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failing an appetite test

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 12 replies. You can also reply via email – be sure to leave the subject unchanged.

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Marie Stephan

Dietitian for inpatient management of malnut /IOCC

Normal user

28 Oct 2013, 13:29

A case of 1 year old girl, with severe acute malnutrition, who is exclusively breastfed with no introduction of solid foods, failed the appetite test and was referred to inpatient care. She was discharged from the hospital because she has no medical problems however she still has severe acute malnutrition; appetite test was repeated and she failed it again. Do you think she should be hospitalized again? What are your suggestions?

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

28 Oct 2013, 21:18

Dear Stephan,

The girl absolutely have to be hospitalized again as she will deteriorate really quickly if you send her back home... You will probably need to start giving her therapeutic milk (F-75 or F-100) if she was not introduced to any solid foods yet and the main activity in the SC will be to start the introduction of solid foods with the mother/main caretaker... She will also require regular home visits once discharged (only if she has appetite again )...

Nina Berry

IFE Consultant

Normal user

28 Oct 2013, 21:40

Hi there, sounds like a bit of a conundrum.
I have seen healthy infants of this age who are exclusively breastfed - some kids seem to refuse solids until early in the second year of life. Generally, they will breastfeed in a pattern that is more common amongst newborns (>10 times in 24hours). I wonder how the diagnosis of SAM was made (what criteria were used), given that she has been examined and found to be without medical problems (healthy?). Is it at all possible that this child is simply small but health and that the mother just needs support to continue to offer family foods until her daughter switches on to solids. And close monitoring, of course. Do you have growth trajectory data for this child or just a single weight for age measure? Growth trajectory data would tell you whether she's growing and just small.
My other thought is, does the mother/family have access to animal based foods? Could she be b12 deficient. Maternal b12 deficiency can affect growth and development in breastfed infants.
I would be careful about the use of therapeutic milks in a child who has no appetite. Unless she is in immediate danger, the use of therapeutic milk might be counter-productive because it makes her sated (perhaps uncomfortably so) and reinforce the lack of appetite. It also might establish a belief in the mother that powdered milk is better for her child than breastfeeding. Would a solid therapeutic food be acceptable?

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

28 Oct 2013, 21:46

I would agree that RUTF would be more suitable than F-75 and F-100 but it might take you several days before she gets used to it as she has never had solid foods...
If she is SAM, i would advise to first treat the malnutrition while working with the mum on the weaning...

Nina Berry

IFE Consultant

Normal user

28 Oct 2013, 23:15

To be clear, when Alexandra says 'weaning', I assume she means complimentary feeding (the addition of complimentary foods to breastfeeding) rather than withdrawal of breastfeeding. 'Weaning' is one of those words that means different things in different places. Breastfeeding is this child's sole source of nutrition at the moment and will remain a very important source of nutrition (and potable water) until at least her second birthday, and probably well beyond that (there is no evidence that breastfeeding ever becomes harmful at any age), given she is in a resource poor setting. The mother will need encouragement and support from those she sees as medical authority figures to continue breastfeeding her daughter. Withdrawing or undermining breastfeeding at this stage could be catastrophc for this little girl.

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

28 Oct 2013, 23:52

I am indeed using the UNICEF definition of weaning meaning adding solid foods to breastfeeding...
We are on the same line Nina...

We don't know exactly what is the condition of this little girl which can lead to several interpretations but in any case, breastfeeding should continue at least till the age of two years...

Nina Berry

IFE Consultant

Normal user

29 Oct 2013, 00:49

Of course. I should have known. I may have become a little hypervigilant around this issue ;-). Probably the result of working with health professionals who are suspicious of breastfeeding, especially in older infants/toddlers. Forgive me.
And you're right, we don't have enough information to make any prescriptions or pronouncements. I hope the OP will accept my contribution as a series of questions to be asked.
cheers
Nina

Namseon Beck

Senior Health and Nutrition Advisor/ Medair

Normal user

29 Oct 2013, 07:43

If a baby has not been exposed to any solid food until she reaches one year, the chewing reflex with solid food does not develop properly though she is healthy. Solid food should be introduced after the baby reaches six months old, which is not only for balaced diet, but also stimulation of chewing and swallowing reflex to solid foods. Some children refuse to solid food at al and become totally dependent on her/his energy on milk or its equivalent. This in turn results in malnutrition including micronutrient deficiency as well as othe problems such as constipation. I would suggest to try cup with fluidy foods. Then increase the density little by littel until she tolerates solid foods.

Nina Berry

IFE Consultant

Normal user

29 Oct 2013, 21:50

"If a baby has not been exposed to any solid food until she reaches one year, the chewing reflex with solid food does not develop properly though she is healthy."

This is a myth. There is no evidence to support this notion. Many many healthy infants refuse solid foods until some time around their first birthdays and go on to eat family foods. I regularly see normal healthy infants who are exclusively breastfed (in spite of being offered family foods) until after their first birthdays who go on to eat a full and varied diet.

Florence

Normal user

29 Oct 2013, 22:28

Moderator, please remind guys to tone down their replies esp Nina! This is not a battlefield of knowledge. it is about trying to reach the best and feasible advise to th eperosn who asked the question. One shouldn't force others to agree with their point of view.
Sorry for sending this, but am pissed off, justhave to say it!

Marie McGrath

ENN

Forum moderator

29 Oct 2013, 22:50

Dear Anonymous956, I am sorry you felt you had to interject in this conversation. I don't think there was any intent in Nina's contributions to knock the experiences of others, but appreciate that is not how you have read it. We need to be mindful that it takes 'guts' to all who contribute personal experiences to this online forum - without this openness it wouldn't exist - and that we all take care when we are challenging contributions of others.

This is a timely point to return to the original question, from which the exchange has gone a little off piste, and how to manage this 1 year old child. Perhaps Marie Stephan could respond again and let us know have these contributions helped or what questions remain?

Marie Stephan

Dietitian for inpatient management of malnut /IOCC

Normal user

31 Oct 2013, 13:08

Dear All,
Thank you for your feedback.
Regarding the case, she tolerated plumpy nut after several trials, so she will be treated as outpatient.
Thanks again

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

31 Oct 2013, 14:06

That's a great news, thanks... She will need home visiting to ensure that the mother continues breastfeeding (at least until 2 years) and knows how to prepare adequate complementary food ...

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