Infant from 0 to 6 months of age

and the treatment of severe

malnutrition

© Michael Golden & Yvonne

Grellety
February 2011
The moral rights of the authors have been asserted. The
authors retain the copyright to this material. It cannot be
abstracted, divided or used to teach fee-paying students. It can
be used without charge for teaching UNICEF staff.
 Learning Objectives
• Define the types and criteria of admission and discharge
• List the types of reference in the IPF
• Fill the SS chart, the IPF register
• Weight the baby on a accurate scale (10g precision)
• Welcome the patient
• Monitor the patient
• Administrate the routine medicines
• Prepare & give the appropriate diet (F75
/F100-dilute/Infant formula/express breast-milk)
• Follow the flow of material, products, drugs, and the
stockpiling
• Follow the nutritional status of the mother
 TFC CFR for marasmic children by height interval
(yr 2000)

Case fatality rate

30

25

20
Dead %

15 obFR%

10

Height interval
 Malnourished infants
• Do not cry - they are thus neglected
• Have no strength - do not stimulate
milk
• Have a very high mortality
• Are often infected
 Breast Milk Output with SS-technique
250

200
Breast Milk output (ml/kg)

150 requirement for maintainance

100

50

Ss-Technique Breast-milk only

0
0.0 7.0 14.0 21.0 28.0
Tim e (day)
 Weight gain with SS-technique
400

350
Cumulative weight gain (g/kg)

300

250
(restart at 0 wt gain)

200

150

100

50
SS-Technique Breast-milk only

0
0.0 7.0 14.0 21.0 28.0
Tim e (day)
 The different Steps
• Admission:
Criteria of admission – Measurements
Registration
• Diet & the SS-technique
• Routine medicine
• Surveillance
• Care for the mother
• Discharge:
Criteria & Type - registration
 Criteria of admission
Infant less than 3kg or less than 6 month

 Too weak or feeble to suckle effectively

(irrespective of his/her WL, WA or other
anthropometry).
or
 Not gaining weight at home (by serial
measurement of weight during growth monitoring,
i.e. change in WA)
or
 W/L less than <-3 Z
or
 Presence of bilateral oedema.
 Registration: SS Chart 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

SS-Chart for Infants with SS feeding (less than 6 months or 3kg) Date

Routine Medicines
ID N0…………………………….. Antibiotic 1 Time

Registration No…………………………………… Major Problems Admission Date___/___/__ Discharge Date___/___/___

Time
Sheet No…………………………………………… IPF Name………………… Time………………...am/pm Successfully Treated Antibiotic 2
Family Name Day care/Pediatric W/Other 1 …………………………… New Admission □ Dead Time ….………...am/pm …………..
Patient's Name…………………………………………
Age (day or mo.)………………… 2 …………………………… Relapse Cause of death.............................................
Address………………………………………………………….
Birthdate___/___/___ 3 …………………………… Readmission Y / N Defaulter Malaria Rx

…………………………………………………………. Sex…………………… Breastfed……………....Y / N If Y, Type Med. Referral To……………… …………..

Phone-No……………………… Receiving other feed…..Y / N Reg No …………………… Non Response to treatment

Special Medicine*
Reason admission 1) Growth Monitoring static: Y / N - 2) Weight/Length...Y / N 3) Weight/Age Y / N 4) Complication Y / N if Y ....................... - 5) Œdema Y /N Time
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Antibiotic 3
Date
Anthropometry

Length (cm)

Weight (kg.g)
Enter Name, dose and route of administration (oral-po, intramuscular-IM, or intravenous-IV) for each drug. Enter an X in the upper left corner if prescribed - the nurse signs the box when the drug is given.
Wt for Ht (Z/%) Mutlivitamin

Mother Trt
Vitamin A
Œdema (0 to +++)
Malaria Rx
CSB

Hb/Pcv

Test Results
Malaria smear
Glucose

OBSERVATION
Weight Chart

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Date

# feeds/day

Infant Formula/F100Dil

SS ml / feed
1
Time Hr
A=Absent
V=Vomit 2
Therapeutic Diet

R=Refused
NG=tube 3
IV=IV Fluid Card DATES
4
Y N Birth 1
Amount
taken 5 BCG

6
100% X X Polio
X X
X 7
3/4 X
X DPT
X 8
1/2 X
9
1/4 X

=ml=extra 10
DISCHARGE
Alert/Lethargic (A/L) Education Given On Dates Sig.
Stool ( 0 to IIII) Causes of malnutrition
Vomit (0 to IIII) Diarrhoea, RTI, Fever
Dehydrated (0 to +++) Skin, eye and ear infection
Play and stimulation
Cough (0 to +++)
Surveillance

Child nutrition
Shock (0 to +++)
Child care
Resp. rate /mn
Hygiene
Pale Conjunct. (0 to +++)
Sexually Transmitted Disease
Temp. AM (Ax/Rec) Family Planning
Temp. PM (Ax/Rec) Other……………………………..
Immunisation up to date Y N
Breastfeeding on discharge Y N
Registration: SS chart feeds
 Measurements

1) Precision of the scale:

10 to 20g for the babies
below 8kg
2) The table W/L stops at
49cm length,
therefore it is difficult to
calculate the WHZ for
these infants.

Salter scales should not be used : it only has a precision of 100g

 Product used
 F100 dilute if wasted infant
Why? Because babies of that age need more
water and they are wasted, they need
100kcal/kg/day
or
 Expressed breast milk
or
 Generic Infant formula if wasted infant
or
 F75 if oedematous infant
 Preparation of the F100 diluted

• Take 100 ml of F100 reconstituted and add 35 ml

of boiled water at 70°C or more if you need 135ml
or less for the feeds.
• Take 200 ml of F100 reconstituted and add 70ml of
boiled water at 70°C or more if you need 270ml or
less for the feeds.
• Do not try to do small quantities!
 CLASS OF ML PER FEED 50% OF THE 75% OF THE
WEIGHT (KG) (FOR 8 FEEDS REQUIRED REQUIRED
/DAY) QUANTITY QUANTITY
(100%)
  F100-dilute    

>=1,2 kg 25 ml per feed 12,5 18 ml

1,3 – 1,5 30 15 24 ml
1,6 – 1,7 35 18 27 ml
1,8 – 2,1 40 20 30
2,2 – 2,4 45 23 35
2,5 – 2,7 50 25 40
2,8 – 2,9 55 28 45
3,0 – 3,4 60 30 45
3,5 – 3,9 65 33 50
4,0 – 4,4 70 35 55
 Diet

 Breastfeed every 3 hours, during at least 20

minutes, more often if the child ask for more.

 One hour after breast-feeding, complete with

F100 diluted using the supplementary suckling
technique:

F-100 dilute: 130ml/kg/day (100kcal/kg/day),

divided in 8 meals
 The Suckling Technique
- The mother holds the tube at the breast with
one hand and uses the other for holding the
beaker.

- It may take one or two days for the infant to

get used of the tube but it is important to
persevere.
 The Suckling Technique
-The supplementation is given via an NGT n°8 or
6: n°5 is too small
-The tip is cut back beyond the side ports
approximately 1cm and the cap at the end of the
tube is removed
-F-100 dilute is put in a beaker. The mother holds
it.
-The end of the tube is put in a cup.
-The tip of the tube is put on the breast at the
nipple and the infant is offered the breast.
 The Suckling Technique
- When the infant sucks on the breast with the tube in
his mouth, the milk from the cup is sucked up
through the tube and taken by the infant.
- The beaker is placed at least 10cm below the level
of the breast so the milk does not flow too quickly
and distress the infant.
- Clean the tube: After feeding, flush the tube
through with clean water using a syringe & spin
rapidly to remove the water & inspect that no water
remains in the tube.
 Routine medicine
Antibiotics
 Amoxicillin (from 2kg):
30mg/kg 2 times a day (60mg/day)
 Gentamicin:
4 mg/kg give once daily IM

Never use chloramphenicol in the young infants

 Surveillance
• Weigh infant daily and see if his/her weight is
increasing using a proper scale (10 to 20g
precision)

• If the infant is taking the same quantity of F100D

and is increasing, it means that the breast-milk
quantity is increasing.
 Surveillance
When the infant is gaining weight at 20g per day,
 Decrease F100D to 1/2 of the maintenance intake
(50kcal/kg),
If the weight gain is maintained at 10g per day,
 Stop “SS” feeding technique completely,

If weight gain is NOT maintained

 Increase the amount by ¾ of the maintenance
intake (75kcal/kg).
Finally,
Keep the child on breast milk alone to make sure that
he continues to gain weight.
 CLASS OF ML PER FEED 50% OF THE 75% OF THE
WEIGHT (KG) (FOR 8 FEEDS REQUIRED REQUIRED
/DAY) QUANTITY QUANTITY
(100%)
  F100-dilute    

>=1,2 kg 25 ml per feed 12,5 18 ml

1,3 – 1,5 30 15 24 ml
1,6 – 1,7 35 18 27 ml
1,8 – 2,1 40 20 30
2,2 – 2,4 45 23 35
2,5 – 2,7 50 25 40
2,8 – 2,9 55 28 45
3,0 – 3,4 60 30 45
3,5 – 3,9 65 33 50
4,0 – 4,4 70 35 55
 Care for the mother (1)
- Explain the mother what you do and
why; do not make the mother feel guilty,
reassure her.
- Be attentive to her.
- She should drink at least 2 litters per
day: sugared water, normal water or
herbal tea, etc....
 Care for the mother (2)
She must eat enough: 2500kcal/day
– 1 porridge in the morning
– 1 family meal
– 1 porridge in the afternoon

which means that at the 2100kcal for the

care takers an additional porridge has to
be given to the mother (~ 400kcal)
 Care for the mother (3)
The mother who is admitted in the centre
with her child has to receive:
• Vitamin A:
– If the child is below 2 months: 200.000UI
(there should be no risk of pregnancy)
– If the child is above 2 months: 25.000UI
once a week
• Micronutrients’ supplementation
 Criteria and type of discharge
Infant less than 3kg or less than 6 month

Criteria
 It is clear that s/he is gaining weight on
breast milk alone after the SS technique has
been used,
 There is no medical problem
 The mother has been adequately
supplemented with vitamins and minerals
Type
Successfully treated
 Follow-up

in SFC/MCH for 6 months