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Use of half strength infant formula instead of F75 Formula

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 6 replies. You can also reply via email – be sure to leave the subject unchanged.

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Gail Cummins

Dietitian Advisor, Samoa NHS

Normal user

17 Jan 2014, 02:29

Hi All

I am currently working as a Dietitian Advisor to the Samoan NHS.

A current practice in the Paediatric ward for infants ranging from about 6 months to 2 years, admitted for severe acute malnutrition, often with diarrhoea and oedema, is to start them on half strength infant formula (Farleys's Golden Infant Formula from Birth) and then grade up to full strength according to the WHO '10 Steps' from the Guideline for the inpatient treatment of severely malnourished children.
The guideline recommends the use of F75 formula, not infant formula and doesn't mention half-strength infant formula anywhere. I've been trying to find references for the use of half strength infant formula or any other guideline mentioning it (the Paediatricians reported that the use of half-strength came from another WHO guideline) but I have had no luck. I have only found advice that infant formula (full strength) should not be substituted for F75.

I would like to develop a protocol with the paediatric team so that everyone is aware of the management with regard to regimes and formulas.

Nutritional supplements are very limited at present, with options being the Farleys's Golden Infant formula or Paediasure (recently ordered to be used for supplementation in stabilised children or as a tube feed) . If the F75 is the best option I will discuss purchasing it with the Paediatric team but if the half-strength infant formula is a suitable option then we can stay with that. Any advice and supporting references would be greatly appreciated.

Regards,

Gail Cummins

Dietitian Advisor
Samoa National Health Service

Jay Berkley

KEMRI/Wellcome Trust Research Programme, Kenya

Frequent user

17 Jan 2014, 20:46

Dear Gail

Thanks for raising this. Half strength infant formula is likely to have much lower energy and potassium than F75:

per 1000ml:


			energy	protein	fats	Sodium	Potassium
			kcal	g	g	mg	mg
F75			750	9	20	<150	1567
F100			1000	>13	>26	<290	1100
IF lower limit 		598	11	25	120	478
IF upper limit 		753	17	36	359	1195
half average IF 	338	7	15	120	418


I would be fascinated to hear about your outcomes: time to stabilisation, oedema resolution, overall cure and mortality rates. It would be worthwhile publishing these if at all possible as there is extremely limited data on different approaches.

Jay

Dr Sylvia Garry

Public Health Doctor / NHS

Frequent user

17 Jan 2014, 21:57

Regarding the management of malnutrition in children over 6 months:

I presume that the question is referring to the stabilisation phase of malnutrition. Generally speaking, the use of diluted formulas seems anecdote-based, rather than evidence based. I can't find any evidence supporting using diluted formula, although this might be because each formula has different levels of protein and electrolytes, and guidelines might not want be seen to be supporting one brand of infant formula above another.

F75 has low protein / lower electrolytes than either diluted F100 or infant formula.

The issues with using either diluted F100 or infant formula in the stabilisation phase is that it may inadvertently increase the risks of diarrhoea (due to altered electrolytes) or refeeding syndrome (which may get mistaken for sepsis or heart failure) in these acutely sick children. The higher protein load may also exacerbate existing renal failure. The other issue that the children (especially those with Kwash) are on the borderline for fluid overload / heart failure so giving them too much fluid may push them into heart failure.


1) Firstly the WHO guidelines:
http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/index.html
Section 4.5 explains the nutritional values of F75 and how to make up solutions if you don't have the prepared powdered F75.

The following references are pretty much the same:
2) http://www.ncbi.nlm.nih.gov/books/NBK154454/
Section 7.4.8 shows the breakdown of what is in each type of formula used, and how to make up alternative formulas.

3) https://www.lshtm.ac.uk/eph/dph/research/nutrition/improving_inpatient_treatment_of_severe_malnutrition.pdf
This guideline is clear on the different electrolyte levels, check Appendix 2

4) There are some sites that suggest alternative recipes depending on what is available:
http://motherchildnutrition.org/malnutrition-management/info/feeding-formulas-f75-f100.html


I would recommend either using F75 or making up replacement feeds to the above specifications only. Breastfeeding in addition would be good. In general, as these kids stabilise, their appetites return. That is when I would consider a slow switch to F100 (rehab phase). You have to be more careful in the ones with oedema and you go by the transition phase first.

This article is interesting, from the end of page 671, as it explains why F75 is important:
http://www.ncbi.nlm.nih.gov/pubmed/20972284

In addition:
In the management of diarrhoea (rehydration), they should use ReSoMal rather than ORS.
If they are using formula and the child has diarrhoea, zinc should be added. If they are using F75/F100/RUTF, these contain zinc so no zinc supplement should be added.


In the question of infants <6months, this is what the WHO recommends:

http://www.ncbi.nlm.nih.gov/books/NBK154454/
“-For infants with severe acute malnutrition and oedema, give infant formula or F-75 or diluted F-100 (add water to formula in recipes up to 1.5 litres instead of 1 litre) to supplement breastfeeding.
- For infants with severe acute malnutrition with no oedema, give expressed breast milk; and when not possible, commercial infant formula or F-75 or diluted F-100, in this order of preference.”

I haven't found recommendations for diluting formula in these cases.

Dr Marko Kerac

Course Director, Global Nutrition MSc, LSHTM

Frequent user

19 Jan 2014, 19:02

This is an interesting approach – it would be helpful to understand the original rationale underlying this practice. My guess is that it might have been about reducing carbohydrate load so as to help the diarrhoea - this makes some sense, esp if thinking lactose intolerance may be playing a part. However, as Jay Berkley has pointed out, dilution also reduces essential electrolytes (notably potassium, phosphate) and this risks adverse effects.

An urgent question to answer is what’s the current mortality / what are the cure rates using this “diluted formula” protocol. I would suspect that the problem of inadequate electrolyte probably trumps any advantage of lower carbohydrate and hence outcomes may not be good. In which case important to switch ASAP to a more standard milk feed such as F75 (or locally made equivalent) or standard infant formula. Of course not forgetting to encourage/support/re-establish breastfeeding wherever possible.

Then again, one never knows. IMO unlikely but the dilute formula might work well and you get a very low mortality…there are plenty of times in clinical practice where the prevailing dogma and popular practice has been challenged and found wanting.

Bottom line is that it’s really vital to document the outcomes using this regime so that others can learn from it and it add to the overall evidence base of what to do or what not to do… I’m sure this won’t be the only place that’s modifying milks in this way.

I look forward to hearing more - do keep us updated

André BRIEND

Frequent user

20 Jan 2014, 09:03

Giving half strength diet to severely malnourished children at the beginning of treatment was often done years ago, « to help the gut to recover ». The explanation given by Marko is probably correct: by giving these diluted formulas, you reduce stool volume, which gives the illusion of “letting the gut recover”, but in the process, you starve the child: if you give diluted formula with standard feed volumes, you put these children in clearly negative energy balance, which is really not desirable, and also delays gut recovery by the way.

This approach of using diluted feeds has been abandoned once maintaining body weight (and not reducing stool volume) became the main objective of treatment. You cannot maintain body weight in a child with a negative energy balance. For the last 20-30 years, the agreement is to aim at energy balance in these patients by providing maintenance energy (80 to 100 kcal/kg/day, depending on degree of intestinal malabsorption), if needed by using tube feeding.

I fully endorse Marko’s statement about “important to switch ASAP to a more standard milk feed such as F75 (or locally made equivalent) or standard infant formula. Of course not forgetting to encourage/support/re-establish breastfeeding wherever possible.”

Elh.Hallarou Mahaman

Nutrition Consultant

Normal user

26 Jan 2014, 12:22


Hi Gummis,

I do not know if you have the chance to take a look to this field study http://fex.ennonline.net/37/diluted.
Without having the pretention of establishing any kind of norm or guideline, the study explores the use of diluted F100 vs infant formula.
In my understanding, the results of this study does not show any difference in recuperation outcomes between diluted F100 and IF.of course, the authors clearly pointed the limitations of the study but I believe the study result is worthy to know.

Dr Marko Kerac

Course Director, Global Nutrition MSc, LSHTM

Frequent user

27 Jan 2014, 22:19

Dear Hallarou and Colleagues,

Thanks for continuing this useful discussion.

The f100d vs formula milk study by Caroline Wilkinson and colleagues that you mention is indeed interesting and good. But I do not believe that it would be correct to apply it to the scenario originally mentioned by Gail which began this thread.
Gail mentions dilute formula milk in >6month olds. If wanting to explore the risks and benefits of that, the correct study to look for in the literature would be one comparing standard formula milk vs diluted formula milk. For the reasons discussed (as well as the important historical experience noted by Andre) it is likely that the dilute formula milk would have worse outcomes. So best avoid that unless you have evidence to the contrary: the current burden of proof is for research to show that it's NOT inferior... rather than infer that absence of evidence = OK until proven otherwise.

In contrast, Caroline's study:
- Focuses on infants under 6 months
- Uses f100 dilute due to the fact that full strength f100 has a high solute load which infants (especially younger and sicker malnourished infants) may not be able to deal with due to impaired renal function (please see WHO 2004 consultation on SAM for further discussion of this http://www.who.int/nutrition/publications/severemalnutrition/9241593318/en/
- Compares f100d to undiluted infant formula
....so this is not really applicable to the original question discussed.

Hope this makes sense. Thanks for a good discussion on this one. Any more relevant studies on this topic, I'd be interested to know.

Kind regards,

Marko.

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