guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 111
This is achieved by stimulating breast-feeding at the same time as supplementing the child during
breast feeding until breast milk is sufficient to allow the child to grow properly. Breast milk output is
stimulated by the Supplemental Suckling (SS) technique 171 ; it is important to put the child to the breast
as often as possible.
� Breast-feed every 3 hours for at least 20 minutes, more often if the child cries or seems to want
more.
� If the child is too weak to suckle, but the mother has milk, the mother should be shown how to
express her milk by hand or by pump 172 . The expressed milk can be given by cup or by NG-tube
to the baby
� Thirty to sixty minutes after offering a normal breast-feed give maintenance amounts of either
F100diluted or generic infant formula using the supplementary suckling technique:
� The diet should provide 100kcal/kg/day. For most infant formulae give 140ml/kg/d, for F00dilute,
give135ml/kg/day - divided into 8 meals.
There are not separate phases in the treatment of infants with the SS technique. There is no need to
start with F75 and then switch to F100diluted unless the infant has oedema.
A specific multi-chart is used for these infants.
Preparation of the SS-milk 173
The SS-milk can be infant formula or made by diluting F100 to make F100diluted. Infant formula is
diluted according to the supplier’s instructions.
- For F100diluted put one small packet of F100 into 670ml of water instead of 500ml 174 .
- To make small quantities of F100 diluted,
� Use 100ml of F100 already prepared and add 35ml of water, then you will get 135ml of
F100diluted. Discard any excess waste. Don’t make smaller quantities.
� If you need more than 135ml, use 200ml of F100 and add 70ml of water, to make 270ml of
F100 diluted and discard any excess waste.
- If there is a choice, use a formula designed for premature infants (Yet the purchase of infant formula
should comply with The Code and IFE guidelines).
Note:
� Unmodified powdered whole milk should never be used (e.g. Nido®)
� F100 undiluted is never used for small infants (less than 3kg)
view that attempts at exclusive breast feeding will not work when the infant has reached this stage. On the other hand
treating the infant with F75 and then F100 rapidly leads to weaning and the mother sees that the “formula” is the only way
to allow her child to recover. Urging the mother to breast feed after this is unsuccessful (as given in manuals for treatment
of SAM). These are both losing options. The SS technique is time consuming and requires skill, but is the only technique
that works in practice; it is lifesaving.
171 This is the SAME as the techniques described in textbooks for re-lactation [118].
172 See Module 2 http://www.ennonline.net/resources/4, for more information on expressing breast-milk
173 Full strength F100 should NEVER be used for small infants of children less than 3kg. The renal solute load is too high
for this category of child and could provoke hypernatraemic dehydration. Older children must either be given ordinary water
with the diet if they are less than 3kg or the diet should be diluted.
174 Or one large packet into 2.7 l of water instead of 2l to make F100 diluted.