MODULE 6A

Inpatient Therapeutic Care (ITC) 1

Resource Speaker
Designation
Inpatient Therapeutic Care
(ITC)
Learning objectives
At the end of the module, you will be able to:
• Explain reductive adaptation
• Assess patients for admission to ITC
• Triage SAM patients to emergency and non-emergency cases
• Give appropriate medications for ITC and their correct administration
• Administer nutritional management of SAM children 6-59 months
• Administer nutritional management of SAM children <6 months
• Orient the mother/caregiver in the care of her child with SAM
• Monitor each child for signs of deterioration in each Phase
• Assess a child’s readiness for discharge
Session 1.
Pathophysiology of
severe acute malnutrition
Reductive Adaptation
Malnourished children have adapted to low food intake by:
• Using energy and nutrients more efficiently
• Doing less work
• The reduced activity affects all the organs and cells in a
malnourished child’s body
• Causes very profound effects on body functions
Children with malnutrition do not show usual signs and
symptoms and the usual life-saving actions may be
dangerous in the malnourished child.
Reductive Adaptation
Acute malnutrition involves internal processes that lead to an
altered metabolism and involving the disruption of:
1. Cardiovascular system
2. Gastro-intestinal system
3. Liver function
4. Genitourinary system
5. Immune system
6. Endocrine System
7. Circulatory system
Muscle Muscle fibers become thin and
Function weak
Slower muscle contraction &
relaxation
Intestinal Atrophy of intestinal villae High volume &
Function Reduction in enzymes to absorb concentrated food can
carbohydrates cause diarrhea
Heart Function Reduced cardiac output Easy to precipitate heart
failure by fluid overload
Kidney Reduced renal blood flow Sodium concentration
Function Glomerular Filtration Rate(GFR) is may increase to
reduced dangerous level
Sodium excretion is impaired
Immune & Reduced (antibody-mediated & 95% of SAM have
Inflammatory cell-mediated immunity are systemic infection
Functions diminished) Blood WBC count is
unreliable

Temperature Failure of sweating response

regulation Body temperature rises steadily

Electrolyte Sodium-Potassium pump activity ORS, high sodium

is reduced diets & IVF are
dangerous
 Reductive Adaptation and
Treatment
As the child is treated
• The body’s systems must gradually
“learn” to function again
• Rapid changes (such as rapid
feeding or fluids) can overwhelm
• Feeding must be slowly and
cautiously increased
Session 2.
Assessment and Admission
Assessment for ITC: Child >6 to 59
months:
Parameter Normal MAM SAM

MUAC ≥ 12.5 cm 11.5 to 12.4 cm < 11.5 cm

and and/or and/or

WFL or WFH
-2 to +2 SD < -2 to -3 SD < -3 SD
Z-Score
and and and/or
Edema None None Present
Assessment for ITC: Child >6 to 59 months:
Diagnosis of SAM + any of:
1. Fails appetite test OR
2. Has any medical complications
•Intractable vomiting
•Hyperthermia (T 38 ○C axillary or T 39 ○ C rectal)
•Hypothermia (T 35 ○ C axillary or T 35.5 ○ C rectal)
•Anemia
•Extensive superficial infection
•Altered alertness
•Dehydration
•Tachypnea for age

≥ 50 resp/min from 6 to 12 months

≥ 40 resp/min from 1 to 5 years
≥ 30 resp/min for over 5 year olds
And any chest in-drawing (for kids
> 6 mos.)
Assessment for ITC:
Child less than 6 months:
Diagnosis of SAM and ANY of:
•recent weight loss/inability to gain weight
•any of the medical complications outlined for
6-59 months of age
•any medical issue needing more detailed
assessment or intensive support (e.g.
disability)
•ineffective feeding (attachment, positioning
and suckling) directly observed
•infant is lethargic and unable to suckle
•exhausted all options for breastfeeding
•depression of the mother/caregiver or other
adverse social circumstances
Session 3:
Triage Patients – Emergency
and Non-Emergency Care
Administer Emergency Care as
Necessary *
Airway,

Breathing,

Circulation and administer life-

saving interventions according
to Pediatric Advanced Life
Support (PALS) protocols

* Remember to provide warmth!

Administer Emergency Care as
Necessary
Check for and immediately treat life threatening complications:
• Hypoglycemia
• Hypothermia
• Dehydration/hypovolemic shock
• Hypernatremic dehydration
• Septic shock
• Severe anemia
• Heart failure
• Absent bowel sounds
• Gastric dilation and intestinal splash
 Note: Electrolyte balance in SAM
• Normally, cells have a balance of sodium and potassium.
• A “pump” functions to take sodium outside and potassium into the cells.
• This is critical for correct distribution of water in, around cells and in blood.

• In reductive adaptation, the ‘pump’ that usually controls the balance of

potassium and sodium does not function properly.

sodium in cells potassium as it leaks out of cells

fluid accumulation outside of the cells (edema)

ReSoMal for SAM
• ReSoMal is a modified rehydration
solution low in sodium.
• With dehydration or persistent
diarrhea, replace potassium but
limit sodium.

• Do not use 0.9 NaCl !

• Give magnesium to facilitate

potassium entry and retention in
cells
Rehydration for SAM patients
Oral Rehydration solutions for SAM

Therapeutic CMV (Combined Mineral and Vitamin Mix), tin 800g/CAR-6

Inpatient Therapeutic Care Requirement
Use to prepared ReSoMal [from the current ORS (WHO formula) + sugar
+ water], phase 1 milk (F-75) and enriched high energy milk
(F-100)

1 levelled measuring scoop can be

used to prepare 2 liters of F75
therapeutic milk (See SAM MOP
Alternative F75 Recipes)
For non-emergency cases
New SAM patients: SAM patients already on
•Conduct IMCI medical check
treatment and transferred:
•Medical history
•Appetite test •Review record
•Anthropometry •Continue with same
•Record all information registration number
•Check information/new
REFER to the OTC if issues on referral document
✓no medical complications •Record all information
✓good appetite
✓record all information on the
patient record and ITC chart
Routine Medications for SAM in
Phase 1/ Stabilization
• Nearly all children with SAM have bacterial infections.
• With reductive adaptation, the usual signs of infection not apparent
• With limited energy so no typical response, such as inflammation or fever
Oral medications for SAM without medical complications

Medication Route Dose Prescription

Amoxicillin* Oral / NGT 4 - 9.9kg = 250 mg On admission

10 - 13.9kg = 500 mg Twice daily for 5 - 7
14 - 19kg = 750 mg days

*Where there is amoxicillin resistance give amoxicillin - clavulanic acid combination

 Routine Medications for SAM in
Phase 1 / Stabilization
Parenteral medications for SAM with medical complications
Medication Route Dose Prescription

Ampicillin* IM/IV 50mg/kg On admission 6 hourly

for 2 days

Followed by Amoxicillin Orally / NGT 4 - 9.9kg = 250mg Twice daily for 5 days
10 - 13.9kg = 500mg
14 - 19kg = 750 mg

Gentamicin IM/IV 5mg/kg On admission once daily

for 7 days

*Where there is amoxicillin resistance give Cefotaxime (IM 50mg/kg once daily) for 2 days then
give amoxicillin-clavulanic acid combination for 5 days
Routine Medications for SAM in
Phase 1 / Stabilization

These regimens should be adapted to local resistance patterns.

 Other Routine Medications in
Phase 1
Vitamin A
• Present in therapeutic amounts in F-75/ F-100 /
RUTF
Give:
• As single dose on admission if child has clinical Vit A
deficiency
• When child has active measles
• When commercial F-75/ F-100/ RUTF not available
Folic Acid
• Present in therapeutic amounts in F-75/ F-100/ RUTF
• Indicated for moderate to severe anemia
 Other Routine Medications in
Phase 1
Measles vaccination
•On admission for children from 6 months old
•Repeat dose upon discharge from Phase 2 or
•When child is 9 months old in the OTC

Antimalarials
•Follow national protocol
•Caution: some antimalarials are toxic in the
SAM child – avoid amodiaquine
•NO Quinine in the first two weeks of treatment
 Medications NOT for Phase 1
Anti-helminthics
• Absorbed through gut and generates active metabolites in the liver
• Would be ineffective as SAM child with poor gut and liver function
• Not given immediately but given later during treatment
Iron
• Increases risk of death by increasing risk of sepsis
• Given only in Phase 2
Zinc
• Only given in Phase 1 if commercial therapeutic feeds not available
AND
• Child has diarrhea
 Test yourself!!
True or False.
1. SAM patients need sodium supplementation.
FALSE
2. All children with SAM are presumed to have a bacterial infection.
TRUE
3. Iron supplementation is given during Phase 1 treatment in ITC.
FALSE

How did you do?

General Guide
to the
Essential
Management
Steps towards
successful
treatment of
severe acute
malnutrition
Session 3:
Nutritional Management of
SAM: > 6 to 59 months
 Three Phases of SAM ITC

1. Phase 1
Stabilization
2. Transition
3. Phase 2
 SAM ITC
Phase 1 Stabilization

• Life-threatening problems are identified and treated

• Routine medications given (plus other meds as
needed)
• Therapeutic feeding using F-75
• Monitoring every 12 h and 24 h including anthropometry
 SAM ITC Transition
(to either OTC or to Phase 2)
• Preparation for Outpatient Therapeutic Care, start RUTF, monitor
feeds
• Can last up to 3 days
• Continue medications
• Every 12 h and 24 h monitoring including anthropometry

Discharge
(Transfer) to OTC
 SAM ITC Phase 2

• Intensive feeding to recover most lost weight using RUTF or F100

• Emotional and physical stimulation
• Daily monitoring, continue recording
• Assessment for discharge

Discharge from ITC

 Therapeutic foods in ITC
F-75 Therapeutic milk F-100 Therapeutic milk RUTF

Stabilization phase in SAM Rehabilitation of SAM Ready-to-use therapeutic food

(RUTF)
*caloric density of 75 kcal/100 ml *caloric density of 100 kcal/100 ml *500 kcal/96 g sachet

*low in protein, fat and sodium and *nutritional value equal to RUTF *consists of a peanut-based paste,
rich in carbohydrates with sugar, vegetable fat and
*used as therapeutic milk for <6 skimmed milk powder, enriched
months old infants with vitamins and minerals
 Phase 1/Stabilization

• If clinical assessment is delayed for any

reason, and the child is able to take oral fluids

• Give 10% sugar water (10g or 1 tablespoon of

sugar in 100mL of water) to prevent
hypoglycemia.
 Phase 1/Stabilization -- Feeding

Feed the SAM child with F-75 (75 kcal,

also low protein, 0.9 g/100ml and low
sodium)
•Meet the child’s needs without
overwhelming the body’s systems
•High in carbohydrate, and provides
much-needed glucose

What you need to do:

•Calculate amount of F-75 needed
•Prepare F-75
•Plan the frequency of feedings
 Phase 1/Stabilization -- Feeding

1. Calculate amount per feeding

based on weight
2. S/he needs: 100 kcal/kg/day
OR 130 ml/kg/day of F-75
3. Plan to feed 6-8 times per day
4. Compare manual calculation,
refer to look up table
Phase 1. Stabilization Phase 1.
Stabilization
- Feeding
Preparation of F-75

- Or use boiled water; prepare F75 w/in 5mins. of

boiling (> 70°C)
- cool to feeding temperature (≤37°C), label cup!
- Re-warm by dipping in warm water
- Discard any unused after 2 hours

https://www.youtube.com/watch?v=_yiIVpVA4Zc&feature=
youtu.be
 When F-75 is not available
• There are alternative recipes
• Or use diluted F-100
• Commercial milk formula is NOT a suitable substitute

Strongly advise against the use of

commercial milk formula for the child with
SAM.
 How to feed a SAM child
• Feed orally by cup and saucer
• Nasogastric tube if warranted
▪ Remove the NG tube when the
child takes more than 75% of the
day’s amount orally; or two
consecutive feeds fully by mouth .

• Breastfed children aged 6 – 59

mos. should always be offered to
breastfeed before the diet and
should always be given on demand
Children with SAM have weak
muscles and swallow slowly.
They are prone to choking and
developing aspiration pneumonia.
 Transition Phase
Ready to transition when:
• Medical complications are
resolving
• Appetite returns
• Edema is reducing
• Amount of energy is increased
by 30% (to 130 kcal/kg/day)
and the amount of protein is
increased
 Transition Phase
Transition may be divided into two distinct management
approaches:
1. Transition to outpatient therapeutic care (OTC) for SAM where it is
available
2. Transition to Phase 2 inpatient care where outpatient care for SAM
is not available
 Transitioning to OTC using RUTF
(where OTC is available)
• Counsel, encourage, and support
breastfeeding
• Explain what RUTF is to the caregiver
• Feed RUTF 5 times per day, always
follow with water or breastfeeding
• Do not mix RUTF with liquids
 Transitioning to OTC using RUTF
(where OTC is available)
Number of Amount to be
Weight of Amount of RUTF
feeds/ 24 eaten over 24
the Child in each feed
hours hours
< 5kg 5-6
¼ packet 1 ¼ to 1 ½
packets

≥ 5kg 6
⅓ packet 1 ¾ to 2 packets
Pointers on
Preparing RUTF
Demonstrate proper
handwashing with
soap and water
 Preparing RUTF to eat

Wash hands and

RUTF packets, then

Massage packet for

30 seconds
 One half One third

Measure the
portions

One fourth
Tear RUTF packet Fingers mark the portion
as the child eats
Or caregiver gives a small amount on he
finger
 On RUTF
If RUTF not consumed --
• Offer F-75 therapeutic milk
• Eating of RUTF and F-75
should not take more than 1
hour
• Store RUTF in a cool dry
place
• Offer RUTF at
the next feeding
until child
consumes full
amount
• Once consistently
eating full
amounts, further
increase amount
 Re-assess, re-assess
• Change the treatment regimen if the child’s appetite does not
improve over 2-3 days (they do not eat the required RUTF
amount)

• If there is clinical deterioration, return the child to Phase 1

• Change the diet to F-100 if the child is stable but the appetite
does not improve after 3 days in the Transition Phase →
continue to Phase 2 inpatient care
 Fully transitioning to OTC
The child is ready to continue nutritional
rehabilitation at home with OTC when:
• At least 75% of full RUTF amount is
eaten in 24 hours
• No other issues identified during
monitoring
• If conditions are fulfilled, discontinue F-75
and give RUTF plus water or
breastfeeding
• Refer to OTC or back to the OTC which
referred the child
Referral Form to ITC or OTC
 Transition to Phase 2 using F-100
Do this when:
1.Child on RUTF in preparation for outpatient care, clinically stable but
appetite not improving

2.No outpatient treatment available → child must be treated & cured of

SAM entirely w/in the ITC setting

3.Increase to 130 kcal/kg/day using F-100 therapeutic milk. F-100

contains 100 kcal/100mL

4.Continue breastfeeding by demand

5.When 90% of F-100 ration taken orally and no other issues → Phase
2
 Preparing F-100
Prepare amount of F-100 milk needed

- use boiled water; prepare F100 w/in 5mins. of

boiling (> 70°C)
- cool to feeding temperature (≤37°C), label cup!
- Re-warm by dipping in warm water
- Discard any unused after 2 hours

https://www.youtube.com/watch?v=_yiIVpVA4Z
c&feature=youtu.be
 Phase 2
• Caloric intake increased to 200 kcal/kg/day using F-100
therapeutic milk

• Iron is added to the therapeutic milk as follows:

1. 200 mg Ferrous Sulfate (1 tablet) in 2 liters therapeutic milk

2. 100 mg Ferrous Sulfate (1/2 tablet) in 1 liter therapeutic milk
3. If smaller quantities of milk are being given, crush 100 mg (1/2
iron tablet) and mix thoroughly in 10 mL of water (ensure the
tablet is well crushed and leaves no sediment)
4. Add 10 mg Ferrous Sulfate (1mL of 10mL Iron solution) in
each 100 mL of therapeutic milk
Responsive Feeding and Emotional
Stimulation
In addition to nutritional management in
Phase 2, while in a hospital environment,
support play and emotional stimulation as
an aid to psychological recovery by:

1. Encouraging the caregiver to talk to

the child with good eye contact
during feeding.
2. Providing a brightly colored ward
environment.
3. Providing toys suitable for children
of various ages
Determine that the child is ready for
discharge as cured from Phase 2 ITC
when:
For those admitted based on MUAC, edema OR both MUAC and
WFH Z-score:
MUAC > 12.5 cm for 2 consecutive days AND
No edema for 10 days AND
Clinically well
For those admitted based on WFH Z-score only:
WFH or WFL > -2 Z-scores for two consecutive days AND
No edema for 10 days AND
Clinically well
Test yourself!
1. What therapeutic food is used during Phase 1 Stabilization for
SAM children > 6 months old?
a. Diluted F-100
b. F-75
c. RUTF
2. What findings would indicate readiness for transition?
d. Bipedal edema
e. Patient is breathing fast, i.e. tachypneic
f. Appetite has returned
3. Phase 2 treatment is opted for when:
g. Patient has stable weight but appetite is unimproved
h. OTC is not available
i. a and b
Test yourself!
1. What therapeutic food is used during Phase 1 Stabilization for
SAM children > 6 months old?
a. Diluted F-100
b. F-75
c. RUTF
2. What findings would indicate readiness for transition?
d. Bipedal edema
e. Patient is breathing fast, i.e. tachypneic
f. Appetite has returned
3. Phase 2 treatment is opted for when:
g. Patient has stable weight but appetite is unimproved
h. OTC is not available
i. a and b
Test yourself!
1. What therapeutic food is used during Phase 1 Stabilization for
SAM children > 6 months old?
a. Diluted F-100
b. F-75
c. RUTF
2. What findings would indicate readiness for transition?
d. Bipedal edema
e. Patient is breathing fast, i.e. tachypneic
f. Appetite has returned
3. Phase 2 treatment is opted for when:
g. Patient has stable weight but appetite is unimproved
h. OTC is not available
i. a and b
Test yourself!
1. What therapeutic food is used during Phase 1 Stabilization for
SAM children > 6 months old?
a. Diluted F-100
b. F-75
c. RUTF
2. What findings would indicate readiness for transition?
d. Bipedal edema
e. Patient is breathing fast, i.e. tachypneic
f. Appetite has returned
3. Phase 2 treatment is opted for when:
g. Patient has stable weight but appetite is unimproved
h. OTC is not available
i. a and b
Session 5.
Carry out the nutritional
management of a SAM infant
<6 months of age
Continue to Encourage and Support
Breastfeeding
• An exclusively breastfed infant will always
be healthy.

• When an infant becomes malnourished, it

is usually preferable to attempt to improve
the breastfeeding practices or to re-
establish them if they have been
discontinued.

• Inpatient staff should encourage and help/

support re-establish breastfeeding.
Nutritional management < 6 months old
Step 1
Ask what the infant is fed with
•If breastfed, ask about other food being given
•When possible, observe and assess position
and latch as she breastfeeds
•Encourage skin-to-skin contact
•At ITC start, breastfeed every one to three
hours and then on demand as the infant’s
appetite improves
•Assist the infant by expressing breast milk
directly into his/her mouth if the child is unable
to empty the breast fully
Check and care for the mother too!
Encourage/Support breastfeeding in a SAM
infant <6 months
Step 2
Where mothers are still trying to re-establish
breastfeeding, options for feeding the infant
include:
• ‘Wet nursing’ by a female member of the family
• ‘Cross nursing’
• Use donor human milk if available.
• Observe proper guidelines on storage.
• Alternatively feed the infant by cup

The aim of treatment:

Stimulate breastfeeding, re-establish and sustain it.
Diluted F-100 (or F-75 for cases with Edema)
As necessary, supplement
the infant’s diet with Diluted
F100 or F-75 (for cases
with edema) until
breastfeeding is re-
established
Preparation instructions:
For F-100 and F-75 in
sachets:
Add 1 packet of F-100 or F-75 to
670-mL of water instead of using
500 mL

For F-100 and F-75 in tin cans:

Add additional 30% to quantity of water needed to reconstitute usual volume
Ex. in usual preparation of F-100, use 2 scoops in 50ml water to make 58ml feed volume.
To make diluted F100, use 2 scoops in 65ml (50ml x 130%) of water
Step 3 Continue to praise efforts at
breastfeeding

Step 4 Infants should be nursed at a

separate space from the older
malnourished children. This area may be
useful to bring breastfeeding mothers
together for mutual support and
counseling by staff.

Step 5 Give counseling and support for

any issues identified during monitoring in
relation to attachment and feeding of the
infant
Step 6
•Continue with breastfeeding and
breastmilk feeding.
•Monitor weight gain.
For infants supplemented with diluted F100:
•Once the infant is gaining weight at 20 g per day (absolute weight
gain), gradually decrease the quantity of diluted F-100 by one-third of
the maintenance intake so that the infant gets more breast milk.
•When after decreasing diluted F-100,weight gain is 10 grams per day
for 2-3 days, stop diluted F-100 completely
•If weight gain is not maintained, increase volume of diluted F-100 to
75% of maintenance for 2-3 days; reduce volume if weight gain is
maintained
Full use of therapeutic milk to manage nutrition
of the SAM infant < 6months when all efforts to
sustain breastfeeding have been exhausted
• Feed using therapeutic milk
in the 3 distinct phases • Criteria to advance through
• Diluted F-100 milk is used in the Phases same as in > 6 –
all phases
• F-75 is used if there is 59 months
edema, until it resolves • Edema must completely
• May use commercial
formula, as last resort resolve prior to Phase 2
Dilute F-100 for infants < 6 months old and
breastfeeding options have been exhausted
Most importantly
• Counsel on the introduction
of age appropriate
complementary foods using
local, indigenous sources

• Refer for IYCF support and

counselling
Assess for discharge of infants < 6
months old
1. There is weight gain more than 5g/kg/day while
completely on breastmilk or as last resort, therapeutic or
formula milk for 3 consecutive days
2. Edema is absent
3. All medical issues have resolved
4. Immunizations checked and updated
Test yourself!!
1. What is the optimum source of nutrition for SAM infants < 6 months
old?
a. F-75
b. Diluted F-100
c. Breastfeeding
d. Commercial milk formula
2. What alternative feeding method is recommended?
e. Feed by nasogastric tube
f. Feed by cup
g. Feed by supplemental suckling technique
h. b and c
Test yourself!!
1. What is the optimum source of nutrition for SAM infants < 6 months
old?
a. F-75
b. Diluted F-100
c. Breastfeeding
d. Commercial milk formula
2. What alternative feeding method is recommended?
e. Feed by nasogastric tube
f. Feed by cup
g. Feed by supplemental suckling technique
h. b and c
Test yourself!!
1. What is the optimum source of nutrition for SAM infants < 6 months
old?
a. F-75
b. Diluted F-100
c. Breastfeeding
d. Commercial milk formula
2. What alternative feeding method is recommended?
e. Feed by nasogastric tube
f. Feed by cup
g. Feed by supplemental suckling technique
h. b and c
Session 6:
Orienting and Caring for
the Caregiver
 For the caregiver
• Assess physical and mental health, provide
treatment and support
• Discuss daily activities while on ITC such as meal
times, laundry, hygiene
• Counsel on nutrition, birth spacing and self care
• Counsel on IYCF practices,
o exclusive breastfeeding 6 months,
o continued breastfeeding to 2 years of age, or beyond and
o age-appropriate complementary feeding (including meal
frequency and food diversity)
• Provide mother with multiple micronutrient tablets
daily during admission if the breastfeeding child is
younger than 2 years of age
Session 7:
Individual Monitoring in
Phase 1
Medical monitoring, Record the feeding
and anthropometry
Inpatient Chart at the back has
four panels:

1. Anthropometry
2. Weight Graph
3. Feeding
4. Feeding monitoring
Surveillance in Phase 1
After every feeding Record any breastfeeding taken before the therapeutic milk
session of Record the amount of therapeutic feed taken carefully on the
therapeutic milk, the therapeutic surveillance sheet
medical staff should: For infants < 6 months: note the amount of therapeutic milk given

Every 12 hours Measure and record the child’s temperature, pulse rate and respirations

Everyday Indicate the prescription for therapeutic milk, measure and record the
weight , measure and record the level of edema, record symptoms such
as cough, indicate if the child has an NGT, for infants < 6 months:
assess breastfeeding practice

On a weekly basis Measure the MUAC

Sample recording of feeding
ON a separate sheet
Surveillance in Phase 1
On an individual basis, closer
monitoring when:
•Ongoing complication
•undergoing fluid rehydration.

Monitor any change in weight

and/or intake of therapeutic milk
•Record accurately
•Vital to medical and nutritional care
Session 8: Monitoring and
Referral during Transition
(to RUTF or F-100)
Surveillance in Transition
MUAC Once a week
Height Every 2 weeks
Weight Every day
Edema Every day
Temperature 2x a day or more often
Heart rate, Respiratory rate 2x a day or more often
CRT (capillary refill time) 2x a day or more often
Feeding information (amount,consumption,route) Each meal time
Medications Each administration of meds
Diarrhea, vomiting Each time it happens
Medical findings/observation (cough, dehydration, Every day
etc.)
Surveillance in Transition
The child should be observed closely
for any signs of deterioration

•Continue to monitor as above for

Phase 1. In addition, after every feed:
• Record the amount of RUTF or
F-100 taken
• Record the amount of F-75 taken
• Record the frequency of
breastfeed
Surveillance in Transition
• Observe passage of stools
• Children may pass several very soft stools during the recovery
process
oNO need to go back into Phase 1
oBUT watch out for: signs of Re-feeding Syndrome, acute watery
diarrhea, or osmotic diarrhea
• Treat diarrhea only if there is weight loss. Zinc is NOT needed.
• Continue RUTF (or F-100 if transitioning to Phase 2 inpatient care)
but observe closely.
Refer from Transition to Phase 1 care
with F-75 if:
If there is deterioration in clinical status of the child, do a
thorough assessment/reassessment of the child’s treatment.
Reasons for deterioration in Transition
Phase:
Re-feeding syndrome - is a complex metabolic reaction when the
energy or nutrient load on the body causes a rapid shift of electrolytes and
fluid between intracellular and extracellular compartments in the body.

The condition may occur when after fasting more than one week, with
rapid ingestion and large amounts of food develops:
acute weakness or “floppiness”, lethargy, delirium, neurological
symptoms, acidosis, muscle necrosis, liver and pancreatic failure,
cardiac failure, sudden unexpected death
Reasons for deterioration in Transition
Phase:
Re-activation syndrome - occurs when a previously undiagnosed
infection becomes apparent.
•Result of the recovery of the immune and/or inflammatory system rather
than the development of a newly acquired infection
•Treatment is according to national protocol except where modified by
other protocols in these guidelines
Reasons for deterioration in Transition
Phase:
Osmotic diarrhea - resulting from a change in diet (less common with
low osmolarity feeds)
Aspiration of food - through improper feeding technique (children with
SAM have weak muscles and swallow slowly. This makes them prone to
choking, with liquid or food particles entering their airways and and
developing aspiration pneumonia).
Nosocomial infection – child contracting illness from other patients
Inappropriate prescription / use of medications – some medicines may
be harmful to child due to abnormal physiology in SAM child
Switch from Transition (RUTF) to Phase 2 F-100 if:
• Stable but appetite is not improving after three days in Transition
• Transition onto RUTF can be attempted again after a couple of days

Be vigilant for any of the following signs that the child is not coping with the transition:
• Rapid increase in the size of • Any significant re-feeding diarrhea
the liver* involving weight loss
• Any sign of fluid overload (i.e. • Any complication arising which
increasing respiratory and necessitates intravenous fluids
pulse rates, increasing edema • Edema not reducing, any increasing
and puffy eyelids, visible neck edema or edema developing when
veins)* it was previously absent
*If these signs occur, stop fluids immediately and reassess after one hour)
Session 9
Monitoring and Referral in
Phase 2
Surveillance in Phase 2
• Continue monitoring until recovery.
• Observations should be recorded
systematically on the Therapeutic
Surveillance Sheet
• Refer back to Phase 1 care with F75 or
transition if:
▪ There is deterioration in the nutritional status
of the child
▪ Do a thorough assessment/reassessment of
the child’s treatment
Surveillance in Phase 2 After
transition,
Daily Record RUTF or F100 intake after each feed
Observations Measure weight
monitor
Assess edema progress by
Count the number of breaths in a full minute
Measure heart rate
rate of weight
Measure temperature gain:
Assess clinical status (vomiting, diarrhea, dehydration,
cough)
Assess nutritional status against discharge criteria Weigh the
child every
Weekly Measure MUAC morning
observations
before
Two-weekly Measure height/length feeding, &
observations
plot the
weight.
Calculating weight gain
This example is for weight gain over 3 days. Classify the weight gain as:
•Current weight of the child in grams = 6300 g •poor (< 5 g/kg per day), the
•Weight 3 days ago in grams = 6000 g child requires a full re-
assessment
Step 1: Calculate weight gain in grams
•moderate (5–10 g/kg per
6300–6000 = 300 g day), check whether the
Step 2: Calculate average daily weight gain intake targets are being met
300 g ÷ 3 days = 100 g/day or if infection has been
overlooked
Step 3: Divide by child's average weight in kg:
•good (> 10 g/kg per day)
100 g/day ÷ 6.15 kg = 16.3 g/kg per day
Pocket Book of Hospital Care for Children: Guidelines for the
Management of Common Childhood Illnesses. 2nd edition.
Geneva:
Session 10: Discharge
Criteria to Start Transition Phase to OTC:
Category Criteria
Child aged 6 to 59 months Medical complications resolved (or chronic
conditions controlled)
AND
edema subsiding (must have reduced to at least
+2)
AND
appetite for RUTF (must be able to eat at least
75% of outpatient ration)

*There is no anthropometric criterion for discharge when transitioning from ITC to OTC because nutritional
rehabilitation is continued and completed in OTC.
Category Discharge Criteria from Transition to OTC

Child Medical complications resolved PLUS

aged (or chronic conditions controlled) •Clinically well and alert
6- 59 AND
•Recovery phase at home
months For patients with edema at least when:
+1 or 1. There is a capable
caretaker
With good appetite (taking all diet 2. The caretaker agrees to
in transition phase) and edema + out-patient treatment
+ 3. There is a sustained
supply of RUTF
AND 4. An OTC is in operation
Good appetite (must be able to in the area close to the
patient’s home
eat at least 90% of RUTF or F-
100 ration)
Discharge procedure to OTC
Step 1 Explain to the caregiver that the child has recovered
sufficiently to be discharged and congratulate them.
Step 2 An adequate supply of RUTF must be given to last
until the next possible appointment in outpatient care.

Step 3 The caregiver must understand (and repeat) the key

messages for giving RUTF. The caregiver must understand
(and repeat) the medications to be given after discharge , if
any. Review basic hygiene.
Discharge procedure to OTC

Step 4 Call the relevant RHU/BHS clinical staff to notify

them of the child’s transfer to outpatient care. RHU/BHS
clinical staff should advise the BHW/BNS of the child’s
return.
Step 5 Complete an appropriate referral form and give it to
the caregiver. This should be presented to the staff of the
outpatient health facility at the next appointment.
Step 6 Record the following on the
referral slip:
• Hospital registration/treatment
number
• Anthropometry: measurements of
MUAC, Weight, Height, WFZ (if able

• Grade of edema
• Ration of RUTF given (number of
packets on discharge)
• Medications received and medicines Children discharged from ITC are
PRIORITY for outreach follow-up in
to be continued after discharge their first week in the OTC
• Clinical condition on discharge
Discharge procedure to OTC
Step 7 Record the child as a “discharge to outpatient care”
in the tally sheet/monthly report.

Step 8 Record the ration of RUTF given in the stock register.

Step 9 Complete other relevant clinical records and

registers.
 Criteria for Discharge cured from ITC Phase 2
Category Discharge Criteria

Child aged 6 to 59 Admitted on MUAC, edema, MUAC ≥ 125mm (12.5cm) for 2 consecutive visits
months or both MUAC and WFH Z- AND
score No edema for 10 days AND Clinically well

Admitted on WFH or WFL ≥ -2 Z-scores for two consecutive days AND No

WFH Z-score only edema for 10 days AND
Clinically well

Infants < 6 months Child is gaining weight more than 5g/kg/day on breast milk for 3
consecutive days**
AND
edema is absent
AND
Clinically well & childhood immunizations have been checked
Discharge Procedure from ITC:
Step 1 Explain to the caregiver that their child has recovered sufficiently
and congratulate them.

Step 2 The caregiver must understand (and repeat) the medications

which must be given after discharge. Review basic hygiene.

Step 3 Complete other relevant clinical records and registers.

Discharge Procedure from ITC:
Step 4
For infants:
Refer ongoing counseling and monitoring as an outpatient at the
RHU/BHS.
Discharge from care completely when the WFL is greater than -2 Z
scores (child’s length is greater than 45cm).
Caregiver appreciates the importance of continued breastfeeding and
timely introduction of appropriate complementary feeding.
Discharge Procedure from ITC:
Step 5
Fill up referral slip and advise the caregiver on
OTC follow-up at nearest local health facility:
• Make sure the following are recorded
• Child’s registration number on all
documentation
• MUAC and WFH/WFL (measurement on
discharge)
• Any continuing medications
• Advise attendance to:
• Growth monitoring program
• further IYCF/nutrition counseling
Linking the caregivers and child with the community

The infant / child continues to be at risk. For preventive services, refer

to/for:
• Therapeutic Supplementary Feeding Program (TSFP) if available or other
supplementary or school feeding program
• On-going IYCF / nutrition counselling (e.g. IYCF Peer counselling, Family
Development Sessions, Pabasa sa Nutrisyon, promotion of good nutrition)
• Mother support groups, well baby clinic
• Multiple micronutrient supplementation or complementary feeding support if
available
• Enrolment in a growth monitoring program Operation Timbang Plus (if not yet
enrolled)
Linking the caregivers and child with the
community
The infant / child continues to be at risk. For
preventive services, refer to/for:
•Food security program, if available
•Ensure enrolment and coverage of the child and mother in PhilHealth
•Provide list of social welfare services available and referral to any
relevant programs such as:
1. Sustainable Livelihood and Pantawid Pamilyang Pilipino
Programs (if eligible)
2. Kapit-Bisig Laban sa Kahirapan-Comprehensive and
Integrated Delivery of Social Services (KALAHI -CIDSS),
3. Self-Employment Assistance-Kaunlaran (SEA-K) Program)
Recording outcome
Register the patients discharged in the registration book and
chart according to the following possibilities:
• Cured: the patient has reached the discharge criteria
• Dead: the patient died during treatment in the facility or during
transit to another facility
• Defaulter: the patient has not returned for 3 consecutive days and a
home visit, neighbor, village volunteer or other reliable source
confirms that the patient is not dead
• Non-cured: the patient does not reach the discharge criteria within
3 months in ITC and all referral and follow-up options have been
tried – link these patients with the OTC or MAM program where
possible and to social support systems
Summary
• Children with SAM have a unique physiology and require careful
judicious evaluation, treatment, monitoring and follow up.
• Inpatient management entails medical and nutritional treatment.
• Feeding is a critical part of the treatment of malnutrition.
• Different protocols exist in the management of those less than 6
months versus over 6-59 months.
• Therapeutic food helps facilitate treatment and recovery in both
inpatient then outpatient settings.
• Breastfeeding is still standard in nutrition for SAM infants and children.
• Caregivers are important partners in the successful treatment of SAM.
Case study!
Case 1. Ana
Ana is 24 months old with weight 4.8 kg and length 65 cm. Her WFL Z score
is < -3SD. MUAC is 10cm. She had no edema. Other physical findings were
unremarkable.
1. What is her nutritional assessment?
She failed her appetite test and was referred for ITC at your hospital where
pediatric staff had undergone the new training for management of severe
acute malnutrition.
2. When she was admitted to the ward on Day 1, you want to prescribe 6
feeds per day and would give ___________ ml per feed.
Case study!
Case 1. Ana
Ana is 24 months old with weight 4.8 kg and length 65 cm. Her WFL Z score
is < -3SD. MUAC is 10cm. She had no edema. Other physical findings were
unremarkable.
1. What is her nutritional assessment? SAM
She failed her appetite test and was referred for ITC at your hospital where
pediatric staff had undergone the new training for management of severe
acute malnutrition.
2. When she was admitted to the ward on Day 1, you want to prescribe 6
feeds per day and would give_____ ml per feed.
Case study!
Case 1. Ana
Ana is 24 months old with weight 4.8 kg and length 65 cm. Her WFL Z score
is < -3SD. MUAC is 10cm. She had no edema. Other physical findings were
unremarkable.
1. What is her nutritional assessment? SAM
She failed her appetite test and was referred for ITC at your hospital where
pediatric staff had undergone the new training for management of severe
acute malnutrition.
2. When she was admitted to the ward on Day 1, you want to prescribe 6
feeds per day and would give 95 ml per feed.
Case 1. Ana
Ana was a reluctant eater, but she finished most of her feeds and
continued 4-hourly feeds (6 feeds per day) on Day 2. At two feeds, she
took less than 75% of the amount offered, but then she took more at the
next feeds.
3. Does Ana need an NGT for feeding? (Yes or No)

On Day 3, Ana’s appetite increased. She finished the ration of F75 milk
each feeding and would ask for more.
4. What are the criteria that signal the readiness to transition?
a. medical complications are resolving
b. appetite returns
c. edema is reducing
d. all of the above
Case 1. Ana
Ana was a reluctant eater, but she finished most of her feeds and
continued 4-hourly feeds (6 feeds per day) on Day 2. At two feeds, she
took less than 75% of the amount offered, but then she took more at the
next feeds.
3. Does Ana need an NGT for feeding? (Yes or No)

On Day 3, Ana’s appetite increased. She finished the ration of F75 milk
each feeding and would ask for more.
4. What are the criteria that signal the readiness to transition?
a. medical complications are resolving
b. appetite returns
c. edema is reducing
d. all of the above
Case 1. Ana
Ana was a reluctant eater, but she finished most of her feeds and
continued 4-hourly feeds (6 feeds per day) on Day 2. At two feeds, she
took less than 75% of the amount offered, but then she took more at the
next feeds.
3. Does Ana need an NGT for feeding? (Yes or No)

On Day 3, Ana’s appetite increased. She finished the ration of F75 milk
each feeding and would ask for more.
4. What are the criteria that signal the readiness to transition?
a. medical complications are resolving
b. appetite returns
c. edema is reducing
d. all of the above
Case 1. Ana
You decided that Ana is ready for transition. The RHU in her vicinity has
a functional OTC.

5. What should Ana be given as feeding for Day 4?

6. What is the right amount of feeding to be given? Her weight is
now 5.1 kg.
7. What would you instruct for Ana’s mother to do?

By Day 6-7, what would you consider to decide that Ana is ready to
be discharged to OTC?
a.At least 75% of full RUTF amount is eaten in 24 hours
b.No other issues identified during monitoring
•a and b
Case 1. Ana
You decided that Ana is ready for transition. The RHU in her vicinity has
a functional OTC.

5. What should Ana be given as feeding for Day 4? RUTF

6. What is the right amount of feeding to be given? Her weight is
now 5.1 kg.
7. What would you instruct for Ana’s mother to do?

By Day 6-7, what would you consider to decide that Ana is ready to
be discharged to OTC?
a.At least 75% of full RUTF amount is eaten in 24 hours
b.No other issues identified during monitoring
c.a and b
Case 1. Ana
You decided that Ana is ready for transition. The RHU in her vicinity has
a functional OTC.

5. What should Ana be given as feeding for Day 4? RUTF

6. What is the right amount of feeding to be given? Her weight is
now 5.1 kg. 1/3 packet every 4 hours (6 feeds)
7. What would you instruct for Ana’s mother to do?

By Day 6-7, what would you consider to decide that Ana is ready to
be discharged to OTC?
a.At least 75% of full RUTF amount is eaten in 24 hours
b.No other issues identified during monitoring
c.a and b
Case 1. Ana
You decided that Ana is ready for transition. The RHU in her vicinity has
a functional OTC.

5. What should Ana be given as feeding for Day 4? RUTF

6. What is the right amount of feeding to be given? Her weight is
now 5.1 kg. 1/3 packet every 4 hours (6 feeds)
7. What would you instruct for Ana’s mother to do?

By Day 6-7, what would you consider to decide that Ana is ready to
be discharged to OTC?
a.At least 75% of full RUTF amount is eaten in 24 hours
b.No other issues identified during monitoring
c.a and b
Case 2a. Marcia
Marcia is a 38 months old girl with weight 8.6 kg, height
is 85.5 cm.
Her WFH Z score is < -3 SD. MUAC is 10.9 cm. She
had bilateral edema with poor appetite.
1. What is the grade of her edema?
2. What is your diagnosis?

On day 1, you plan to start her nutritional management.

Case 2a. Marcia
Marcia is a 38 months old girl with weight 8.6 kg, height
is 85.5 cm.
Her WFH Z score is < -3 SD. MUAC is 10.9 cm. She
had bilateral edema with poor appetite.
1. What is the grade of her edema? +
2. What is your diagnosis?

On day 1, you plan to start her nutritional management.

Case 2a. Marcia
Marcia is a 38 months old girl with weight 8.6 kg, height
is 85.5 cm.
Her WFH Z score is < -3 SD. MUAC is 10.9 cm. She
had bilateral edema with poor appetite.
1. What is the grade of her edema? +
2. What is your diagnosis? SAM

On day 1, you plan to start her nutritional management.

Case 2a. Marcia
Write the following entry in the ITC chart
3. What Phase of Nutritional management is this?
4. What is the therapeutic milk you will give?
5. You want to give feeding every 4 hours. What volume of
milk will you give each feed?
Case 2a. Marcia
Write the following entry in the ITC chart
3. What Phase of Nutritional management is this? Phase 1
4. What is the therapeutic milk you will give?
5. You want to give feeding every 4 hours. What volume of
milk will you give each feed?
Case 2a. Marcia
Write the following entry in the ITC chart
3. What Phase of Nutritional management is this? Phase 1
4. What is the therapeutic milk you will give? F75
5. You want to give feeding every 4 hours. What volume of
milk will you give each feed?
Case 2a. Marcia
Write the following entry in the ITC chart
3. What Phase of Nutritional management is this? Phase 1
4. What is the therapeutic milk you will give? F75
5. You want to give feeding every 4 hours. What volume of
milk will you give each feed? 180 mL
Did you fill it in the same?
Case 2a.
On Day 1, her oral feeding intake is reflected in the chart below.
Case 2a. Marcia
6. What proportion of her recommended feed is she taking per
feeding?

7. What will you do to help increase her intake of the

recommended volume of meal?
Case 2a. Marcia
6. What proportion of her recommended feed is she taking per
feeding? 50%

7. What will you do to help increase her intake of the

recommended volume of meal?
Case 2a. Marcia
6. What proportion of her recommended feed is she taking per
feeding? 50%

7. What will you do to help increase her intake of the

recommended volume of meal? NGT
Case 2a. Marcia
By Day 2, you looked at her
feeding monitoring and
asked Marcia’s mother how
Marcia is and has her
eating changed since
yesterday. Below is her
chart. She mentioned that
as of 4pm, Marcia asked to
eat by mouth. Her chart is
below. You decided to
observe how much she
would eat on her own.
You saw her again on Day 3 and looked at
Marcia’s feeding chart.
8. What would you decide to do?

On further physical examination, you also tested that her edema is

reducing.

9. Is Marcia ready to transition?

8. What would you decide to do? Remove NGT

On further physical examination, you also tested that her edema is

reducing.

9. Is Marcia ready to transition?

8. What would you decide to do? Remove NGT

On further physical examination, you also tested that her edema is

reducing.

9. Is Marcia ready to transition? YES

Case 2b. Marcia
TRANSITION
There is no OTC near where Marcia lives. You plan to transition her
to what phase of nutritional management?

1.What type of therapeutic feeding will you give Marcia?

2.How much calories will this give her per kg body weight?

3.How much volume would you give her at each meal if you plan
to give her 6 meals/day? She is now 8.8kg
Case 2b. Marcia
TRANSITION
There is no OTC near where Marcia lives. You plan to transition her
to what phase of nutritional management?

1.What type of therapeutic feeding will you give Marcia?

Transition to Phase 2 using F100

2.How much calories will this give her per kg body weight?

3.How much volume would you give her at each meal if you plan
to give her 6 meals/day? She is now 8.8kg
Case 2b. Marcia
TRANSITION
There is no OTC near where Marcia lives. You plan to transition her
to what phase of nutritional management?
1.What type of therapeutic feeding will you give Marcia?
Transition to Phase 2 using F100
2.How much calories will this give her per kg body weight? 130
Cal/kg/day
3.How much volume would you give her at each meal if you plan
to give her 6 meals/day? She is now 8.8kg
Case 2b. Marcia
TRANSITION
There is no OTC near where Marcia lives. You plan to transition her
to what phase of nutritional management?
1.What type of therapeutic feeding will you give Marcia?
Transition to Phase 2 using F100
2.How much calories will this give her per kg body weight? 130
Cal/kg/day
3.How much volume would you give her at each meal if you plan
to give her 6 meals/day? She is now 8.8kg 180 ml
Case 2b. Marcia
On Day 5, her mother tells you that Marcia eats all the therapeutic
milk on her own and seems to want for more.

4.You decide that she is ready for what phase in nutritional

management?

5.To what calorie intake per kg body weight will she now be
increased?

6.How much volume of feed will you give per meal for 5 feeds
per day? She is now 9 kg.
Case 2b. Marcia
On Day 5, her mother tells you that Marcia eats all the therapeutic
milk on her own and seems to want for more.

4.You decide that she is ready for what phase in nutritional

management? Phase 2

5.To what calorie intake per kg body weight will she now be
increased?

6.How much volume of feed will you give per meal for 5 feeds
per day? She is now 9 kg.
Case 2b. Marcia
On Day 5, her mother tells you that Marcia eats all the therapeutic
milk on her own and seems to want for more.

4.You decide that she is ready for what phase in nutritional

management? Phase 2

5.To what calorie intake per kg body weight will she now be
increased? 200 kCal/kg/day

6.How much volume of feed will you give per meal for 5 feeds
per day? She is now 9 kg.
Case 2b. Marcia
On Day 5, her mother tells you that Marcia eats all the therapeutic
milk on her own and seems to want for more.

4.You decide that she is ready for what phase in nutritional

management? Phase 2

5.To what calorie intake per kg body weight will she now be
increased? 200 kCal/kg/day

6.How much volume of feed will you give per meal for 5 feeds
per day? She is now 9 kg. 270mL
Case 2b. Marcia
DISCHARGE

7. What criteria will help you decide when she is ready for
discharge? Encircle the letter of the correct answer.

a. MUAC > 12.5 cm for 2 consecutive visits AND

b. No edema for 10 days AND
c. Clinically well
d. All of the above
Case 2b. Marcia
DISCHARGE

7. What criteria will help you decide when she is ready for
discharge? Encircle the letter of the correct answer.

a. MUAC > 12.5 cm for 2 consecutive visits AND

b. No edema for 10 days AND
c. Clinically well
d. All of the above
Demo time!
New Packaging for F-75 and F-100

• F-75 and F-100 are now supplied in 400g canisters allowing for
longer shelf life of 4 weeks when opened
• Each canister comes with a specifically developed scoop (white for
F-75 and blue for F-100) that allows smaller amounts of therapeutic
milk to be prepared
• Smaller amounts of freshly made up milk reduces wastage and
minimizes the risk of contaminated feeds being given to children
• Using the corresponding look-up tables, the amount of therapeutic
milk to be prepared will determine the number of scoops and amount
of boiled water needed
 Reference Table for F-75
F-75
Level Scoop Quantity of Water (ml) Approximate Feed Volume (ml)

1 25 ≈28
2 50 ≈56
4 100 ≈112
8 200 ≈224
10 250 ≈280
20 500 ≈560
Whole canister of 400g 2200 ≈2480

24 canisters (9.6kg net weight) =52.8 Liters ≈59.5 Liters

 Reference Table for F-100
F-100
Level Scoop Quantity of Water (ml) Approximate Feed Volume (ml)

1 25 ≈29
2 50 ≈58
4 100 ≈117
8 200 ≈234
10 250 ≈290
20 500 ≈580
Whole canister of 400g 1850 ≈2158

24 canisters (9.6kg net weight) =44 Liters ≈52 Liters

Materials required
• F-75 or F-100 therapeutic milk • Soap for handwashing
• Water for boiling and cleaning • Soap for cleaning equipment
• Cooking pot, kettle, or stove to boil the • Bowl to wash equipment
water • Brush
• Markers and labels for recording
• Thermometer
• Measuring cups
• Feeding cup
• Spoon for stirring
• Clock or timer
• Clean cloth or disposable single-use
tissues
Tips for Preparation
• It is best to prepare fresh feeds and to give the feed to children
in care as soon as it is prepared and ready to drink
• Ideally, each feed should be prepared in an individual feeding
cup
Preparing a cup feed of F-75
• Clean the surface area where you will be preparing the
feed
• Observe proper handwashing
• Wash feeding cup, utensils, and food-grade
thermometer in hot soapy water. All equipment should
be able to withstand hot liquid
Preparing a cup feed of F-75
• To sterilize equipment, fill a large pan with
water and completely submerge all equipment
to be used.
• Cover the pan with a lid and bring the water to
a rolling boil. Leave items to boil for at least 2
minutes.
• Dry equipment with clean cloth or single-use
towel.
• To avoid contamination, it is recommended to
use sterilized items just before they are
needed. If not used immediately, cover and
store equipment in a clean, dry place.
Preparing a cup feed of F-75
• Refer to the recommended protocol or the WHO feed
reference chart to see how much therapeutic milk is
needed
• For example, we have a patient who is 2.6kg who we
have prescribed to give 8 feeds per day. Checking the
look-up table for F-75 on Annex 28 of the SAM Manual
of Operations, how many ml of feed will we need to
prepare?
Preparing a cup feed of F-75
Annex 28: Amount and preparation of F-75 milk to be given for Phase 1
Weight of the child Amount of Milk per feed Amount of Milk per feed
8 feeds per day 6 feeds per day
2.2 – 2.4kg 40mL 50mL

2.5 – 2.7kg 50mL 60mL

2.8 – 2.9 kg 55mL 65mL

•For a patient weighing 2.6kg who will be given 8 feeds per day, we will
need to prepare 60ml of F-75 per feed
•Check the corresponding table for preparation of F-75 to determine the
number of scoops and amount of water necessary
 Preparing a cup feed of F-75
F-75
Level Scoop Quantity of Water (ml) Approximate Feed Volume (ml)

1 25 28
2 50 56
4 100 112
8 200 224
10 250 280
Since we will 20
be needing 56ml of feed, we500 will need to prepare 2 scoops
560 of F-75 and
Whole50ml
canisterof
of water
400g to produce an approximate
2200 feed volume of2480
56ml

24 canisters (9.6kg net weight) =52.8 Liters 59.5 Liters

Preparing a cup feed of F-75
• Boil a sufficient volume of water. Make sure water
comes to a rolling boil. Once boiled, allow water to
cool slightly (maintain >70º C).
• For this example of a 2.6kg patient with 8 feeds per day,
we will be using 50ml of water
• Take temperature of water using sterile
thermometer. Add the powder in less than 3-5
minutes after water has boiled
• Pour the appropriate amount of boiled water into a
clean and sterilized vessel or pitcher with
measurement markings for milliliters. For accurate
measurement, read water at eye level.
• Transfer and pour the boiled water into a clean
feeding cup to mix with the powder.
Preparing a cup feed of F-75
F-75
Level Scoop Quantity of Water (ml) Approximate Feed Volume (ml)

1 25 28
2 50 56
4 100 112

• From this table, we will need to add 2 scoops of F-75 to the 50ml of boiled water in the feeding
cup to make 56 ml of F-75 feed
• Do not press the scoop on the side of the can as the scoop will become too tightly packaged
• Using the rim of the can of flat edge of a spoon, level off the excess powder
• Adding more or less powder than instructed can make the children ill.
• Make sure scoop does not come into contact with moisture or water.
• Replace scoop in can and close securely.
Preparing a cup feed of F-75
• Mix powder and water thoroughly by stirring with a spoon. Stir
until consistency is smooth and lumps are dissolved. Be careful to
avoid scalding.
• Cool to feeding temperature ≤37ºC.
• You may use a cooling bowl to reduce the temperature of the
feed. Ensure that the feed does not come into contact with the
water bath.
Preparing a cup feed of F-75
• When cooled, give the feed to the child. Throw away
any milk not consumed within 2 hours after
preparation.
• Dry the outside of the feeding cup and label.
• Include on the label the type of therapeutic milk, the
patient’s name, date and time of preparation, amount
of feed required, and preparer’s name or initials
• Check temperature of the feed before giving to the
child. Drop a small amount of feed to the wrist,
without putting the cup in contact with the skin.
• If it is at room temperature, then it is ready to give to
the child.
Preparing a cup feed of F-75
Options for feeding, use:
1. Cup and saucer
• The child drinks from cup
• Any spillage while drinking will be caught with the saucer
• Spilled therapeutic milk will be returned to the main cup used by
the child
2. Nasogastric tube

Give the feed to the child, and then throw away any milk
not consumed within 2 hours after preparation
Preparing a cup feed of F-100
• Follow the same procedure for F-75, noting the
required amount to be prepared and following the
appropriate F-100 look up table to determine scoops
and mls of water needed
• Make sure to use the correct blue scoop for F-100
Preparing a batch of cup feeds ( if more
than one patient)
• When you have more than 1 SAM patient, it will be
necessary to prepare more than 1 cup feed
simultaneously.
• A larger batch of therapeutic milk can be made
and transferred to individual feeding cups
• Take note that therapeutic feeds are more
susceptible to contamination in large, open
containers
• Large volume of feeds will take a longer time to
cool down, leaving potential for growth of harmful
bacteria if not prepared properly
• Preparing batches of milk will save time, but it is
important to decant the milk into serving cups
immediately to avoid bacteria growth
Preparing a batch of cup feeds
• After determining the total amount of feeds that need to be prepared,
prepare the appropriate amount of water and therapeutic milk needed
based on the look up table
• Observe the same procedures in sterilizing the materials, boiling the
water, and mixing of the powder
• After preparation, immediately pour the appropriate amount of feeds in
the prepared feeding cups and give to the children