Treatment of malnutrition in refugee camps.

In May 1993 in France, Doctors without Borders, Epicentre, and INSERM met to develop a practical protocol for treatment of severely malnourished children in refugee camps and to discuss use of WHO's oral rehydration solution (ORS) for treating the children who may be dehydrated. The suggested treatment formula for catch-up growth for severely malnourished children is 80 gm dried skimmed milk; 50 gm sugar; and 60 gm oil, minerals, and vitamins per liter of feed (energy density; 1 kcal/ml). Adequate potassium, magnesium, zinc, copper, selenium, iodine, and each of the vitamins must be part of this diet. (Concentrations adequate for repletion and rapid recovery of malnourished children ingesting 100-200 ml/kg/day are tabulated in the article.) The various vitamins and minerals must be packaged separately to assure stability. During the early treatment stages, refugee workers should give this formula, diluted 3:1, either orally or through a nasogastric tube. They should administer 100 ml/kg/day of the formula (133 ml with water) during the first few days. Once the children regain their appetite, refugee workers should increase the undiluted feed to about 200 ml/kg/day. Refrigeration or lactobacillus fermentation prevent pathogenic contamination of the formula. Fermentation reduces the pH and the risk of lactose intolerance and generates antibacterial products. The potassium concentration of WHO-ORS is too low and the sodium concentration too high for severely malnourished children, especially those with kwashiorkor and marasmic-kwashiorkor. Further, it does not contain the minerals needed to stop diarrhea. Refugee workers can mix 1 WHO-ORS packet, 1 sachet of each mineral used in making the formula, and 50 gm sugar in 2 l of water to make an isotonic rehydration solution. A field trial in refugee camps in Ethiopia showed that this formula and modified WHO-ORS are practical and acceptable. Participants also suggested administering broad-spectrum antibiotic treatment, parenteral vitamin A, and measles vaccine to all children, regardless of HIV status.