144 Shahrin Chisti Ahmed
If the child is sick looking or has complica-
tions, give ampicillin at 50 mg/kg i.m./i.v.
6-hourly for 2 days, then oral amoxicillin at
15 mg/kg 8-hourly for 5 days and gentamicin
at 7.5 mg/kg i.m./i.v. once daily for 7 days. If
the child fails to improve clinically by 48 h or
deteriorates after 24 h, a third-generation
cephalosporin (e.g. ceftriaxone at 50–75 mg/
kg i.v. or i.m. once daily) may be started with
gentamicin. Where specific infections are
identified, add specific antimicrobials as ap-
propriate
- Start careful feeding. During the stabilization
phase, a cautious approach is required because
of the child’s fragile physiological state and re-
duced capacity to handle large feeds. Feeding
should be started as soon as possible after ad-
mission with the WHO-recommended milk-
based starter formula F-75, which contains 75
kcal/100 ml and 0.9 g protein/100 ml. The
feeding frequency is gradually decreased ( ta-
ble 3 ). If the child is anorexic and oral intake
does not reach 80 kcal/kg/day, give the re-
maining feed by a nasogastric tube
- Achieve catch-up growth, which starts when
the energy intake is >150 kcal/kg/day. In set-
tings where a program for the community-
based management of SAM with ready-to-use
therapeutic food (RUTF) is not available,
F-100 is used. During the nutritional rehabili-
tation phase, feeding is gradually increased to
achieve a rapid weight gain of >10 g/kg/day.
The WHO recommends the milk-based diet
for nutritional rehabilitation F-100, which
contains 100 kcal and 2.9 g protein/100 ml.
Modified porridges or family foods can be
used, provided they have comparable energy
and protein concentrations. Readiness to enter
the nutritional rehabilitation phase is signaled
by a return of appetite, usually about 1 week
after admission. A gradual transition is recom-
mended to avoid the risk of heart failure,
which can occur if children suddenly consume
huge amounts. In case of infants with SAM <6
months old, feeding should be initiated with
F-75. During the nutritional rehabilitation
phase, F-75 can be continued, and, if possible,
relactation should be done
Community-Based Management of SAM
Children with SAM without any complications
can be managed in the community with RUTF.
Children who have been treated for complica-
tions can also be treated in the hospital with
RUTF if they have appetite. In general, most chil-
dren with SAM can be treated in the community.
The requirements for a community-based pro-
gram for SAM are: a cadre of trained health work-
ers who can screen children for SAM, a referral
mechanism for the stabilization of children with
complications, a functional stabilization center
with adequate staff, F-75, F-100, medicines and
RUTF. RUTF has the nutrient composition of
F-100 but is more energy dense and does not con-
tain any water. Bacterial contamination, there-
fore, does not occur, and the food is safe for use
also in home conditions. The prototype RUTF is
made of peanut paste, milk powder, vegetable oil
and a mineral and vitamin mix as per WHO rec-
ommendations. It is available as a paste in a sa-
chet; thus, it does not require any cooking, and
children can eat directly from the sachet. The pro-
duction of RUTF from locally available food in-
gredients has recently commenced in some coun-
tries; such RUTF can make programs more cost-
effective and sustainable.
Ta b l e 3. Feeding of children with SAM
Days Frequency Volume/kg
per feed, ml
Volume/kg
per day, ml
1 and 2 2-hourly 11 130
3 – 5 3-hourly 16 130
6 and 7 4-hourly 22 130
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 139–146
DOI: 10.1159/000367880
