guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Transition phase 101
TRANSITION PHASE
During the Transition Phase, a new diet is introduced: this is normally either RUTF or F100.
This Phase prepares the patient for Recovery-phase treatment as an out-patient. Occasionally the
recovery-phase is as an in-patient where there is no appropriate home for the child to go to, or the
caretaker chooses to remain in in-patient care (see also the care of the less than 6 month old infant).
The transition phase usually lasts between 1 and 5 days – but may be longer, particularly when there
is another pathology (e.g. TB or HIV); a prolonged transition phase is a criterion for failure-to-respond.
1. DIET
The ONLY change that is made to the treatment on moving from Acute-phase to the Transition Phase
is a change in the diet that is given from F75 to RUTF (or F100).
• It is preferable to use RUTF in the Transition Phase. Those children who have been very ill and
are going to continue treatment as out-patients with take-home treatment need to become
habituated to RUTF before they go home. The table below gives the total amount of RUTF that
should be taken during the day. When the patients are taking the full amount they should be
transferred to continue their treatment at home. In the in-patient facility, the full day’s amount of
RUTF can be given to the mother and the amount taken CHECKED five times during the day: it is
important for the nurse/assistant in charge to check regularly.
• Children that are not taking sufficient RUTF are either given F100 for a few days and then RUTF
re-introduced or returned to the acute-phase or given F75 to make up the deficit in intake
(whichever is most efficient and effective in the circumstances of the IPF). No other food should
be given to the patient during this period and the caretaker must still not eat in the same room as
the malnourished children. Care must be taken that the caretaker or other children to not consume
the patients’ RUTF.
• They should be offered as much water to drink as they will take during and after they have taken
some of the RUTF. One advantage of the RUTF is that there is no need for surveillance during the
night so that minimum night staff is sufficient. There is also no need for the staff to spend time
preparing and dispensing liquid feed (F100).
• Some patients initially refuse the RUTF completely. If this is the case they should be given the
F100 diet for one or two days and then the RUTF re-introduced. Other children prefer the RUTF. It
is good practice to give the diet that the children prefer – the two diets are nutritionally equivalent.
If RUTF is not available, or the child does not readily take the RUTF (younger children and about 10%
of the older children prefer a liquid diet) then:
• Use F100 (130ml = 130kcal). When F100 is used the number of feeds, their timing and the
volume of the diet given remains exactly the same in Transition Phase as it was in Acutephase.
• It is made up from one small package (=114g) diluted into 500 ml of water or one large package
(=456g) of F100 diluted into 2 litres of water 162 .
In all cases, breast-fed children should always get the breast-milk during at least 20 – 30
minutes before RUTF or F100 and on demand.
162 In previous versions it was recommended that for small volumes the red-scoop is used. However, there is a major
difference in the amount of water to add depending upon the compression of F100 powder in the scoop. With uncompressed
powder one scoop equals 14 ml of water, and with compressed powder one scoop equals 18ml of water. This variation is too
large to make the reconstitution of F100 using the red scoop sufficiently accurate to recommend its use.