol/L) rehydration 
3:l with water. About 100 mL/kg per i solution with sodium (45 m o l / L ) ,  
day of the formula (total 133 mL with i potassium (40 mmoI/L), magnesium - -  
Concenbatlon (per 
litre of made-up feed) 
30 mmol/L 
day) once appetite has returned. i Magnesium 
potassium, magnesium, zinc, copper, : Selenium 0.6 pmol/L 
45 pmol/L The diet must contain adequate i Zinc : Copper 
selenium, iodine.'and each of the i Iodine i 0.6 pmol/L 
vitamins. In the case 'of diets not i 
pre-formulated for 
alnutrition, addition of i 
minerals &d vitamins is feasible only i 
from ready-*made sachets (or stock i 
solutions). For stability, the minerals 
and vitamins have to be packaged i 
separately. Mineral and vitamin con- i 
centrations, calculated to provide the i 
the amounts needed for repletion and i 
rapid recovery of malnourished chil- i 
dren taking 100-200 mL/kg per day of i 
Water soluble vftamlns 
Thiamine 
Riboflavine 
Niacin 
Pyridoxine 
Cobalamin 
Folic acid I 
Ascorbic acid 
Pantothenic acid 
Biotin 
~" 
1 0 7 m g  
- 2.0mg 
10 mg 
O 7 m g  
i 
O 35 mg 
180 mg 
3 mg 
too pg 
Fat solublevitamlns 
Retinol 
Tocopherol 
Calciferol 
Vitamin K 
i Titrate should be added (the same number of equivalents 
Where no refrigeration exists, lacto- : as MG) since magnesium chloride may induce acidosis. Iron 
the feed, are given in the table. 
- . 
is not included because it may increase mortality when given 
Of the fon;lut" i to malnourished children: i t  must be given separately during (which lowers PH and produces Ttl- i rapid weight gain. The same minerai-mix is used to make up 
bacterial products) is a practical way of i the rehydration solution. 
preventing contamination with patho- i Concentration of minerals and vitamins 
gens. In addition it reduces the risk of : In diets for malnourished children 
(3 mmol/L), zinc, copper, and carbo-. 
hydrate in concentrations more appro- 
priate for children with malnutrition is 
obtained. A preliminary field trial of 
mineral-& sachets for use with the 
diet and the new rehydration solution, 
by Médicins Sans Frontière in Ethio- 
pia, shows this approach to be both 
practical and well received by the 
children and staff of refugee camps (B 
Le Lin, personal communication). 
WHO-ORS is best suited for treating 
dehydration in the absence of malnu- 
trition and in patients with copious 
watery diarrhoea. 
have infections and bacterial over- 
growth of mucosal surfaces. In view of 
the usual lack of signs of infection, the 
Nearly all malnourished children I 
I 
i 
i 
I absence of laboratory facilities, and the working conditions and training of most staff, blind, unselective, broad- spectrum antibiotic treatment should be given to all patients. 
Persistent diarrhoea usually re- 
sponds to intensive feeding alone. 
Failure to grow despite adequate in- 
take of nutrients is often due to tuber- 
culosis. Parenteral vitamin A and 
measles vaccine should be given to all 
children. In certain countries, up to 
50% of malnourished children have 
HIV infection, which in future is 
bound to alter the epidemiology and 
outcome of severe malnutrition. HIV- 
infected children should not be treated 
differently from other malnourished 
children. If HIV testing is done, it is 
1 
i 
1 Alkyne GAO, Hay RW, Picou DIM, 
Stanfield JP, Whitehead RG. Protein energy 
ondon: Edward Amold, 
2 
3 Wharton BA. Howells GR, McCance RA. 
pxdiac failure in kwashiorkor. Lancet 1967; 
ii:384-87., - . ' ~ 
4 Michaelsen KF. Clausen T. Inadequate 
supplies of potassium and magnesium in 
relief food implications and 
countermeasures. Lancet 1987; i: 1421-23. ' 
w radiation in the UK ' 
~ ~~ 
The National Radiological Protection 
Board will prepare weekly summaries of 
solar ultraviolet radiation. Each report will 
consist of a chart showing relative intensity 
of W radiation for each of the days 
concerned, a chart of solar index for each 
day, a figure showing the weekly solar 
index, and a key relating daily solar index to 
time for skin to bum. 
360 


Treatment of malnutrition in refugee camps

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