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Which quantity of infant formula for SAM <6m?

This question was posted the Management of acute malnutrition in infants less than 6 months forum area and has 3 replies. You can also reply via email – be sure to leave the subject unchanged.

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Nathalie Avril

Nutrition Advisor / MSF

Normal user

23 Jul 2015, 13:31

Following the 2013 WHO guidelines "Updates on the management of severe acute malnutrition in infants and children":
for infants with severe acute malnutrition but no oedema, expressed breast milk
should be given, and, where this is not possible, commercial (generic) infant formula or
F-75 or diluted F-100 may be given, either alone or as the supplementary feed together
with breast milk;

Infant formula does not have the same energetic density (kcal/ml) than therapeutic milk. So which quantity of infant formula shall we give? If we give 100kcal/kg /day in the 1st days (as for therapeutic milk): it will increase the quantity of ml, is there no risk to increase it?


Dr Sylvia Garry

Public Health Doctor / NHS

Technical expert

28 Jul 2015, 16:59

This is a particularly interesting question, and is a largely unknown area. The WHO guidelines mentioned above then go on to point out that future research is required to look into exactly what milk is best to feed to these infants, since the current evidence is sparse.

Their recommendations also state that the re-establishing breastfeeding, if possible, is of the utmost priority.

When you mention therapeutic milk, do you mean diluted F100 (SDTM)? Protocols based on infant formula are more difficult since each formula differs slightly in terms of calorie and electrolyte content. I understand that formula milk tends to contain 60-70kcal/100ml. Undiluted F100 is not recommended due to the risks of renal impairment and hypernatraemia.

I have always used diluted F100 (diluted as per guidelines to 70-75kcal/100ml) in my clinical practice during the initial phases of refeeding these infants. The differences in calorie intake won’t be huge be huge between diluted F100 and many infant formulas.

The volumes are then reduced as breastfeeding is re-established, or increased if breastfeeding / alternatives are not available. The baby may not complete the volumes: in this case they are still offered the full volume at each feed and the remaining volume is measured. The next steps depend on whether or not the infant is improving and gaining weight over the subsequent days. If the infant doesn’t gain weight and has a poor appetite, other reasons should be sought out.

Take a look at these guidelines also:

Jessica Bourdaire

Normal user

28 Jul 2015, 18:19

Assuming it is a SAM <6 without any prospect of being breastfed admitted in the acute phase presenting medical complications, no oedema and able to drink (orally/NGT).

I would not increase systematically the amount of infant formula in the first feeds just to meet 100 kcal/kg/d because the risk of fluid overload. Large/infrequent/rapid feeds could also increase the risk of refeeding syndrome, refeeding diarrhoea and refeeding oedema, depending on the infant’s condition on admission.

I would start cautious feeding (130-135 ml/kg/day) and observe the infant’s response before increasing progressively the amount to match the table in page 174:

Depending on the infant formula composition, you might not be very far from 100 kcal/k/d though, but I will be careful with providing too much iron, protein and sodium which is not suitable in the acute phase.

WHO might want to provide further/different advice?

Marie McGrath


Forum moderator

28 Jul 2015, 18:49

Dear Nathalie
There is a section in Module 2 on infant feeding in emergencies, that deals with acute malnutrition in non-breastfed infants, including the use of breastmilk substitutes. See Part 8 of the Additional Materials section and relevant Annexes (Annexes 16, 17, 18 as well as Annexes 5 and 13).

Best regards, Marie

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