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inpatient SAM management

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 2 replies. You can also reply via email – be sure to leave the subject unchanged.

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Ruba Abu-Taleb

Nutrition project manager/International medical co

Normal user

4 Sep 2018, 13:08

hi..
in Jordan, the CMAM program is integrated into primary healthcare...thus, only children with urgent complications are referred for secondary healthcare services.

F-100 and F-75 are not regularily procured in Jordan because the rate of SAM children referral is insignificant....as NWG, we tried to find a way to manifacture the F-100/F-75 locally but we were not successful...

for individual SAM cases.,...what would be the best practice to feed inpatients?
the hospital to which those children are referred is currently providing them with either infatrini or concentrated formula.

please advise


thank you

Paul

Technical expert

10 Oct 2018, 03:34

Hi Ruba,

The constituents of some of the ingredients of F75 / F100 and infantrini are indicated below for comparison.

Constituent Amount per 100 ml
F75 F100 Infantrini
Energy 75 kcal (315 kj) 100 kcal (420 kj) 101 kcal (420 kj)
Protein 0.9g 2.9g 2.6g
Lactose 1.3g 4.2g 5.2g
Potassium 3.6 mmol 5.9 mmol 2.4 mmol
Sodium 0.6 mmol 1.9 mmol 1.6 mmol
Magnesium 0.43 mmol 0.73 mmol 0.4 mmol
Zinc 2.0mg 2.3mg 0.8mg
Copper 0.25mg 0.25mg 0.065mg

Percentages of energy
Protein 5% 12% 10.3%
Fat 32% 53% 47.9%

Osmolarity 333 mOsm/L 419 mOsm/L 305 mOsm/L

Notably, Infantrini also contains 1.2mg iron / 100 ml.

The documentation on infantrini indicates it is for use in children from 0-18 months with growth faltering. However an infant with growth faltering may not have the same physiological disturbances as an infant / child with severe acute malnutrition (SAM).

WHO recommend that full strength F100 formula should not be given to infants with SAM due to the risk of renal solute overload and hypernatraemic dehydration (particularly in hot climates where high insensible fluid losses may occur).

Although the osmolarity of infantrini is lower than F75, the calculation of the potential renal solute overload (PRSL) depends on the amount of protein and other solutes. Although I cannot calculate the PRSL here, indirectly the protein level appears to be similar to full strength F100 and there are higher amounts of sodium than we would expect to see in F75. It would appear that infantrini may not be suitable for use in infants with SAM on that basis.

Infantrini also contains 1.2mg iron / 100 ml. The addition of iron to formulas for the recovery of children with SAM is contraindicated until the rehabilitation phase of treatment.

Although the amount of protein and energy density are similar to F100 there are lower levels of zinc which may be restrictive to the growth rate compared to F100 although I have no data to support such a position.

The levels of lactose are higher in infantrini than in either F75 or F100. Although Infantrini is cited in several papers as being well tolerated by infants I am not aware of any trials specifically with the initial feeding phase (stabilisation). It is common for children with SAM to have low levels of lactase and high lactose feeds may not be well tolerated in such children with resulting diarrhoea.

Studies that have suggested the successful use of full strength F100 in the initial feeding phase have subsequently been criticised for having not been robust enough to support the conclusions.

Overall then, it would appear that the use of Infantrini is unsuitable especially for infants with SAM and for children in the initial stabilisation phase of treatment.

In terms of the use of "concentrated formula", the use of such formulae for SAM cases should follow WHO guidelines. Diluted F100 (without iron) used as an alternative to F75 for infants is obtained by adding an extra 30ml water / 100ml full strength F100. Hopefully the figures posted above will be able you to judge whether the dilution of the "concentrated formula" would be acceptable, however, be aware that most infant formulas will contain iron which will be unsuitable for the stabilisation phase of treatment.

I would strongly urge you to consult UNICEF / WHO in Jordan or the nearest regional office for official guidance on this subject.

Paul

Technical expert

10 Oct 2018, 03:42

Apologies. The formatting for the table was lost. Trying again....

Constituent----------------------------------------Amount per 100 ml------------------------------------
-----------------------------------------------------------------------------------------------------------------------------

---------------------------------------------F75----------------------------F100----------------------Infantrini
Energy--------------------------75 kcal (315 kj)-------------100kcal (420 kj)------101 kcal (420 kj)
Protein----------------------------------0.9g---------------------------2.9g--------------------------2.6g
Lactose--------------------------------1.3g---------------------------4.2g---------------------------5.2g
Potassium----------------------------3.6 mmol-------------------5.9 mmol------------------2.4 mmol
Sodium---------------------------------0.6 mmol-------------------1.9 mmol------------------1.6 mmol
Magnesium--------------------------0.43 mmol----------------0.73 mmol-----------------0.4 mmol
Zinc--------------------------------------2.0mg-----------------------2.3mg------------------------0.8mg
Copper---------------------------------0.25mg---------------------0.25mg----------------------0.065mg

Percentages of energy
Protein-------------------------------------5%----------------------------12%--------------------------10.3%
Fat-------------------------------------------32%---------------------------53%-------------------------47.9%
Osmolarity--------------------------333 mOsm/L------------419 mOsm/L----------305 mOsm/L

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