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treatment of SAM in 2 month old

This question was posted the Management of At Risk Mothers and Infants forum area and has 6 replies. You can also reply via email – be sure to leave the subject unchanged.

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Suzanne Fuhrman

Nutrition in Emergencies, WFP

Normal user

22 May 2014, 08:43

I am seeking advice on how to best manage this case: 2 month old twins admitted to a stabilization centre in South Sudan. Mother has been unable to breastfeed for 1 month due to 'sores' on her breasts. To me, it looks like the milk duct is blocked, but there is no redness. She said it bleeds when she breastfeeds and has a lot of pain. Mother has been feeding the children infant formula for 1 month.

One twin, female, admitted to the stabilization centre on the basis of visible wasting. The other twin, male, appears healthy and has not been admitted. The admitted child is being fed with diluted F-100 (35 ml extra water added per 100 ml). The goals is to try to re-establish lactation. The mother has been advised to place warm cloth on breasts and to drink extra water.

I appreciate any guidance on this case.

I also am looking for advice on measuring acute malnutrition in children under 6 month. I see chest circumference mentioned as a measurement, but no guidelines on what measurement would indicate malnutrition.

Mark Manary

Washington University School of Medicine

Frequent user

23 May 2014, 11:13

Susanne; The very same measurements that you would use in 6 mo children apply to younger children to determine malnutrition. Length, weight and MUAC all give a measure of nutritional status and growth. There are data to support that MUAC < 11 cm is severe malnutrition. WHO charts start at 45 cm, is the child shorter than 45 cm? These charts are at the following website The child could well be critically ill if the child has not received adequate food for a month. In terms of management this is a little simplier, here is a young child with nothing to eat. Find a wet nurse, if none available, give the child diluted f-100 or infant formula ad lib. No other menu of complementary foods can be safely substituted.

Marie McGrath

MAMI Special Interest Group Coordinator

Frequent user

23 May 2014, 11:41

Dear Susanne,
There may be a number of causes for the acute malnutrition in this infant. It is relevant that only one twin has been affected, so this suggests there may be something about this infant that is led to this - related to illness and/or feeding technique. I am assuming that she is breastfeeding the second twin?

The fact that you suspect some blocked ducts and she has bleeding nipples suggests a problem with how the baby is latching on for a feed. This may be causing the problem/malnutrition or may be secondary to the infant not being well and being less engaged and demanding for feeds - especially when there is a hardy 'competitor' in the form of a nourished twin sibling. Some gentle massage around the hard area, especially whilst the infant is feeding, may help.

Out of interest, does the mother favour one breast for one twin? if so, it might help to encourage her to alternate with both infants - if one infant is suckling well, then it may help to stop blockage.

There are some useful graphics in video footage about latching on technique for breastfeeding from a UK produced breastfeeding support for mothers.

Your goal to re-establish lactation with this infant is absolutely right. Are you using the supplemental suckling technique, where the diluted F100 can be provided via an NG tube whilst the infant suckles on the breast? I can send links to resources and I am sure there are others in the en-net world with direct experiences of this who can share with you. For example, see Module 2 on IFE where chapter 7 specially deals with malnourished infants < 6 months.

What is the state of well being of the mother? Is she well and nourished? She will need support through all of this, including decent food and adequate fluids.

Warm regards

Tamsin Walters

en-net moderator

Forum moderator

23 May 2014, 11:44

[i]From Jay Berkley:[/i] Hi There is good information on the Australian Breastfeeding Association website: Basically, the key thing is to keep feeding and try to keep emptying the breast, if necessary by pump or manually expressing. They suggest cold packs to help with pain/inflammation. On assessment, the current recommendation is to use weight for length z score or poor feeding or VSW. We are doing quite a bit of research on this at the moment and WFLZ doesn’t seem to be a very good measure, but we have to wait for that to be formally recognised. Best wishes Jay

Dr Sylvia Garry

Public Health Doctor / NHS

Technical expert

24 May 2014, 12:00

Weight monitoring To decide if the baby is malnourished is difficult at this age. Find out which twin was bigger at birth and compare this baby to her twin. I usually admit these babies (especially to look for underlying illness) and monitor their weights. You can calculate how much weight gain they have over a period of time once you are sure she is having enough milk. If the only problem is milk intake, she should start gaining weight pretty quickly (calculate in grams per kilogram per day). You can use these growth charts too to see if weight gain progresses along the centile: (for girls) (for boys) Background Find out how the other twin has been feeding. Is the mother exclusively breastfeeding or does she give them something else? It may be that the mother preferentially gives her milk to the boy rather than the girl, which I have certainly seen happening in South Sudan. What are the issues with the mother? Does she have good technique for breastfeeding? What is her nutritional status? Does she have family support? Is she unwell? The mother may need additional food (higher nutritional needs), multivitamins and lots of clean water. She may need extra psychological support. Feeding the infant For re-feeding the child, I usually take a graded approach, depending on how the child is. If there is diarrhoea / vomiting then I usually establish the feeds more slowly, starting at 120ml/kg/d in divided feeds. The risk of re-feeding is difficult to quantify in this age group. If the child is well, I would start at around 135-150ml/kg/d. Ask the mother to express her milk into a clean container and then you can measure how much the child is being given. Top up with formula or diluted F100. Milk-wise, the choices would be in this order: - Breast milk (from the mother) - Donor breast milk - Formula - Diluted F100 (1.5L rather than 1L to make it up. See page 212 of this manual for the recipe on how to make it up ) Method of re-lactation is nicely described in this WHO manual, page 58: The same book covers dealing with breast problems including mastitis and sore nipples. The essence is to keep getting the milk out of the breast (by expressing it) on page 65 onwards. If the nipples are cracked, put some EBM on them. Do not introduce any solids yet, although the mother may have been giving them. The practise of using animal milk in neonates is very common in South Sudan, and unfortunately amongst many of the tribes wet nursing is often not seen as acceptable. The use of animal milk will predispose the baby to multiple illnesses. Comorbidities It is odd that one twin is malnourished if the other is in a good healthy condition, since they have been exposed to the same factors. Consider illnesses that may be present – congenital (cardiac, poor sucking, abnormal neurology) and infection. Brucellosis / TB/ HIV / bacterial infection are all fairly common. Discharge Also prior to discharge find out what the mother plans on doing at home. Something needs to change otherwise the baby will just fall back into malnutrition. Check technique for how she has been making up the formula at home (if you are unable to re-establish lactation) and check the right ratios of water to powder are used. Check that the water is boiled, that the container is clean and that no teats are used (difficult to clean, high risk of infection).

Tamsin Walters

en-net moderator

Forum moderator

26 May 2014, 11:44

From Rukhsana Haider:

Basically here in Bangladesh all I do (and can do) is encourage and support mother with practical help to feed the babies. If they are too small or weak to suck (weights were not mentioned in your post) then expressed breastmilk is required initially and babies allowed to suckle for short periods when they can, increasing duration as they become stronger. Position and attachment at the breast will need to be checked and corrected (I did not understand what were the "breast sores" - was it a feeling of nipple soreness or soreness in the breasts itself?); any other supplement fed by cup and spoon or nursing supplementer, and re-lactation will need to be assisted with lot of patience.

We had a mother with twins - birth weights 2.2 and 2.0 kg and they could be helped to breastfeed exclusively for 6 months! All that was needed was to show mother how to breastfeed the twins simultaneously in the "underarm hold" position.

I hope this helps.

Tamsin Walters

en-net moderator

Forum moderator

27 May 2014, 15:25

From Fatema Mofid:

In Afghanistan there is the same protocol. Soreness of nipple is belong to attachment and position problems. When we aware mother from method of a successful breast feeding, the problem is solved. During the cracking and soreness of the nipple, mother can apply some of her breast milk around the nipple. Also we can educate mother about safer methods of expressing mild to a cup and how to give it to the small child unable to suck. Whenever the child can be able to suck, should put on the breast and encourage to suck (with spot of attachment & position technique).


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