guidelines for the integrated management of severe acute malnutrition

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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).
ACF-In Guidelines for the integrated management of SAM In-patient 63 Class of Weight (kg) Table 11: Amounts of F75 to give during Acute-phase 8 feeds per day ml for each feed 6 feeds per day ml for each feed 5 feeds per day ml for each feed 2.0 to 2.1 kg 40 ml per feed 50 ml per feed 65 ml per feed 2.2 - 2.4 45 60 70 2.5 - 2.7 50 65 75 2.8 – 2.9 55 70 80 3.0 - 3.4 60 75 85 3.5 – 3.9 65 80 95 4.0 – 4.4 70 85 110 4.5 – 4.9 80 95 120 5.0 – 5.4 90 110 130 5.5 – 5.9 100 120 150 6 – 6.9 110 140 175 7 – 7.9 125 160 200 8 – 8.9 140 180 225 9 – 9.9 155 190 250 10 – 10.9 170 200 275 11 – 11.9 190 230 275 12 – 12.9 205 250 300 13 – 13.9 230 275 350 14 – 14.9 250 290 375 15 – 19.9 260 300 400 20 – 24.9 290 320 450 25 – 29.9 300 350 450 30 – 39.9 320 370 500 3. Naso-gastric feeding 40 – 60 350 400 500 NOTE: Children on F75 are NOT expected to gain weight. Naso-gastric tube (NGT) feeding is used when a patient is not taking sufficient diet by mouth. This is defined as an intake of less than 75% of the prescribed diet (thus for children about 75 Kcal/ kg/ day). The reasons for use of an NG tube are: � Taking less than 75% of prescribed diet per 24 hours � Pneumonia with a rapid respiration rate � Painful lesions of the mouth � Cleft palate or other physical deformity � Disturbances of consciousness.
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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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