1. 27-11-14

2. Severe Acute Malnutrition (SAM) is defined as  Bipedal pitting oedema of nutritional origin And/or  Severe wasting – indicated by weight for height < -3SD or

3.  SAM is increasingly being recognized in infants who are < 6 months of age(1)  In addition to aetiologies such as low birth weight, persistent diarrhoea and recurring sepsis or chronic underlying diseases or disability, the development of SAM in this age group commonly reflects suboptimal feeding practices, especially breastfeeding practices.

4.  Infants who are < 6 months of age should be exclusively breastfed to gain optimal nutrition  Yet, rates of exclusive breastfeeding worldwide remain disappointingly low, with only an estimated 25–31% of infants who are 2–5 months of age being exclusively breastfed (2)

5.  Risk factors for increased mortality are likely to include recent weight loss, failure to gain weight, failure to feed effectively and the presence of bilateral oedema (3)  To date, management of SAM in this age group has focused on establishing, or re- establishing exclusive breastfeeding, and, use of formula feeds and early introduction of complementary foods to treat these infants, when breastfeeding is not possible(3)

6.  Poor feeding practices  Poor breastfeeding counselling and support  Wrong advice concerning PMTCT- stop breastfeeding and supplement with formula Formula that is;  Wrongly constituted  Constituted with poor hygiene Diarrhoea

7.  Early weaning Mother unwell Mother pregnant (poor child spacing) Introduction of Cow`s milk, supershake, maheu, water,tea  Co-morbidities CP Hydrocephalus HIV, trisomy 21 with cardiac complications

8.  Manual for Management of Severe malnutrition was published in 1999 and 2000  However, these were not developed with active consideration to infants <6 months.

9. 1. Treat and prevent hypoglycaemia 2. Treat and prevent hypothermia 3. Treat and prevent dehydration 4. Treat and prevent infection 5. Correct electrolyte imbalances

10. 6. Correct micronutient deficiencies 7. Start cautious feeding – F75 8.Promote Catch-up growth –F100 9. Emotional and sensory stimulation 10.Prepare for discharge and follow-up

11.  Before 6 months of age, physiological processes, thermoregulation and renal and gastrointestinal functions, are relatively immature and may require modified management approaches or clinical interventions.  Clinical signs of infection and hydration status may also be more difficult to identify and interpret in the younger infant. As a result, criteria for admitting and discharging infants with SAM have not been adequately defined.

12.  Weight-for-length less than –3 Z-score, or presence of bilateral pitting oedema;even without complications  Infants with poor weight gain and who have not responded to nutrition counselling and support (IMCI)  Infant with a general danger sign as defined by the IMCI

13.  Medical complications  weight loss or failure to gain weight;  ineffective feeding (attachment, positioning and suckling)  any medical or social issue needing more detailed assessment or intensive support (e.g. disability, depression of the caregiver, or other adverse social circumstances)  (strong recommendation, very low quality evidence)

14. OBJECTIVES To review management of;  Severely malnourished infants aged <6months  Severely malnourished children living with HIV/AIDS

15.  The Consultation by WHO reaffirmed that the 10- step approach does apply to these young infants, but that consideration needs to be given to the type of feed and volume given. Guidelines advise  F75 – stabilisation phase  F100 – rehabilitation phase Potential renal solute load of these and other formulations was focus of discussion.

16.  PRSL refers to solutes of dietary origin that would need to be excreted in the urine if none is diverted into new tissue or lost through extrarenal routes  Sum of dietary nitrogen (mmol of urea), sodium, potassium, chloride, and available phosphorus

17. TYPE OF MILKESTIMATED PRSL(mOsmol/L) Human milk93 Infant formula135-177 F75154 F100360 Diluted F100238

18.  Parenteral antibiotics  Treat other medical complications such as TB, HIV, surgical conditions or disability;  Prioritize establishing, or re- establishing, effective exclusive breastfeeding by the mother  Should also be provided a supplementary feed: Infant formula, F75 ( with oedema)

19.  SAM with no oedema to be given diluted F100  Should not be given undiluted F100

20.  A randomized controlled trial in the Democratic Republic of the Congo (37, 162) recruited 161 infants who were less than 6 months of age with SAM - weight-for-length less than 70% of the median NCHS reference values, and who did not have oedema.  However, infants who were not gaining weight at home or were too weak to breastfeed, or where the mother reported an inability to breastfeed, were also included.  Infants were randomized to receive either diluted F-100 therapeutic milk (73.11 kcal/100 mL) or an isocaloric standard generic infant formula milk (76.7 kcal/100 mL).

21.  Infants were otherwise given the same treatment, which included support for continued breastfeeding, supplemental suckling when needed and vitamins, folic acid and antibiotics. The volumes of dilute F-100 or generic infant formula milk supplement were decreased by half when the infant was gaining at least 20 g/day for three consecutive days and were completely stopped when the infant maintained 10 g/day weight gain.  No differences were found in weight gain, total duration of treatment, or treatment outcome (death, recovery or default).

22.  Exclusively breastfeeding  Medical complications and oedema have resolved  Good appetite  Weight gain  Checked for immunizations  Linked to out- patient and follow up centre

23.  Breastfeeding effectively or feeding well with replacement feeds  Have adequate weight gain, and  Weight-for-length ≥–2 Z-score. (strong recommendation, very low quality evidence)

24. NUTRIENT FACTORBREAST MILK CONTAINSFORMULA CONTAINSCOMMENT Fats Rich in brain-building omega 3s, namely DHA and AA -Rich in cholesterol -Nearly completely absorbed -Contains fat-digesting enzyme, lipase -No DHA -Doesn’t adjust to infant’s needs -No cholesterol -Not completely absorbed -No lipase Fat is the most important nutrient in breastmilk; the absence of cholesterol and DHA, vital nutrients for growing brains and bodies, may predispose a child to adult heart and central nervous system diseases.

25. BreastmilkFormulaComment Protein-Soft, easily-digestible whey Lactoferrin for intestinal health -Lysozyme, an antimicrobial --Rich in growth factors -Contains sleep- inducing proteins -Harder-to-digest casein curds -Not completely absorbed, more waste, harder on kidneys -No lactoferrin, or only a trace -No lysozyme -Deficient or low in some brain-and body- building proteins -Deficient in growth factors -Does not contain as many sleep-inducing proteins. Infants aren’t allergic to human milk protein.

26. BreastmilkFormulaComment Carbohdrates-Rich in lactose -Rich in oligosaccharides, which promote intestinal health -No lactose in some formulas -Deficient in oligosaccharides Lactose is considered an important carbohydrate for brain development. Studies show the level of lactose in the milk of a species correlates with the size of the brain of that species.

27. BreastmilkFormulaComment Immune Boosters-Rich in living white blood cells, millions per feeding -Rich in immunoglobulins -No live white blood cells-or any other cells. Dead food has less immunological benefit. -Few immunoglobulins and most are the wrong kind When mother is exposed to a germ, she makes antibodies to that germ and gives these antibodies to her infant via her milk.

28. BreastmilkFormulaComment Vitamins and Minerals -Better absorbed, especially iron, zinc, and calcium -Iron is 50 to 75 percent absorbed. -Contains more selenium (an antioxidant) -Not absorbed as well -Iron is 5 to 10 percent absorbed -Contains less selenium (an antioxidant) Vitamins and minerals in breast milk enjoy a higher bioavailability-that is, a greater percentage is absorbed. To compensate, more is added to formula, which makes it harder to digest.

29. BresatmilkFormulaComment Enzymes and Hormones -Rich in digestive enzymes, such as lipase and amylase -Rich in many hormones: thyroid, prolactin, oxytocin, and more than fifteen others -Varies with mother’s diet -Processing kills digestive enzymes -Processing kills hormones, which are not human to begin with -Always tastes the same Digestive enzymes promote intestinal health. Hormones contribute to the overall biochemical balance and well- being of baby. By taking on the flavor of mother’s diet, breastmilk shapes the tastes of the child to family foods.

30.  Breastmilk is the preferred food for young infants, although in HIV-affected populations decisions about breastfeeding are complex.  In AO7, our aim is to discharge infants < 6months on exclusive breastfeeding

31.  Need to conduct observational studies and comparable randomised trials of alternative formulations in the management of SAM in children < 6 months.

32.  1. Kerac M et al. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch. Dis. Child. 2011;96:1008–13. 156  2. Black R et al. Maternal and child undernutrition and overweight in low-income and middleincome countries. Lancet, 2013;382:427–51.  3. Briend A, Maire B, Fontaine O, Garenne M. Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern. Child Nutr. 2012;8:130–3.

33.  4. Department of Child and Adolescent Health and Development, World Health Organization. Management of the child with a serious infection or severe malnutrition. Guidelines for care at the first-referral level in developing countries. Integrated Management of Childhood Illness.Geneva: World Health Organization; 2000 (WHO/FCH/CAH/00.1).  Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health Organisation,1999.  Severe malnutrition: Report of a consultation to review current literature 6-7 September 2004