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What to do when ReSoMal and CMV not available?

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 11 replies. You can also reply via email – be sure to leave the subject unchanged.

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Anonymous 94

Normal user

21 Jul 2014, 13:09

We are having shortages and cannot find in-country sources for some our needed products. The shortage is expected to last until next year. In particular, I need to know how I can make ReSoMal and F-100 equivalents without access to CMV (while I search for a source).

I found one posting online that advised for ReSoMal you can use a standard ORS 1litre packet, 4 g potassium and 50 g sucrose in 2L of water to replace ReSoMal. The posting said that this was second hand from someone who worked at MSF so I don't have any official source to verify this. Is this suggestion valid or recommended?

Jan Komrska

UNICEF Supply Division

Normal user

21 Jul 2014, 21:47

I am concerned about this message. ReSoMal is widely available from FDC in India. The company produces product in batches so they may be reluctant to supply small quantities to individual clients. However UNICEF country offices can easily accesss any quantity of ReSoMal though UNICEF Supply Division warehouse in Copenhagen where sufficient stocks are kept at any time. The product is very cheap. I advise to contact UNICEF country office and ask for an assistance. Information on Resomal supplied through UNICEF could be accessed here: http://www.unicef.org/supply/files/Resomal.pdf IMPORTANT: It is NOT possible to produce ReSoMal from CMV. UNICEF specifically requested Nutriset to remove label instructions on prepration of ReSoMal from their CMV. I would also strongly discourage "home" made preparations of ReSoMal from ORS by adding other ingredients. I am wondering how quality of these ingredients could be assess in low resource setting as well as where would one source them?

Anonymous 94

Normal user

21 Jul 2014, 23:07

Jan,

I appreciate your response and your suggestions. You are stating some of the same concerns I have had. My post is one of almost-desperation as I have already exhausted many avenues.

We are a UNICEF Haiti partner, and I have asked several times and been told that there will not be any ReSoMal available for us in the near future; possibly until next year. UNICEF Haiti is under considerable restriction for nutrition funding this year. I contacted Nutriset to buy ReSoMal but we don't need a large amount and the shipping would be complicated for my organization as it would need to be imported to the US and then sent by sea to Haiti. It would take several months to reach me. We have checked with many private suppliers and pharmacies but we can't source any.

Haiti's national protocol for the treatment of severe malnutrition provides options. Those being using a mineral solution or using CMV. This national protocol was written in 2010 and is supported by UNICEF - I haven't heard of any criticism or controversy. It provides a recipe for ReSoMal: 1 sachet of standard ORS + 50 g sugar + 6.5 g CMV (or 40 ml of mineral solution) + 2 L of water.

If you have more information about not using CMV to prepare a ReSoMal substitute, I would love to have it. The recommendation for CMV may be an issue that needs to be addressed with the ministry of health.

We also are not able to get F100 in the country currently and the producer in the US doesn't have any available for us to buy. The milk powder recipe also calls for mineral solution or CMV.

One of the other options I have is to have a pharmacy or laboratory make the mineral solution for us, but we would not be able to verify the composition and would have to trust that it was done correctly. It is a risk in this environment. This is why I am looking for CMV so that I can mitigate the risk and use a commercially made product.

Any other suggestions would be accepted gratefully,

Ellen

Regine Kopplow

Sen. Advisor Food& Nutrition Security

Normal user

22 Jul 2014, 06:36

Taken from 'MSF nutrition guidelines 1st edition 1995 p.79 and p.155':
- in the treatment of dehydration for severely malnourished children, it is necessary
to reduce the sodium content of the traditional ORS formula and increase the potassium content
- if ReSoMal is not available in the field it is necessary to dilute normal ORS to half strength (use 1 sachet classical WHO ORS diluted in 2 litres rather than 1 + sugar (25g/litre) + potassium (KCI) (2g/litre)
- thus to make 10 litre of ORS for severely malnourished children use 10 litres of water + 5 packets of ORS (1 litre sachets) + 250 g sugar + 20g KCI
- the required amount of diluted ORS is given (5-15ml/Kg/hour) slowly over the whole treatment period until signs of dehydration have disappeared and not unlike the normal ORS, al large initial dose to begin of the treatment

Regine Kopplow

Sen. Advisor Food& Nutrition Security

Normal user

22 Jul 2014, 06:44

Again taken from MSF Nutrition Guidelines:
The preparation of High Energy Milk (100Kcal/100ml with 2.8g of protein/ 100ml)
1) Recipe based on dried skimmed milk: DSM 80g; oil 60g, sugar 50g, add water to make 1 litre = 1 litre with 1019 Kcal and 28.8g protein
2) Recipe based on full cream milk: FCM 110g, oil 30g, sugar 50g, add water to make 1 litre = 1 litre with 1016 Kcal and 28.6g protein
- the premix should be prepared in advance; always weight the ingredients, do not use quantities measured by volume; the premix (milk powder, sugar, oil) can be kept for about one week, provided that it is stored in a dry place
- the milk should be made up just before distribution; the water should be boiled cold water; once made up the high energy milk should not be kept for more than 2 hours and should be protected from flies

Anonymous 94

Normal user

22 Jul 2014, 14:54

Thank you Regine. The instructions you give for replacing ReSoMal are the same that I found posted online without the source verified but quoted as being from MSF. This recipe is possible for us to prepare at our facility. The MSF recommendations are dated 1995 so is there anyone who can tell me they are still valid? Jan's concerns have me rethinking it.

I looked at the 2013 WHO Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children and found the recommendation for ReSoMal replacement includes both mineral solution and CMV:

p 49 "Dissolve one sachet of standard WHO low-osmolarity oral rehydration solution in 2 L water (instead of 1 L). Add 1 level scoop of commercially available combined minerals and vitamins mix1 or 40 mL of mineral mix solution (5), and add and dissolve 50 g of sugar. In some countries, sachets are available that are designed to make 500 mL of standard WHO low-osmolarity oral rehydration solution. In this situation, dilution can be revised to add 1 L."

Interestingly, the 2003 WHO Guidelines for the Inpatient Treatment of Severe Malnutrition only lists electrolyte/mineral solution in the recipe for ReSoMal.If mineral solution is not available, it gives instructions on how to give K, Mg, and Zn separately.

Regine Kopplow

Sen. Advisor Food& Nutrition Security

Normal user

22 Jul 2014, 15:12

The MSF guidelines were reviewed and there is a 2006 draft version available on the internet but I have not checked whether there are any changes made to the recipes for replacing ReSoMal and F100. Not sure there is a final version. You might want to approach MSF in your country directly.

Anonymous 94

Normal user

22 Jul 2014, 20:16

Hello Regine. I located the 2006 draft of MSF Nutrition Guidelines. Both the F-100 and ReSoMal replacement recipes given call for the addition of CMV; neither mentions electrolyte/mineral solution.

Kerstin Hanson, MD

Medecins Sans Frontieres OCP

Normal user

23 Jul 2014, 12:49

Current MSF guidelines do not recommend producing or using "homemade" ReSoMal. We recommend that our fields follow current WHO guidelines regarding the use of ReSoMal and ORS. When ReSoMal is absolutely not available we recommend that our fields 1) lobby to make it available and 2) use low-osmolarity ORS as a substitute until it becomes available.

Anonymous 94

Normal user

23 Jul 2014, 14:50

Dr. Hanson, what does MSF do for K and Mg? Separate supplementation?

We are using the low osmolarity ORS at half-strength but it doesn't provide these minerals. The most recent WHO guideline (2013) recommends adding CMV or mineral mix solution. Our pediatrician is pushing for a resolution to this problem and suggested using Pedialyte, of which we do have a consistent supply. I don't feel that it is a good substitute, but if anyone has suggestions on how it could be used I would be open to it.

This has been an interesting problem. Like many things, I didn't know there would be these differences in approach until I had to investigate it. I really don't want to go with a homemade option as there is too much room for error and harm. I appreciate everyone's input.

Kerstin Hanson, MD

Medecins Sans Frontieres OCP

Normal user

28 Jul 2014, 15:12

Hello Ellen-

In addition to the Oral Rehydration Solution (whether ReSoMal or low osmolarity ORS), children should generally continue receiving therapeutic food. (For sick and hospitalized malnourished children, usually F-75). Although not a complete source of Potassium or Magnesium in the case of ongoing losses, better than nothing. We do not provide additional supplementation, as we are not generally in situations were we can monitor electrolytes and "blind" supplementation could cause as much harm as benefit.

Having said this, we are not convinced that either ReSoMal or ORS (in whatever form) is the ideal oral rehydration solution for malnourished kids. I refer you to the CMAM forum's technical brief entitled "SAM and Infections Technical Brief, May 2013". It highlights the lack of evidence related to the use of ReSoMal, and strongly recommends further research in this area.

Any anticipated or ongoing studies aimed at understanding the best approach and solution to use for the oral rehydration of acutely malnourished children? If so, would love to hear about it!

Nwokedi Kene

Medical Doctor/ University if Abuja Teaching Hosp.

Normal user

20 Sep 2014, 11:34

Hi, here in my institution, we use ORS in 2L with addition of 50g of glucose and 4g of potassium, once ReSoMal is not available. I was told it was a WHO recommendation. Never tried to look it up.
Until a new recommendation/ guideline, we would continue to use the above.

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