1
What should be the nutritional support to adult patients and children with Ebola Virus Disease (EVD) in treatment centres in the current crisis areas?
Version 7, Geneva, 4 Sept 2014
Mija Ververs,
Manuel Duce and Valerie Captier (ICRC),
Nathalie Avril (MSF-CH)
This question refers to patients infected with EVD who are not malnourished.
QUESTION:
Please help me with more suggestions and ideas and experiences from the field, what worked, what did not, etc?
One specific question: what experience do you have on preparing normal food/RUSF/RUTF for NG tube feeding? What worked, what not taking into consideration the operational constraints in the field?
ADULTSNote: Most patients at this stage are adults.
Before suggestions could be listed we need to look at a few questions:
- Are there specific symptoms that would hinder normal food?
- What are the clinical treatment priorities?
- Are there specific nutritional needs?
- Are the specific circumstances in the treatment centre that impact nutritional care?
1. Are there specific symptoms that would hinder normal food?
Symptoms in patients with EVD that could interfere with nutrition (ref1,ref2):
Most patients suffer from:-anorexia[1] and sore throat
(most common complaint)
-Stomach pain
-Diarrhoea
-Vomiting
-Nausea
-General malaise
-Fever / Some patients suffer from:
-Difficulties in swallowing (it seems to be present in half of the patients)
-Bleeding (external, internal)
-(note: bleeding in <50% of confirmed cases; mostly in later stage of diseases)[2]
The lack of appetite and sore throat/difficulty swallowing is particularly hampering eating.
Anti-emetic medications may provide some relief and facilitate oral rehydration if nausea and vomiting are common (ref1).
If swallowing is difficult risk of aspiration is high. Then either food should be given via naso-gastric tube or patient should be positioned semi-supine (‘half sitting’ position) or upright.
2. What are the clinical treatment priorities?
Standard treatment for Ebola HF is still limited to supportive therapy. This consists of:
• balancing the patient’s fluids and electrolytes (note: it seems that survival rate is strongly related to rehydration – mostly done with ORS/fluids; IVs are not really an option!)
• maintaining their oxygen status and blood pressure
• treating them for any complicating infections
3. Are there specific nutritional and food needs?
Like most infectious diseases patients with EVD need sufficient energy (kcal), proteins and especially lots of fluid (and electrolytes) to compensate for losses through diarrhea, vomiting, and fever.
Patients should be provided with food if they are conscious and can swallow. As most patients lose their appetite, soft foods and fluids are easier to tolerate (ref1). Small frequent meals often are tolerated better. Important is to offer food the patient likes to eat.
4. Are the specific circumstances in the treatment centre that impact nutritional care?
The following description refers to the crises areas at present in West-Africa. In most cases, once diagnosed, the patients with EVD are in a hospital/special treatment centre. The current reality on the ground is as follows:
-There is limited access to staff (or visitors) being able to help to feed the patients
-Health care has NO extra time for feeding patients
-There is NO time for inserting and monitoring naso-gastric tubes by health staff (because of lack of staff; this might change over time)
-Eating utensils (as well as food) can be a source of transmission
-Those that die, die within one week. Those that survive stay around 10-15 days. This is subject to change as the situation is evolving with patients coming in earlier and in less severe state.
For logistical reasons food that is offered should ideally be appropriate to ALL infected patients. This might nevertheless clash with the strategy of providing food that the individual patient prefers to eat.
Field feedback[3]: Over the last weeks it seems that EVD patients are now coming in the treatment centres earlier, the length of stay has increased and people arrive in better conditions. From 30% of people that were able to eat a normal food (beginning of the ebola crisis) now this % is around 50-60 %. This means more patients will be able to tolerate normal meals.
WHAT FOOD COULD BE OFFERED?
The features of food and how to should be offered can be summarised:
- Food could be offered in
a) disposable materials (for single use only) that should be burned after use (plastic, polystyrene, straws, wooden/paper/plastic spoons, foil)
or
b) cutlery that is kept on the patient’s ward(at bedside) with chlorination procedures in place to clean utensils.
- Food should be easy to ingest whilst lying down or in half-sitting position (semi-solid or liquid: mashed, porridge or completely liquid)
- Food should be sufficient in energy (calories)[4] and protein (electrolytes are corrected through other means, e.g. ORS[5])
- Food should be attractive to the patient as he/she suffers from anorexia, sore throat and general malaise.
Note: for all those that have difficulties to swallow or are too sick naso-gastric feeding should be offered. However, due to workload and reality at bedside this seems not yet an option, but in the future this needs to be reconsidered.
IMPORTANT: Whenever possible an assessment should be done on what patients themselves indicate what they can and prefer to eat in order to bridge that what is nutritionally needed is similar to what patients with EVD want.
Food to be considered for in-patient treatment of Ebola:
Food commodity / Advantages / CommentsSPREADS
-Ready-to-Use Therapeutic Food (PlumpyNut, EezeePaste)
-Ready-to-Use Supplementary Food (Plumpy’Soy/Sup, EezeeRUSF)
in individual packaging / Hygienic, individual portions, easy to eat
Does not need preparation and can be positioned at bedside
(Plumpy’Soy for adults) / Rather dry and plenty of liquid should be offered separately
Problematic in patients with minor swallowing difficulties
Ready-to-Use Supplementary Food = cheaper
BISCUITS
Ready-to-Use Therapeutic Food in biscuit form (BP100) / Can be made into a porridge with adding water.
Does not need preparation if used as dry biscuit and can be positioned at bedside / If offered as biscuit, plenty of water should be offered separately
Super cereal (i.e. Corn-Soy-Blend = CSB+)
(without milk powder for adults) / Offered as porridge / Requires preparation in a kitchen and regular distribution
F100 / Offered as liquid drink (through straw), easy to ingest and contributes to fluid intake / Risk for those with lactose intolerance present
Risk of contamination if kept at ward >2 hrs
Enteral feeding products, supplement, e.g. Fortimel, Fresubin / Individual package, easy to ingest with straw and contributes to fluid intake / Expensive; possibly not an option for current area of crisis
Normal food (mashed or solid)
Based on preference of the individual patients / E.g. rice-gruel or rice porridge, fou-fou, mashed carrots, etc / Not suitable for those that have eating difficulties. This might be nutritionally insufficient if this is the only food offered.
Question: does anyone know more on cereal based-ORS food (see annex)? / This was used in Bangladesh in case of diarrheal epidemic like shigella (to treat dehydration and bringnutrients simultaneously) / This is relatively low in calories. Option needs to be tested for results.
Note: a new option has been suggested – dilute PlumpyNut with water in blenders / This will make PlumpyNut easier to ingest, ensures fluid intake and avoid it to be stuck in the mouth (possibly useful for the very sick) / This option only possible when blenders are available, operational and in small centres.
This option needs to be tested for results and feasibility.
Others? / IDEAS????
ADULTS - SUGGESTED PROTOCOL FOR THE TIME BEING:
The following nutritional protocol is developed for ADULTS and is divided for two categories of patients.
Category of patients ADULTS / Nutritional protocolCategory 1:
Patients who are alert (confirmed cases and recovering patients[6]),can eat and swallow semi-solid/solid food AND have appetite /
- 1-2 porridges per day (CSB+/Supercereal)
- normal meal
- Ready-to-Use Supplementary Food as snacks or BP100 (as biscuit or porridge)
Category 2:
Patients who hardly eat
Naso-gastric feeding recommended, but as not possible for the time being the listed suggestion /
- Porridges (made from CSB+/Supercereal, BP100)
- And/or Ready-to-Use Supplementary Food
- anything the patient likes(cookies, local juices, BP5)
Note: soups and cereal-based ORS are not encouraged for the time being as they are low in calories
See Annex 2 for a menu for ADULTS.
Ideally, a ‘menu’ of 4-5 choices could be presented (e.g. CSB+/Supercereal porridge, rice-gruel or rice porridge, fou-fou, F100, mashed carrots, BP100 porridge) every day. This increases the likelihood that the patients will eat and is logistically probably still manageable.
Glucose/fructose and tasty fluids should be available at bedside.
CHILDREN
CHILDREN > 6 months - SUGGESTED PROTOCOL FOR THE TIME BEING:
The following nutritional protocol is developed for CHILDREN > 6 months and is divided for two categories of patients.
Category of patients CHILDREN > 6 months / Nutritional protocolCategory 1:
Patients who are alert (confirmed cases and recovering patients[7]), can eat and swallow semi-solid/solid food AND have appetite /
- 1-2 porridges per day (CSB+/Supercereal)
- normal meal
- Ready-to-Use Supplementary Food as snacks or BP100 (as biscuit or porridge)
Category 2:
Patients who hardly eat
Naso-gastric feeding recommended, but as not possible for the time being the listed suggestion /
- F100
- Porridges (made from CSB+/Supercereal, BP100)
- And/or Ready-to-Use Supplementary Food
- anything the patient likes (cookies, local juices, BP5, mashed fruit)
Note: soups and cereal-based ORS are not encouraged for the time being as they are low in calories
See Annex 3 for a menu for children > 6 months.
CHILDREN < 6 months - SUGGESTED PROTOCOL/GUIDANCE FOR THE TIME BEING:
See infant feeding and EVD
and
IMPORTANT
Care Support: In the near future the option needs to be considered to recruit ex-patients with EVD as carers; they could be a support in the feeding process as they have access to the patients and they are at low risk to fall ill (for the particular EVD strain they recovered from).
If visitors in protective gear are allowed to regularly stay with patients with EVD other (normal/mashed) food can be offered. Visitors can then be requested to support the feeding process with offering regularly small portions of food and drinks.
At discharge of the patient: Provision of food ration.
Thank you experts in the field and at home who contacted us directly. Your inputs are essential and have been very helpful. Keep on writing!*********
Ref 1. Clinical Management of Patients with Viral Haemorrhagic Fever: A Pocket Guide for the Front-line Health Worker 13 April 2014 Interim emergency guidance-generic draft for West African adaptation. World Health Organization.
Ref 2. Ebola hemorrhagic Fever. Fact Sheet,Centers of Disease Control CDC, (2014). National Center for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and Pathology (DHCPP)
Annex 1.DIFFERENT CEREAL BASED ORS STUDIED IN ICDDR, BANGLADESH
Type of Cereal ORS / Quantity/ Water
Rice flour / 50g/litre[8]
Maize flour / 60g/litre
Millet flour / 60g/litre
Sorghum Flour / 60g/litre
Wheat flour / 60g/litre
Mashed Potatoes / 200g/litre
Mashed GN Plantain / 250g/litre
Recipe
1 one litre water to be taken in a clean saucepan
2 Then to add 50ml more water for cooking loss
3 Now to add two pinch of salt and the cereals
4 Then to mix thoroughly and cook to make it even solution, it needs one minute boiling when bubbles come out
5 It needs continuous stirring when cooking
6 Now the solution is ready to serve
7 Solution can be kept 6 hours in room temperature during summer season and 8 hours in the winter in Bangladesh
Annex 2. Menu for ADULTS with EVD
Category 1:- 1-2 porridges per day (CSB+/Supercereal):
10 g oil
10 g sugar
- normal meal (mashed or solid):
60 g pulses (or meat[9]/chicken/fish)
50 g vegetables
10 g oil
- Ready-to-Use Supplementary Food:
OR
Ready-to-Use Therapeutic Food (if porridge is preferred):
3 bars/6 tablets of BP100 + water
Provides ± 2500 kcal and 13 en% protein
Category 2:
- 1-2 porridges per day (CSB+/Supercereal):
10 g oil
10 g sugar
OR
Porridge from BP100[11]:
3 bars/6 tablets of BP100 + water
- Ready-to-Use Supplementary Food: (2 sachets)[12]
- Other food: anything the patient likes (cookies, BP5, mashed meals, etc) and plenty of tasty drinks[13] (an assessment is needed). This category is particularly important for those that have limited chance of survival.
Annex 3. Menu for CHILDREN > 6 MONTHS with EVD
Category 1:- 1-2 porridges per day (CSB+/Supercereal):
10 g oil
10 g sugar
- normal meal (mashed or solid) (in 2-3 portions):
- Ready-to-Use Supplementary Food:
OR
Ready-to-Use Therapeutic Food (if porridge is preferred):
3 bars/6 tablets of BP100 + water
Category 2:
- F100 (as much as the child wants)(see Annex 4 for guidance)
- 1-2 porridges per day (CSB+/Supercereal):
10 g oil
10 g sugar
OR
Porridge from BP100[15]:
3 bars/6 tablets of BP100 + water
- Ready-to-Use Supplementary Food: (2 sachets)[16]
- Other food: anything the patient likes (cookies, BP5, mashed meals, etc) and plenty of tasty drinks[17] (an assessment is needed). This category is particularly important for those that have limited chance of survival.
Annex 4. Guidance on F100
Children weight in kg / F-100 X 4 meals + RUSF X 2 meals = 6 meals / dayml of milk per feeding
4 feedings / day / quantity of RUSF per feeding
2 feedings / day
3 / 100 / 1/4
4 / 150 / 1/4
5 / 150 / 1/2
6 / 200 / 1/2
7 / 250 / 1/2
8 / 300 / 1/2
9 / 300 / 1
10 / 300 / 1
11 / 350 / 1
12 / 350 / 1
13 / 400 / 1
14 / 450 / 1
15 / 500 / 1
[1] Worse in acute phase of EVD
[2]Despite a common belief that haemorrhage is a defining feature, visible bleeding is not universal. When present, bleeding is not an early presenting feature, but often only appears in the later stage (ref1).
[3] From one treatment centre
[4]≥2500 kcal/day and 10-15 en% protein (suggestion authors)
[5] Note: ORS cannot be replaced by fruit juices.
[6] Suspected cases are in isolation centres and could receive normal food
[7] Suspected cases are in isolation centres and could receive normal food
[8] Low in energy (in kcal)
[9] No bush meat
[10] If RUSF not available, this can be replaced by PlumpyNut or EezeePaste
[11] If BP100 is not available, BP5 can be used temporarily.
[12]If Ready-to-Use Supplementary Food is not available Ready-to-Use Therapeutic Food can be used (e.g. PlumpyNut, EezeePaste)
[13] Juices in tetra/carton package
[14] If RUSF not available, this can be replaced by PlumpyNut or EezeePaste
[15] If BP100 is not available, BP5 can be used temporarily.
[16]If Ready-to-Use Supplementary Food is not available Ready-to-Use Therapeutic Food can be used (e.g. PlumpyNut, EezeePaste)
[17] Juices in tetra/carton package