Treatment of Children severely

malnourished age 0-6 months and

infants > 6months weigh less than 4 Kg weight
 Objective of the presentation

• To understand the classification system for these

special babies and rational behind involving them
in the treatment.
• To describe the step-by-step approach in treating
them once they have been admitted.

• To have a comprehensive explanation for the

nutritional and medical rehabilitation for these
special categories of admissions.
 Components of the presentation
• Glossary
• Introduction
• What are the differences in treatment between the
under 6 months and the older children
• Classification of the infants under 6 moths age
• Management of severely acute malnourished under 6
months infants with a potential lactating care giver.
• Management of severely acute malnourished under 6
months infants with no lactating care giver or without
prospect of being breast fed.
• Conclusion
 Glossary
Term Meaning
Special baby Child under 6 month and Infants >6 months
and weigh under 4 kg with SAM
F100 Diluted Special therapeutic formula for the under 6
months children therapeutic feeding
Supplementary suckling technique Is a technique for feeding the SAM children
under 6 months and to stimulate initiation of
breast feeding .
Care giver Is a general term used to describe who ever
takes care of or wet nursing the child under 6
months with SAM
SAM Severe acute malnutrition
MUAC Mid Upper Arm Circumference
IYCF Infant and Young Child Feeding
MAMI Management of acute malnutrition in infants

IFE Infant and young child feeding in

emergencies
 Introduction
Who should be considered as a special baby:
1. Infants younger than 6 months
2. Infants less than 4 kg regard less their age
Potential problems that lead to SAM in infants which need to be
addressed:
1. Lack of breast feeding.
2. Partial breast feeding
3. Inadequate and unsafe artificial breast feeding
4. Mother dead or absent
5. Mother is malnourished , traumatized, ill , and or unable to
respond normally to her infant’s needs.
6. Infant has a disability which affect his ability to suckle or
swallow and/or a developmental problems which affect the
infant’s feeding.
 differences in treatment between the
under 6 months and the older children
Children younger than 6 months with SAM
Should be treated only in the inpatient care
Receiving usually F100 Diluted or if edema present F75
until edema resolution , NEVER shall be given RUTF
MUAC is not considered in admission
The admission criteria although expressed
anthropometrically the gold standard measure is to
restore enough and effective weight gain and the
infant is sustaining adequate weight gain
No upper limit for length of stay
Non respondent categories does not exist
Not included in the performance indicators calculation
Breast feeding is integral part of therapeutic care for SAM
infants
Children treated separately from SAM children 6- 59 months
Children 6-59 months with SAM
Can be treated in the inpatient care or outpatient
care
Can be given F75,F100 or RUTF
MUAC is an independent criteria for admission
Mainly discharged upon achieving anthropometric
measures of discharge
There is limit for length of stay
Non respondent categories exists
Included in the performance indicators calculation.
Breast feeding is complementary to therapeutic care
Children treated in the same place in general
 Classification
With potential • The objective is to gradually withdraw the F100 diluted and
depend more on the care giver breast milk

care giver able to • It is recommended for mothers who are not able to breast their
infants effectively
• any child with care giver should be put in these categories until
breast feed the otherwise is proven.

infants

With no care • The objective is to gradually increase the F100 diluted until the
child reach an age when we can introduce the complementary
food or available ,safe ,affordable alternative feeding
giver or no • It is recommended if the mother is died or severely ill to the
extent it is impossible for her to breast feed the infants
prospect of being • We don’t use these classification unless we lose hope with the
above classification if the care giver is available

breast fed
Management of severely acute malnourished under 6 months
infants with a potential lactating care giver.

• Criteria of admission:
 presence of bilateral pitting edema.

Has visible wasting ( no z score used).

High risk of SAM because of a defective breast

feeding secondary to a mother or infant
related problems
 Higher risk of SAM will include

 infant is too week to suckle or unable to

suckle.
Infant is not gaining satisfactory weight at
home despite breast feeding counseling.
Mother has no enough breast feeding and/or
malnourished.
Lactating mother is absent or died.
 Aim of the treatment

To restore full and exclusive breast feeding

which allow the catch-up growth depending
on the breast feeding alone
 Components of the care

Care of the infants:

 medical and nutritional rehabilitation
 Breast feeding counseling and good practices
Care of the care giver:
 Screening and nutritional support
 Medical check and medical treatment if needed.
 Breast feeding counseling and good practice
 Initial steps!!
 welcoming the child and care giver
 Reassurance
 Registration
 Medical history:
a) Length of gestation
b) Breast feeding practice before
c) Previous child illness and family response toward that
d) Medical check ( as per infants examinations guidelines).
e) Suckling ( use clean little finger)
f) Fill the CCP Chart for the child
No place for appetite test in here as we can’t introduce RUTF
in such age
Routine medicine and supplements
Antibiotics:
 we don’t give antibiotics unless the infant shows signs
of infections .
 One major sign of infection is abrupt refusal of breast
feeding, other include hypothermia, loss of primitive
reflexes , etc….
 for infants weighing minimum of 2 kg we give
Amoxicillin 30 mg/kg twice a day in association with
Gentamicin 7.5 mg/kg /day once for 7 days I.M or I.V
 We should avoid Chloramphinicol in young children as
it induce bone marrow failure as idiosyncratic reaction.
 Cont’d
Vitamin A:
 Give 5,000 IU daily for 10 days ( total of
50,000 IU ) or as single dose in week four or
upon discharge .
 Vit A should be avoided in edematous infants.
Folic acid:
 give 1 crushed tablet of 2.5 mg in a single
dose
General dietary recommendations

 breast feed on demand , or offer breast feeding

for at least 20 minutes every three hours . The
infant should be breast fed as frequently as
possible
 Between breast feeding sessions , give
maintenance amount of therapeutic milk
 Provide milk diet or sips of 10% sugar-water
solution until thirst of the infant is satisfied to
prevent hypernatraemia and hypoglycemia.
 Options for therapeutic milk

If the infant has no edema

• Start with the F100 Diluted

If the infant has an edema

• Start with the F75 until edema resolve
and continue then with F100 Diluted
 F100 Diluted
F100 Diluted is a special therapeutic formula made
specially for the infants younger than 6 moths.
 Should be provided for the infants younger than 6
months without edema.
 Given at 130 ml / kg body weight / day.
 Gives 130 kcal / kg body weight / day.
 F100 Diluted is provided to the infants using the
SST(Supplementary Suckling Technique).
 The amount of F100 Diluted is not increased as the
child starts to gain weight. (increase 5ml/feed only if child losses weight
or has static weight for three consecutive days and continue to be hungry after taking
all his daily F100 diluted feeds)
 Look up table for maintenance amount of F100 D (Severe wasting) or
F75 ( Bilateral pitting edema until edema is resolved) to be given to an
individual infants per feed
Weight of the child (kg) F100 Diluted or F75 in case of edema
ml per feed if 8 feeds per day
≥1.2 kg 25
1.3-1.5 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 dietary treatment is depending on the
weight attitude and F100 diluted intake rates
 If the infant loses weight or has a static weight
over 3 consecutive days but continues to be
hungry and is taking all of his F100 Diluted , then
add 5 ml extra to each feed.
 if over some days the child continue to gain
weight and not finishing all the F100 Diluted
supplemental feed , it means that infant’s intake
of breast milk is increasing and the infant is taking
adequate quantities to meet his/her metabolic
needs
 Cont’d
When the infant sustain 20 gram per day weight gain:
 gradually decrease the amount of F100 D with 1/3 of
the maintenance intake so the baby gets more breast
milk.
 If again with these reduced amount, the infant is
sustaining 20 gram weight gain then stop the F100
Diluted and observe the child weight attitude with the
breast feeding only.
 If the infants is not maintaining weight gain we should
increase the amount of F100 D given to 75% of the
maintenance amount for two or three days, then
reduce it again if weight gain is maintained.
 Monitor the weight daily (scale graduated 10-20 gram)

Weight loss or static

IF IF the weight increases
for 3 consecutive by 20g/day for 3 days
days and/or the and
baby is hungry There is no illness
despite finishing regular
all: B/M still increase of
insufficient weight:
B/M is
increasing

Decrease F100D by third

Increase F100D: and observe for few days
5ml in each feed
Do not increase F100D

29 mai 2011 21
 After 2-3 days increasing weight ?

IF

The baby gains 20gr/day Weight loss or static

Increase F100D to 75% of the maintenance

Stop F100D and maintain amount. Observe 2-3 days
on B/F alone

The child should gain 10gr/day

before stopping F100D

THE CHILD SHOULD PUT ON WEIGHT ON BREAST

MILK ALONE 20g/day FOR 5 DAYS BEFORE
DISCHARGE
29 mai 2011 22
 Cont’d
 Once the child is gaining weight at a rate of 20
gram he should be kept in the health facility if the
care giver is agreeable for 3-5 days to make sure
the infant continue to gain weight if she chosen
to be discharged she should be discharged and
encourage her to bring the infant for follow up or
arrange home visit schedule.
 On discharge current weight or WFL status
doesn’t matter .
 F100 Diluted preparation and feeding
technique
 For large number of children:
Add one packet of F100 to 2.7 liters of clean water instead of 2 liters

 For Small number of children:

Add 35 ml of clean water to 100 ml of F100 already prepared to have
135 ml F100 Diluted , discard any excess milk soon after use
 If you need more than 135 ml, add 70 ml of clean water to 200 ml
of already prepared F100 to have 270 ml of F100 Diluted.
 If no F100 is available we can use commercial formula milk although
it is not designed for catch up and it is recommended to use
formula specified for premature babies.
 Unmodified whole powdered milk should not be used .
Objective of feeding SAM children <6 months or infants > 6months
weigh <4kgs :
To provide the maintenance amount of F100 Diluted and to help in re-
establishing the breast feeding through suckling .
Feeding advises:
 Ensure the good breast feeding , good attachment and the
effective suckling.
 Build the mother confidence.
 Provide suitable non-distractive environment for both the care giver
and the child .
 ONLY use the naso-gasrtric tube when the infant is not taking
enough milk by mouth.
 Encourage more frequent and longer breastfeeding sessions to
increase milk production, continue breast feeding advises either
individually or for a group, encourage the care givers to share their
positive experiences with breast feeding or SST.
 Use the SS technique to provide maintenance amounts of F100-
Diluted.
 The use of NGT should not exceed three days.
Supplementary Suckling Technique (SST)
 Steps of Supplementary Suckling (SS)
feeding technique
 The caregiver hold a cup of with F100 Diluted.
 Prepare a size 8 naso-gastric tube , one end is put in the
cup and the tip of the tube put on the breast.
 The cup should be placed 5-10 cm below the level of the
nipple for easy suckling, with strong suckling it can be
lowered to up to 30 cm.
 The infants is offered the breast with the right attachment.
 The tube should be flushed upon completion of the
feeding with a clean water using a syringe , it is then spun
(twirled) rapidly to remove water from the lumen by
centrifugal force , the tube can be exposed to direct sun
light .
 Individual monitoring
Monitoring Remark

Weight Daily and try to weigh before feed

Degree of Bilateral pitting edema Daily

MUAC Every seven days. Only if the child is over 6

months and less than 4 kg
Length ( if less than 87 cm ) , or Height ( if Should be taken every 21 days
more than 87 cm)
Body temperature Twice a day as routine , or as recommended
by the medical team if needed

Standard Clinical signs recording Daily

Others : IV infusions , absents , refusal of Whenever happen should be recorded

feeding or NGT feeding
 Supportive Care for mothers(care
givers)
 Supportive Care for Breast feeding Mother
• Creating supportive conditions such as: breastfeeding corners, counseling and
mother to mother support.
• Mental and emotional support as well as MUAC assessment and checking of
Oedema
• Educate mother on SAM treatment and relevant maternal health issues
 Adequate Nutrition and supplementation for breast feeding mother:
• Breast feeding mother needs 450 kcal per day of extra energy and she need
daily energy consumption of 2,500 kcal.
• Breast feeding mother should drink at least 2 L of water.
• Should receive Vitamin A , if the infant is <2 months ,unless pregnant
• Should be screened for SAM and receive supplementary feeding services.
 Psychosocial care of the breast feeding mother.
 Establish good communication and build trust with the care giver .
 Breast feeding counseling .
 Treat mother physical difficulties related to breastfeeding
 Possible Difficulties Encountered by Mothers of
Infants with SAM

Mother Difficulties Action Points

Nutrition and fluid intake Provide enough fluid and balanced food.
Screen the mother for malnutrition.

Physical and mental health Provide medical advice whenever

requested.

Physical difficulties related to Treat sore nipples, cracked nipples and

breastfeeding mastitis with breastfeeding counselling.

Misinformation and misconception Establish good communication with the

mother.
 Discharge Criteria
Infants under 6 months or infants > 6months weigh less than 4
kg being breast fed should be considered for discharge if :

 Successful re-lactation with effective suckling equates a

minimum 20 gram weight gain per day on breast milk alone
for five days.
 No bilateral pitting edema for two weeks.
 Clinically well , alert and has no medical problems.
Upon discharge ensure that the mother has been adequately
counseled and received the needed amount of
micronutrient supplementation during her stay and for use
at home.
 Follow up after discharge
• In areas where services are available, mothers
are to be enrolled in SFP and receive high
quality food to improve quality and quantity
of breast milk
• Monitor infant progress
• Support breastfeeding and introduction of
complementary feeding at age of 6 months
 General advises and Rules
 Infant younger than 6 months with edema = start
treatment with F75 until resolution of edema.
 No complementary food should be introduced before 6
months .
 No MUAC should be taken under 6 months age.
 No certain limit for the stay
 No child younger than 6 months shall be included in
calculating the performance indicators ( should be linked to
the IYCF indicators).
 Once the child reach 6 months and he /she is weighing
more than 4 kg then move to inpatient or outpatient care
as his nutrition status classified based on the CMAM
classification.
 Infant younger than 6
months and /or weighing
less than 4 kg

Age become more than 6 months or /and weight more

than 4 kg while his/her stay in center

If no If medical
complication complication
consider present
Outpatient consider
care inpatient care
 Infants under 6 months without
prospect of being breast fed
These definition involve:
 Cases where hope is lost in restoration of
effective breast feeding or sucking upon applying
the previous way of treatment.
 Care giver is died and no care giver is available to
be wet nurse for the infant e.g. orphans
 Mother is severely ill to the extent it is
impossible to her to produce milk or breast feed
her baby e.g. mothers with chronic debilitating or
end- stage diseases.
 Aim of the treatment

Provision of F100 Diluted until they are old

enough to take semi-solid complementary
food or to use home modified cow milk in
case of no access to infant formula
 Admission Criteria

 Presence of pitting bilateral edema

 Visible wasting
 Their treatment resembles the usual
inpatient care management
Stabilization phase
If the infant has got edema then he/she should
receive F75 until edema resolve.
Transition phase
Criteria to go to transition phase:
1. The child is drinking the milk well and gaining
weigh
2. No edema and no medical complication
Rehabilitation phase
Criteria to go to rehabilitation phase:
1. Has a good appetite, taking at least 90% of
the F100 Diluted.
2. Complete loss of edema
3. Minimum 2 days stay in the transition phase.
4. No medical problems
For start up the treatment , using F100 Diluted in
the same way before and the same routine
medication but instead of decreasing the F100
Diluted here we tend to increase it as convenient
. SST is not standard we can use a cup and saucer
Use NGT when the infant is not taking enough
milk by mouth
Only F100 diluted should be used
Increase the F100 Diluted by 1/3 of the amount
the infant used to receive in the stabilization
phase
- Only F100 diluted should be used
- Infant shall receive twice the amount of the
F100 Diluted been given in the stabilization phase
- The amount of F100-Diluted given is calculated
based on 130 kcal/kg bodyweight/day
 Individual monitoring
Monitoring Remark

Weight Daily and try to weigh before feed

Degree of Bilateral pitting edema Daily

MUAC Upon admission and every seven days. Only if

the child is over 6 months and less than 4 kg
Length ( if less than 87 cm ) , or Height ( Should be taken every 21 days
if more than 87 cm)
Body temperature Twice a day as routine , or as recommended by
the medical team if needed

Standard Clinical signs recording Daily

Others : absents , vomits, refusal of Whenever happen should be recorded

feeding when fed by NGT or given IV
infusions or transfusions
 F100 Diluted amounts in stabilization
phase
Weight of the child ( Kg) F100 Diluted in stabilization phase
Ml/feed in 6-8 feeds per day in the
absence of breast feeding
≤ 1.5 30
1.6-1.8 35
1.9-2.1 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
 F100 Diluted amounts in transition
phase
Weight of the child ( Kg) F100 Diluted in transition phase
Ml/feed in 6-8 feeds per day in the
absence of breast feeding
≤ 1.5 45
1.6-1.8 53
1.9-2.1 60
2.2-2.4 68
2.5-2.7 75
2.8-2.9 83
3.0-3.4 90
3.5-3.9 96
4.0-4.4 105
F100 Diluted amounts in rehabilitation
phase
Weight of the child ( Kg) F100 Diluted in rehabilitation phase
Ml/feed in 6-8 feeds per day in the
absence of breast feeding
≤ 1.5 60
1.6-1.8 70
1.9-2.1 80
2.2-2.4 90
2.5-2.7 100
2.8-2.9 110
3.0-3.4 120
3.5-3.9 130
4.0-4.4 140
Criteria for the discharge from the rehabilitation
phase for non-breast fed infants
 15 % gain of weight
 No bilateral pitting edema for two weeks
 Clinically well and alert, no medical problem

Other consideration:
 At discharge , infant can be switched to infant formula or
home modified cow milk and the care giver is well trained
to do that at home.
 Care giver has been adequately counseled.
 Follow up to supervise the of quality of recovery and
progress
 Introduce complementary food at the age of 6 months