Decision 4487/QD-BYT 2016 on the promulgation of the Guideline for diagnosis and treatment of acute malnutrition in children who are 0-72 months of age

DECISION

ON THE PROMULGATION OF THE GUIDELINE FOR DIAGNOSIS AND TREATMENT OF ACUTE MALNUTRITION IN CHILDREN WHO ARE 0-72 MONTHS OF AGE

__________

THE MINISTER OF HEALTH

Pursuant to Government’s Decree No. 63/2012/ND-CP dated August 31, 2012, defining the functions, tasks, powers and organizational structure of the Ministry of Health;

At the request of the Director of the Medical Services Administration under the Ministry of Health,

DECIDES:

Article 1. To promulgate together with this Decision the Guideline for diagnosis and treatment of acute malnutrition in children who are 0-72 months of age.

Article 2. The Guideline for diagnosis and treatment of acute malnutrition in children who are 0-72 months of age, promulgated together with this Decision, shall be applicable at health-care facilities.

Based on this Guideline and specific conditions of each facility, the director of the health-care facility shall develop and issue the Guideline for the diagnosis and treatment of acute malnutrition in children who are 0-72 months of age, which is suitable for implementation at such facility.

Article 3. This Decision takes effect from the date of signing for promulgation.

Article 4. Chief of the Ministry’s Office, Director of the Medical Services Administration, Chief Inspector of the Ministry, Directors of Departments/Agencies under the Ministry of Health; directors of health-care facilities under the Ministry of Health; Directors of Health Departments of provinces and centrally-run cities; leaders in charge of health of ministries and sectors; and heads of other relevant units shall be responsible for the implementation of this Decision./.

GUIDELINE

DIAGNOSIS AND TREATMENT OF ACUTE MALNUTRITION IN CHILDREN WHO ARE 0-72 MONTHS OF AGE
(Promulgated together with Decision No. 4487/QD-BYT dated August 18, 2016)

I. Acknowledgement

Acute malnutrition (AM) is a medical condition in which the body does not have sufficient energy and protein intake compared to its needs due to deficiencies or diseases, causing rapid weight loss (severe thinness) or oedema in children.

The mortality risk of children with severe acute malnutrition is 5 to 20 times higher than that of normal children and may be a direct cause of death in children or may play an indirect role in rapidly increasing mortality risk in children with common illnesses, such as diarrhea and pneumonia.

This guideline applies to children who are 0-72 months of age.

II. Diagnostic criteria for acute malnutrition

Children who have 1 out of 2 anthropometric indicators, namely mid-upper arm circumference (MUAC) or weight-for-height (W/H), lower than the limits, shall be identified as having acute malnutrition.

1. Children with moderate acute malnutrition have the following symptoms:

- Anthropometric indicators

+ Mid-upper arm circumference: MUAC of between >115mm and 125mm (The diagnostic criteria based on MUAC only apply to children who are 6-59 months of age); or

+ Weight for height/length: W/H of between >-3 standard deviations (SD) and -2SD

- Clinical symptoms are often subtle and unnoticeable.

2. Children with severe acute malnutrition have the following symptoms:

- Anthropometric indicators

+ Mid-upper arm circumference: MUAC ≤ 115mm; or

+ Weight for height/length: W/H ≤ -3SD.

- Clinical symptoms: depending on the symptoms, one of the following may be encountered:

+ Kwashiorkor (edematous malnutrition)

- Nutritional oedema: Oedema begins in the lower extremities, then spread on the whole body. It is bilateral pitting oedema. Nutritional oedema is considered the diagnostic criterion for complicated acute malnutrition. It should be differentiated from oedema due to other causes (heart or renal failure...).

- The mid-upper arm circumference and weight-for-height may be normal.

- It usually occurs with digestive disorders or pneumonia.

- Skin pigmentation disorders: Red nodules appear in the groin, extremities, buttocks and around the anus of children. These nodules become red and dark patches and then peel off, leaving thin skin that is susceptible to infection, making the children’s skin become patchy.

- Malnutrition also manifests in other tissues and organs such as: osteoporosis due to calcium deficiency or vitamin A deficiency, or enlarged liver due to fatty degeneration, or heart failure due to protein deficiency.

- Subclinical symptoms: Hemoglobin decreased. Hematocrit decreased, blood protein decreased, pre-albumin decreased, sodium and potassium decreased. Blood sugar level decreased; Albumin/Globulin ratio reversed. White Head Index: non-essential amino acids/essential amino acids sharply increased (normally 0.8-2).

+ Marasmus (deficiency in calorie intake)

- Children lose all the subcutaneous fat on the face, buttocks and upper extremities, so they are very thin and emaciated with sunken eyes, dry skin and wrinkles like an old man.

- Children have symptoms of milder deficiencies of vitamin A, D, K, B1, B12...

- Children may lose their appetite.

- Subclinical symptoms: Hemoglobin decreased, Hematocrit decreased, blood protein decreased, pre-albumin decreased, blood sugar and electrolyte level changed.

+ Combined malnutrition: Children with clinical and subclinical symptoms of both types.

III. Guidelines for the treatment of acute malnutrition:

1. Classification of acute malnutrition

Based on the clinical conditions and anthropometric indicators of the children, they are:

- Inpatient treatment

- Outpatient treatment

- Maintenance/prophylactic treatment

Types of treatment shall be inter-changed or transferred to each other depending on the occurrence of complications as well as the severity of acute malnutrition (Figure 1). According to it, pediatric patients with acute malnutrition with complications shall be treated as inpatients at hospitals until the complications disappear (usually within 1 week), then will be transferred to the primary health-care facilities for continued outpatient treatment. When the criteria for discharge from outpatient treatment are met (usually after 6 to 10 weeks), the patients will be transferred to maintenance/prophylactic treatment for 2 to 4 months (see “Therapeutic procedures for acute malnutrition in children” in Appendix I).

* Integrated Management of Childhood Illness (IMCI) danger signs include: unable to drink or breastfeed; vomits everything; lethargic or unconscious; has had convulsions; stridor; chest indrawing pneumonia; severe dehydration; severe anemia.

** The MUAC-based diagnostic criteria only apply to children who are 6-59 months of age.

- Instructions on how to measure mid-upper arm circumference (MUAC) are provided in Appendix II

- The table of weight for height/length is provided in Appendix III

- For children who are less than 6 months of age, see “Inpatient treatment” section.

2. Sub-clinical tests:

- Routine screenings: complete blood count, electrolytes, liver and kidney function tests, protein/albumin/blood sugar, serum iron, ferritin and calcium tests.

- Tests to monitor and predict the disease: pre-albumin test, albumin/globulin ratio, White Head index: non-essential amino acids/essential amino acids.

- Diagnostic tests and tests of treatments carried out upon professional requests.

3. Treatment:

3.1. Inpatient treatment:

Inpatient treatment is for patients with acute malnutrition having complications or being worsen or failing to respond to outpatient treatment. Inpatient treatment is divided into 2 phases:

● Stabilization phase for children with acute conditions and severe injuries.

● Transition phase before transferring the patients to outpatient treatment.

Inpatient treatment is carried out in hospitals.

Persons responsible for such treatment are medical doctors.

Persons in charge of using and monitoring the use of nutritional products on children with malnutrition are nurses.

3.1.1. Admission criteria

3.1.2. Requirements for treatment

Organizational and operational factors that play an important role in determining the outcome of treatment for children with acute malnutrition include:

- Appropriately arranged environment: there is an isolation area for cases with high risk of infection, and clean toilets; room temperature is warm enough (28 - 32°C, no drafts).

- Clean area for preparation of therapeutic milk.

- Adequate equipment (scales; height/recumbent length measurers; mid-upper arm circumference measurers, milk and ReSoMal preparation tools) which are maintained and regularly checked/calibrated.

Clinical assessments must be done carefully, frequently and repeatedly to ensure that all health problems are detected and treated promptly.

- Maintaining records of children with malnutrition and identifying risk-of-mortality factors, including:

+ Unconsciousness (exhaustion/coma).

+ Convulsions.

+ Bradycardia.

+ Signs of shock with/without dehydration.

+ Hypoglycemia (< 3 mmol/l).

+ Hypothermia.

3.1.3. Treatment

* Stabilization phase

Common complications during this phase are: hypoglycemia, hypothermia, electrolyte disorders, infections, micronutrient deficiencies.

The purpose of this phase is to stabilize complications and initiate the use of appropriate treatment products.

It includes the following steps:

- Treatment/prophylaxis of hypoglycemia

- Treatment/prophylaxis of hypothermia

- Treatment/prophylaxis of dehydration

- Balance of electrolytes

- Treatment/prophylaxis of sepsis

- Treatment of micronutrient deficiencies

- Start giving therapeutic products with right doses.

Step 1: Treatment/prophylaxis of hypoglycemia

Treat hypoglycemia if it is present. Be careful when using intravenous sugar solutions.

Step 2: Treatment/prophylaxis of hypothermia

Make sure the child is warm (dressed in enough clothes, wrapped in a warm blanket or heater, or warmed by skin-to-skin contact between the child and the mother). Prevent the child from getting wet. Use the nutritional products immediately (see Step 7).

Step 3: Treatment/prophylaxis of dehydration

It is often difficult to assess dehydration in children with severe malnutrition. The use of intravenous fluid therapy shall be limited unless the child suffers shock, electrolyte disorder or hypoglycemia so that he/she cannot drink.

- WHO’s oral rehydration solutions (ORS) with a high concentration of sodium and low potassium is not suitable for children with acute malnutrition, so ReSoMal should be used instead.

Table 2. Composition of ReSoMal (WHO 1999)

If ReSoMal is not available, it can be mixed in the following way: 2 liters of water for 01 pack of ORS (standard ORS shall be mixed with 1 liter of water), added with 50g of sucrose and 45 ml of 10% potassium chloride (This preparation has 45 mmol of sodium and 40 mmol of potassium).

- Children should be rehydrated slowly, either orally or by nasogastric tube, with an amount of 5-10 mL/kg/h up to a maximum of 12 hours.

- Do not use ReSoMal in case of suspected cholera or watery diarrhea.

- How to give intravenous fluids to prevent shock in children with severe acute malnutrition:

When the child shows signs of shock, and is lethargic, unconscious or unable to drink, the preparation shall be given intravenously. One of the following preparations shall be used (chosen in order):

Ringer’s lactate solution with 5% dextrose; or half-normal 0.9% saline (NaCl) solution diluted with 5% dextrose; or half-strength Darrow’s solution with 5% dextrose or Ringer’s lactate. Dose: 15ml/kg/h. If there is no improvement: the diagnosis should be reconsidered because the child may have septic shock or other comorbidities.

Step 4: Adjusting electrolyte balance

F-75, F-100 or ready-to-use therapeutic food (RUTF) that contains sufficient potassium and magnesium.

If other nutritional products are used, they must be added with potassium (3-4mmol/kg/day) and magnesium (0.4-0.6 mmol/kg/day).

During the preparation of food, no salt shall be added, low-sodium oral rehydration solution (e.g. ReSoMal).

Step 5: Treatment/prophylaxis of sepsis

For children with severe acute malnutrition, common signs of infection such as fever are often found difficult to detect, so it is assumed that all children with severe acute malnutrition admitted to hospitals have infections and require appropriate antibiotic treatment.

Step 6: Treatment of micronutrient deficiencies

If children with severe acute malnutrition are treated with F-75, F-100, RUTF or equivalent therapeutic nutritional product that complies with WHO specifications (as specified in Appendix XI), the micronutrient deficiencies are resolved, so there is no need to add iron, vitamin A, zinc, folic acid, multi-micronutrients...

- Vitamin A

+ If the child has severe acute malnutrition and eye signs of vitamin A deficiency and/or recent measles (although the child is taking F-75, F-100, or RUTF): Provide high doses of Vitamin A (Children who are  0-6 months of age: 50,000 IU/time; Children who are 6-12 months of age: 100,000 IU/time; Children who are 1-6 years of age: 200,000 IU/time). The 1^st dose shall be given on day 1, the 2^nd dose on day 2, and 3^rd dose on day 15 (or on the child's discharge day)

+ If the child is not taking F-75, F-100 or therapeutic nutritional product that complies with WHO specifications, the child shall take daily supplements of 5000 IU or be given a high dose of vitamin A (50,000 IU; 100,000 IU or 200,000 IU, depending on age) on admission.

- Zinc

All children with acute malnutrition who have diarrhea should be given additional zinc supplements immediately so as to reduce the duration and severity of illness as well as the risk of dehydration. If the child is taking F-75, F-100, or RUTF, zinc supplements shall not be given. Otherwise, zinc supplements shall be given within 10-14 days as follows:

Children who are less than 6 months of age: 10mg of zinc/day.

Children who are more than 6 months of age: 20mg of zinc/day.

- Other micronutrients: Daily supplementation within at least 2 weeks if no specific therapeutic nutritional products are taken

+ Folic acid: 1 mg/day (Providing 5mg only on the first day)

+ Multi-micronutrients: Copper 0.3 mg/kg/day; Iron 3 mg/kg/day at the onset of stabilization and weight gain.

Step 7: Start giving therapeutic nutritional products

Therapeutic nutritional products shall be given with caution, yet as soon as possible. The goal of this step is to provide enough energy and protein to maintain the body's basic physiological activities and stabilize complications, reducing the risk of death. Do not expect too much weight gain of the child in this step. The use of F-75 (specified in Appendix V) is recommended and used according to the following basic principles:

Feed therapeutic nutritional products 8 times a day (about every 3 hours) even at night, with priority given to children who cannot eat for many days and those who are seriously ill or vomit a lot or have bowel movements.

If nighttime therapeutic feeding is found difficult to conduct, it is sometimes acceptable to feed therapeutic nutritional products 6 times a day.

* Transition phase

The purpose of the transition phase is to effectively manage the transition from the stabilization phase to the rehabilitation phase with sharp increase in nutritional intake. Be especially careful if this phase is done too quickly, it can lead to diarrhea and refeeding syndrome, which less frequently occurs but can cause acute renal failure and even result in sudden death.

Children are ready to be changed from the stabilization phase to the transition phase when:

Treatment during the transition phase depends on the child's response. It usually lasts from 2-3 days but can also be longer if the child is unwell. The therapeutic nutritional product used in this phase is RUTF (specified in Appendix VI) or F-100 (specified in Appendix VII). Gradually increase the volume by 10%/2 days until the child cannot use more, with an attempt to reach 100-135 kcal/kg/day. It is necessary to breastfeed the child before using therapeutic nutritional products.

- If RUFT is provided in the transition phase (following F-75 in the stabilization phase): there are two methods to change from F-75 to RUTF, as follows:

Method 1: Start feeding by giving RUTF as prescribed for the transition phase (100-135kcal/kg/day). Let the child drink water freely. If the child does not take the prescribed amount of RUTF, then top up the feed with F-75. Increase the amount of RUTF over 2-3 days until the child takes the full requirement of RUTF (150-220 kcal/kg/day, or 170kcal/kg/day on average). Do not give RUTF to children who are less than 6 months of age, or

Method 2: Give the child the prescribed amount of RUTF for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of RUTF in the first 12 hours, then stop giving the RUTF and give F-75 again. Retry the same approach after another 1-2 days until the child takes the appropriate amount of RUTF to meet energy needs.

- If F-100 (or equivalent products) is provided in the transition phase:

+ When the child is ready for the transition, replace F-75 with an equal volume of F-100 over at least 2 days. If it sees good progress, gradually increase the volume of F-100 to the full requirement (150-220 kcal/kg/day, or 170kcal/kg/day on average).

+ When the child is gaining weight rapidly with F-100, change to RUTF and see if the child can take the prescribed amount before transferring the child to outpatient treatment.

- Children who are transferred from outpatient care to inpatient care because of recent weight loss or failure to gain weight without serious medical complications can be immediately given RUTF if they have an appetite. Otherwise, the child must begin the stabilization phase with F-75.

- Children do not need to achieve the target weight (W/H = -2SD) while still in inpatient treatment. Nutritional and clinical rehabilitation can continue in outpatient settings. To ensure success, before transferring the child to outpatient treatment, the child’s use of therapeutic nutritional products should be monitored within at least 24 hours to ensure that the child does not have complications.

- Problems encountered during the transition phase:

+ If the child shows danger signs (Table 1), restart the stabilization phase, administer F-75 and provide necessary medical care.

+ If the child cannot take RUTF within 4-5 days, change to F-100 but continue to give RUTF to the child. If RUTF is not available or the child does not like to take RUTF, F-100 may be used instead because of their similar nutritional value.

For infants who are less than 6 months of age with acute malnutrition

- All infants who are less than 6 months of age with acute malnutrition shall be admitted to inpatient care

- The mothers or female caregivers should be supported to breastfeed the infants. If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate. If this is not possible, wet nursing should be encouraged;

- Infants who are less than 6 months of age should also be provided a supplementary feed:

o Infants who are less than 6 months of age should not be given the following feeds during treatment (in a priority order, use one kind of feed on combine it with breast milk): expressed breast milk, generic infant formula; or diluted F-100 or F-75 (specified in Appendix VII). Infants who are less than 6 months of age should not be given undiluted F-100 at any time (owing to the high renal solute load and risk of hypernatraemic dehydration);

o Infants who are less than 6 months of age with any pitting oedema should be given generic infant formula or F-75 (together with breastfeeding).

3.1.4. Criteria for discharge/referral

3.2. Outpatient treatment:

Outpatient treatment provides home treatment and rehabilitation for children who have acute malnutrition without complications. Outpatient treatment should be provided every week.

Outpatient treatment is performed mainly at the primary care level. On a case-by-case basis, outpatient treatment may be performed at another health-care facility suitable to the malnourished child's conditions.

Persons responsible for such treatment is medical doctors or physicians.

3.2.1. Criteria for admission

3.2. Treatment

- Other medications shall be supplemented depending on comorbidities of the children in accordance with other diagnostic and treatment guidelines.

- Use of antibiotics in the management of children with acute malnutrition in outpatient care (specified in Appendix VIII).

- Provide RUTF with a volume of 170 kcal/kg/day for nutritional rehabilitation.

+ Calculate the adequate amount of RUTF for the caregivers. The amount of RUTF is calculated based on the weight of the children and the time until the next use (specified in Appendix IX).

+ Advise the caregivers on RUFT nutritional therapy during the treatment of acute malnutrition (Appendix X).

- If the child is transferred from the inpatient treatment facility, evaluate the health status, health record and used medications to have appropriate treatment.

- Guide and counsel those directly caring for the children on medication management, the importance of adherence to treatment regimens, nutrition and home care. People who have infectious diseases should not be allowed to care for the children.

- Monitoring: Health workers at any health-care facility should collect and record the following information in the logbook and outpatient monitoring sheet during each visit:

+ Measuring weight and MUAC during every visit

+ Measuring weight/length on admission; on a monthly basis; and at the end of outpatient treatment (e.g. when the W/H reaches the prescribed deviations)

+ Recording medical history (in order to detect other diseases compared to the previous visit)

+ Conducting physical examination

+ Conducting appetite test with RUTF.

+ Determining the appropriate amount of RUFT and record it in the sheet of therapeutic nutritional products. Providing counselling and education on nutrition.

+ Asking caregivers to adhere to medications.

- Malnourished children need special attention if they present with one of the following signs/symptoms:

+ Weight loss after 2 consecutive visits (2 consecutive weeks).

+ No improvement of weight and health status after 3 weeks (same weight or poor weight gain).

+ The children not complying with treatment.

+ The children being transferred from inpatient treatment.

Children should be examined or visited at home to find out the causes in order to have appropriate treatment.

3.2.3. Criteria for discharge/referral

* Target weight is the weight when the W/H = -2SD

3.3. Maintenance/prophylactic treatment:

Maintenance/prophylactic treatment shall be applied to children with moderate, uncomplicated acute malnutrition or children with severe acute malnutrition after being discharged from outpatient care but requiring continued care. Replenish energy and nutrients that may be deficient in children's diets by teaching them to take ready-to-use supplementary food (RUSF) or nutritious foods at home within 2-4 months to gain the weight and health status that they are eligible for discharge from maintenance/prophylactic treatment.

Maintenance/prophylaxis treatment is mainly done at the primary health care level. The person responsible for treatment is a doctor or a physician.

3.3.1. Criteria for admission

* The MUAC-based diagnostic criteria only apply to children who are 6-59 months of age.

3.3.2. Treatment

Admission for such treatment is an opportunity for children to access other common medical care, such as vaccinations, vitamin A intake, and deworming.

It includes:

- Monthly weight measurement

- Length/height measurement every 3 months

- Adherence to instructions on therapeutic nutritional products.

- Counseling on health and nutrition for caregivers, especially on optimal infant and young child feeding, prevention and treatment of common diseases (diarrhea, acute respiratory infection), and nutrition for ill children.

- Monthly check-ups to provide therapeutic nutritional products and nutritional counselling

- Continued use of therapeutic nutritional products until the child's W/H exceeds -2SD and remains the same within the next 2 months.

3.2.3. Criteria for referral/end of treatment

IV. Prevention

Education and communication shall be promoted to improve nutritional care practices regarding mothers and children, including:

- Nutritional counseling and care for pregnant women and lactating mothers.

- Recommended breastfeeding: Early breastfeeding in the first hour, exclusive breastfeeding for the first 6 months, breastfeeding on demand.

- Recommended supplementary feeding, starting at 6 months of age and continuing breastfeeding until 2 years of age or older.

- Nutritional care for children with diseases and growth retardation.

- Sufficient supplements of iron/folic acid and prevention of anemia for women and children.

- Prevention of vitamin A deficiency in women and children.

- Use of iodized salt/seasoning for all family members.

- Full vaccination as scheduled

APPENDIX I

THERAPEUTIC PROCEDURES FOR ACUTE MALNUTRITION IN CHILDREN WHO ARE 0-72 MONTHS OF AGE
(Promulgated together with Decision No. …/QD-BYT dated …. )

APPENDIX IV

APPETITE TEST
(Promulgated together with Decision No. …/QD-BYT dated …. )

Appetite is essential for a child to be admitted to whether inpatient or outpatient treatment. Appetite is tested by feeding the child RUTF or equivalent nutritional products used to restore the child's nutrition.

Results of the appetite test:

- Have an appetite: A child who eats at least as much as the amount of RUTF shown in the moderate/good columns of the Table below is considered as having an appetite.

- No appetite: A child who does not eat at least the average amount of RUTF shown in the Table below should be transferred to an inpatient facility.

Table of the minimum amount of RUTF a child should take to pass the appetite test

Notes: If the caregiver or health worker believe that a child is refusing to take RUTF because the child does not like the taste of the food or is afraid, then it is also necessary to transfer the child to an inpatient facility for a short time. In that case, when starting giving F-75, try to perform the appetite test under better conditions. If it is found that the child is actually able to take enough RUTF to pass the test, the child should be transferred immediately to an outpatient facility.

APPENDIX V

Table determining volume of F-75 used in the stabilization phase of inpatient treatment
(Promulgated together with Decision No. …/QD-BYT dated ….)

* Most children are given 8 feeds a day by default. Severely weak children can be fed 2-hourly on admission.

** In some circumstances (e.g. no night staff) that 8 feeds a day (3 hourly feeds) may not be possible: Replace with the most optimal option - even so, the purpose is still to provide the weakest children with the most feeds.

APPENDIX VI

TABLE DETERMINING VOLUME OF RUTF USED IN THE TRANSITION PHASE OF INPATIENT TREATMENT WITHIN 24 HOURS
(Promulgated together with Decision No. …/QD-BYT dated ….)

APPENDIX VII

TABLE DETERMINING VOLUME OF F-100 USED IN THE TRANSITION PHASE OF INPATIENT TREATMENT
(Promulgated together with Decision No. …/QD-BYT dated …. )

The above table is the volumes of undiluted F-100 needed for malnourished children during the transition phase if the children do not take RUTF. They are usually given 6 feeds a day and should not eat at night.

Diluted F-100 for children under 3kg or children who are less than 6 months of age: Add 35ml of water to 100ml of reconstituted F-100 to get 135ml of diluted F-100.

APPENDIX IX

TABLE DETERMINING VOLUME OF RUTF USED IN OUTPATIENT TREATMENT
(Promulgated together with Decision No. …/QD-BYT dated …. )

500 kcal/92g packet of RUTF
(170 kcal/kg/day on average)

APPENDIX XI

THERAPEUTIC NUTRITIONAL PRODUCTS FOR CHILDREN WITH ACUTE MALNUTRITION
(Promulgated together with Decision No. …/QD-BYT dated …. )

Using therapeutic nutritional products for children is one of the important contents in the management and treatment of severe acute malnutrition. However, malnourished children have specific physiological conditions. They can have immunodeficiency, continue to be severely malnourished or even die if given the wrong foods. Therefore, children should be treated with special preparations for each phase of treatment, and at the same time, the regimen of using therapeutic preparations must be very cautious and closely monitored to ensure the volume and feeding approaches as instructed.

1. Therapeutic nutritional products used in hospital settings

The World Health Organization (WHO) has recommended 2 therapeutic nutritional products, F-75 and F-100, for treatment of children with severe acute malnutrition 1. Of them, F-75 is used during the stabilization phase and F-100 is used during the rehabilitation phase.

Requirements of F-75.

F-75 is a nutritional product to use during the stabilization phase (starter formula)2. The F-75 is specifically designed to meet the needs of the child without overloading the body in the initial phase of treatment. F-75 contains 75 kcal and 0.9g protein/100ml. With low protein and sodium content and high carbohydrate content, the formula is easily digested by children and provides most of the glucose needed by children. Using F-75 can prevent the risk of mortality in children with severe acute malnutrition.

Composition of F-75 (100ml)

Requirements of F-100

After the stabilization phase, the children begin to feel hungry and have their appetite. The requirement off therapeutic nutritional products in this phase is to help children rebuild lost tissues and make catch-up growth. The F-100 is designed to allow children to make catch-up growth (catch-up formula) as well as rebuild lost tissues. F-100 contains higher energy and protein content: 100 kcal and 2.9g protein/100 ml.

Nutritional composition of F-100

2. Therapeutic nutritional products used during community-based treatment

The World Health Organization (WHO) has recommended Ready-to-Use Therapeutic Food (RUTF) for treatment of children with severe acute malnutrition during the rehabilitation phase, especially under community-based management.

Requirements for therapeutic nutritional products used for children with severe acute malnutrition during community-based treatment:

Children with severe acute malnutrition need safe, palatable foods with a high energy content and adequate amounts of vitamins and minerals to help them rebuild lost tissues and continue to make catch-up growth during the rehabilitation phase. In addition, therapeutic nutritional products used during community-based treatment need to ensure food safety and hygiene, be easy to calculate the volume, and minimize supervision.

RUTF is a ready-to-use therapeutic diet with high energy and protein content, fortified with vitamins and minerals, especially designed for children with severe acute malnutrition, and developed since 1998. RUTF have a similar nutrient composition to F-100.

(Note: Although RUTF contain iron, F-100 does not; At least half of the proteins contained in the foods should come from milk products)

RUTF diets are made into paste or bars with a high energy density and are almost water-free, meaning that bacteria cannot grow in them. Therefore, these foods can be used safely at home without refrigeration and even in areas where hygiene conditions are not optimal. In addition, RUTF can be eaten without any preparation, thus avoiding the loss of vitamins and minerals as well as reducing preparation time. It is also particularly suitable in conditions where facilities and fuel for preparation are limited.