Transition feeding of children 6–59 months of age with severe acute malnutrition
In children who are 6–59 months of age, severe acute malnutrition is defined by a very low weight-for-height/weight-for-length, or clinical signs of bilateral pitting oedema, or a very low mid-upper arm circumference. Severe acute malnutrition affects an estimated 19 million children under 5 years of age worldwide and is estimated to account for approximately 400,000 child deaths each year.
Severely malnourished children requiring inpatient care have medical complications and are generally unable to tolerate usual levels of certain nutrients such as proteins, fats and sodium. Thus, standard inpatient management of severe acute malnutrition involves two phases:
- initial stabilization when life-threatening complications are treated
- nutritional rehabilitation when catch-up growth occurs
F-75, a low-protein milk-based formula diet, is given as the therapeutic food in the stabilization phase, followed by a gradual transition over two days or so (transition phase) to F-100, a milk formula with higher protein and energy content, in the rehabilitation phase. Ready-to-use therapeutic food (RUTF) has replaced liquid F-100 in the rehabilitation phase in a variety of settings where severe acute malnutrition is treated. Most RUTFs are lipid-based pastes combining milk powder, electrolytes and micronutrients and offer the malnourished child the same nutrient intake as F-100, with the addition of iron.
Many treatment settings currently implement a transition phase of feeding, during which, the amount of the rehabilitation diet, namely F-100 or RUTF, is introduced in carefully restricted amounts for several days, until ad libitum feeding is introduced. However, the optimal approach to transition phase feeding is unclear from practice.
For children who are 6–59 months of age with severe acute malnutrition in inpatient settings where RUTF is provided as the therapeutic food in the rehabilitation phase (following F-75 in the stabilization phase), WHO recommends that once children are stabilized, have appetite and reduced oedema and are therefore ready to move into the rehabilitation phase, they should transition from F-75 to RUTF over 2–3 days, as tolerated.
The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend on the number and skills of staff available to supervise feeding and monitor the children during rehabilitation.
This is a summary of one of several WHO recommendations on the management of SAM in infants and children. The full set of recommendations can be found in 'Full set of recommendations' and in the guidelines and guidance documents under ‘WHO documents’ below.
Updates on the management of severe acute malnutrition in infants and children
Pocket book of hospital care for children: second edition. Guidelines for the management of common illnesses with limited resources
Other guidance documents
Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund
The treatment of diarrhoea: a manual for physicians and other senior health workers
Management of severe malnutrition: a manual for physicians and other senior health workers
Systematic reviews used to develop the guidelines
Systematic review of transition phase feeding of children with severe acute malnutrition as inpatients