guidelines for the integrated management of severe acute malnutrition

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.