guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient 62
Diet (F75)
The diet used in the acute-phase of treatment is F75 80 .
- Six (or five) feeds per day are given where there are few staff at night 81 .
- Eight feeds per day are given for 24h care units for the few children who cannot tolerate the
increased volumes given with 5 or 6 feeds quite closely spaced during the day and where there are
sufficient staff to prepare and distribute the feeds at night. Where night feeds are problematic then
give 6 or 5 feeds during day time only 82 .
Reserve the full 8-feed regimen for those few children who develop significant re-feeding diarrhoea
when they are given fewer feeds, each of larger volume during the day only. Also, those that have had
very little intake during the day (e.g. new admissions), those who are very severely ill, vomiting or have
had an episode or hypoglycaemia or hypothermia.
In particular, 8 or more feeds need to be given when the larger volume of F75 required with the
daytime only regimen provokes osmotic diarrhoea in some children. This is uncommon; as it only
applies to a few children the work load for the night staff is greatly reduced when the 8-feeds per day
are individually prescribed for those children that really require this regimen. These children need
residential 24/24h care and should not be treated with the “day-care” regimen. Very occasionally it is
necessary to give the diet continuously by naso-gastric drip to reduce the load at any one time on the
intestinal absorptive capacity (see section on re-feeding diarrhoea).
- Breast-fed children should always be offered breast-milk before the diet during at least 20 to 30
minutes and always on demand. The number of breastfeeds during the day should remain (or be up
scaled) to comply with the recommendations regarding the child’s age.
1. Preparation
Add either one large packet of F75 to 2 litres of water or one small packet of F75 to 500 ml of water 83 .
Where very few children are being treated smaller volumes can be mixed using the red scoop 84 . If F75
is not available use one of the recipes given in the annex 15.
Note: there are some recipes in current use that have high concentrations of sugar: these provoke
osmotic diarrhoea and should not be used (see note on re-feeding diarrhoea).
2. Amounts to give
Give the amounts in the table below to each patient.
80 F75 is NOT a dilute form of F100; it has a completely different nutrient composition and balance. It is designed for
children with severe complicated malnutrition who have impaired liver and kidney function with infection. Children should
NOT gain weight on F75; the diet allows their biochemical, physiological and immunological function to start to recover
before they have the additional stress of making new tissues.
81 It is better to organise the service so that 5 or 6 feeds are actually given, than to try to give 8 or more feeds per day and
find that the night feeds are not supervised or not given at all. With staff shortages and junior staff at night, the latter
strategy can lead to systematic underfeeding of the children and incorrect information recorded on the multi-chart.
82 Hypoglycaemia is only a risk if the daytime intake is very low.
83 Where small numbers of children are being treated as in-patients, do not order the large packets of F75. These are for use
in emergency settings with large numbers of SAM patients.
84 The amount of powder in the red-scoop varies with the degree to which the powder is compressed into the scoop – if there
is moderate compression then one scoop should be added to 21ml of water: if the powder is uncompressed then one scoop
should be added to 18ml of water. The red scoop comes with the box of F75 packets. Do not use any other scoop, or spoon
or other measures as this can lead to either over-concentrated diet (vomiting, osmotic diarrhoea, hypernatraemic
dehydration, etc.), or over-dilute diet (failure to recover, deterioration).