guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 112 Amounts to give by SS technique The look up table gives the amount of SS-milk to give at each feed. The amount given is NOT increased as the child starts to regain strength, suckle more strongly and gain weight 175 . Table 19: Look up table of the Amounts of SS-Milk (F100diluted or infant formula) to give for infants during Supplementary suckling. Class of Weight (kg) Progress ml per feed (8 feeds/day) Infant formula or F100diluted >=1.2 kg 25 ml per feed 1.3 to 1.5 kg 30 1.6 – 1.7 35 1.8 – 2.1 40 2.2 - 2.4 45 2.5 - 2.7 50 2.8 – 2.9 55 3.0 - 3.4 60 3.5 – 3.9 65 4.0 – 4.4 70 The progress of the child is monitored by the daily weight. Children less than 6 months with oedema should be started on F75 and not on F100diluted. When the oedema has resolved and they are suckling strongly they should be changed to F100 diluted or infant formula. � If the child loses weight over 3 consecutive days yet seems hungry and is taking all his F100 diluted/infant formula, add 5mls to each feed 176. � The supplementation is not increased during the stay in the centre. If the child grows regularly with the same quantity of milk, it means the quantity of breast milk is increasing and the mother is “responsible” for recovery. � If after some days, the child does not finish all the supplemental food, but continues to gain weight, it means that the breast milk is increasing and that the child has enough. The amount of SS-milk given at each feed should be reduced. � Weigh the child daily with a scale graduated to within 10g (or 20g). � When a baby is gaining weight at 20g per day for 2 consecutive days (whatever her/his weight): 175 The aim is NOT to have the child gain weight on the supplemental food. This amount is given to ensure that the child does not become more malnourished whilst breast-milk output is increasing. The weight gain is due to the additional intake coming from breast-milk, and the mother should be encouraged when she is told that the recovery is due to her own breast milk. If excess SS-milk were to be given the infant will stop suckling before the breast is emptied and further increases in breast milk output will be inhibited. 176 The Supplemental Suckling feed is giving maintenance amounts. If it is being taken and there is weight loss, either the maintenance requirement is higher than calculated or there is significant mal-absorption.
ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 113 Decrease the quantity of SS-milk given at each feed to one half of the maintenance intake. � If the weight gain is maintained for 2 consecutive days (10g per day whatever her/his weight) then stop supplement suckling completely. � If the weight gain is not maintained when the SS-milk intake is cut in half, then change the amount given to 75% of the maintenance amount for 2 days and then reduce it again if weight gain is maintained. � If the mother wishes to go home as soon as the child is taking the breast milk greedily and gaining weight then they should be discharged. If the mother is agreeable, they can be kept in the centre for a further 2 days on breast milk alone to confirm that s/he continues to gain weight. � If the infant is gaining weight on breast milk alone and the mother understands the importance of continuing breastfeeding, s/he should be discharged, no matter what his current weight-for-age or weight-for-length. 4. Supplementary Suckling Technique The supplementation is given using a tube the same size as n°8 NGT (a n°5 tube can be used and is better for the infant, but the milk should be strained through cotton wool to remove any small particles that block the tube). � The appropriate amount of SS-milk is put in a cup. The mother or assistant holds it. � The end of the tube is put in the cup. � The tip of the tube is put on the breast at the nipple and the infant is offered the breast in the normal way so that the infant attaches properly. At the beginning the mothers find it better to attach the tube to the breast with some tape, later as she gets experience this is not normally necessary. � When the infant suckles on the breast, with the tube in his mouth, the milk from the cup is sucked up through the tube and taken by the infant. It is like taking a drink through a straw. � At first an assistant needs to help the mother by holding the cup and the tube in place. She encourages the mother confidently. Later the mothers nearly always manage to hold the cup and tube without assistance. � At first, the cup should be placed about 5 cm to 10 cm below the level of the nipple so the SSmilk can be taken with little effort by a weak infant. It must NEVER be placed above the level of the nipple, or it will flow quickly into the infant’s mouth by siphonage with a major risk of inhalation. As the infant becomes stronger the cup should be lowered progressively to about 30cm below the breast. � With experience, the mother, instead of the assistant, can hold the tube at the breast with one hand and the other holds the infant and the cup. In this way she can perform SS-feeding without assistance. � It may take one or two days for the infant to get used of the tube and the taste of the mixture of milks, but it is important to persevere. � By far the best person to show the mother the technique is another mother who is using the technique successfully. Where possible all the mothers with malnourished infants should use the SS-technique together at the same time in a social context. Once one mother is using the SS-technique successfully the other mothers are greatly encouraged and find it relatively easy to copy her. � The mother should be relaxed. Excessive or officious instructions about the correct positioning or attachment positions often inhibit the mothers and make her think the technique is much more difficult than it is. Any way in which the mother is comfortable and finds that the technique works is satisfactory.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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