HEM Fathia Abdalla 17.02.98
Re: HEM Michael Golden 17.02.98
WFP/UNHCR energy requirement estimates Colin Mills 18.02.98

from : Fathia_Abdalla_at_po330a01atsmtplink.unicef.org (Fathia Abdalla)


My name is Fathia I am a nutritionist. I would like to have your

opinion on giving F100 HEM to severely malnourished children <1 year

old. where I work now we face quite a number of severely malnourished

young children. Braestfeeding is not an option as many of them are

unaccompanied and there is very little supplementary feeding

available. Health workers give HEM to younger children too (diluted)

but as I know HEM is not tested for young children and it is low in

iron too so it might not be suitable the same for DSM so What is our

best available option?

Thanks a lot and hear from you

Sincerely, Fathia

Date: Tue, 17 Feb 1998 12:23:48 +0000

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: Ngonut: Re: HEM


Dear Fathia,

We used F100 type of formula extensively in children 6 months to one year with severe malnutrition in Jamaica, and it works in this age group as well as in the older children. Within ACF we have data from many hundreds of children between 6 and 12 months treated with F100 and again it is as good as in the older children.

FOR ALL severely malnourished children below about 4 kg we now dilute the F100 into 2.7 litres instead of 2.0 litres - which gives a formula with an energy density of about 75 kcal/100 ml. We do this because these children have a sufficiently high surface area to volume ratio, to make water the limiting nutrient in some circumstances. When diets of a higher nutrient density are given and there is a low humidity, high ambient temperature, high respiratory rate or fever the renal solute load can become to high and hypernatraemia can occur. This is particularly likely to happen in the Sahalian countries.

For SEVERELY malnourished children below 6 months we have also used the F100 (diluted) successfully for rehabilitation.

There are some important points to make however.

1) F100 is designed for the rehabilitation of severely malnourished children only. As such it will only be given to these children until they have recovered in weight-for-height which usually takes about 20 to 40 days. Thus, the diet is used for short term therapeutic use.

2) For those children who are rapidly growing IRON should be added to the diet when it is made up. The reason why iron was omitted from the formula is because many agencies use only F100 and have not yet started to use the special formula for the acutely sick malnourished child called F75 (this is used from admission until they regain their appetite and start to gain weight rapidly). The acutely sick severely malnourished child should never be given iron.

3) In some programs many children below 6 months are "classified" as severely malnourished on a weight-for-age basis when they are actually premature births and small-for-dates infants, rather than being post-natally malnourished. I have seen children who are doing well and catching up on breast milk being admitted and treated for "severe malnutrition" when they are "normal" premature births. Such children should not be admitted and treated as if they have post-natal severe malnutrition.

4) The other question - what should we feed to orphans and abandoned children below 6 months of age who are stunted but not wasted/ premature/ small-for-dates births and those who were wasted (low weight-for-height)?

I think that we need discussion on this point - I would favour feeding them as normal children. There was discussion on ngonut about this some time ago and the consensus agreed with a submission by Lola Nethanial from SCF-UK who advocated a priority list:

Mother's breast-milk

Wet nursing

Generic infant formula (without manufacturer's label - and labelling that indicates it is only for abandoned children etc with carefully controlled distribution)

Proprietary infant formula (used under the same conditions as above) Whole animal milk / F100 type diet

DSM formulated feeds.

However, there is still controversy about this aspect.

5) There is still a lot of difficulty about malnutrition in this age group even if we sort out these problems -

a) The EPI-INFO software that most use for calculating weight-for-height does not accommodate children of the height of most of these children so we cannot easily calculate weight-for-height (percentages or Z-scores) - this is a major problem.

b) The present US-based-standards are very misleading for this age group as they are based on bottle fed children who gained excessive adipose tissue and are heavier than normal breast-fed infants (so that a child may be diagnosed as malnourished when he is normal!). New international standards are being formulated but they are not yet available.

c) There is a major difference between % of the median and Z-score for this age group so the way in which the diagnosis is made is critical. To my knowledge studies of mortality have not been done in this age-group to see which is the most specific and sensitive way of expressing the data.

Claudine Prudhon found that % of the Median is better than Z-score for the severely malnourished child in a therapeutic feeding centre. This may have been because of the inclusion of children 6-12 months where the two indices differ.

d) Other measures such as MUAC are not useful in this age group

e) There are almost no survey data - nutritional surveys concentrate on the 6-59 month age groups and there is abundant data for these children under many circumstances. Because the <6month old is normally excluded we have little data on their status in most emergency settings.

Best wishes,

Prof. Michael H.N.Golden

Date: Thu, 19 Feb 1998 10:49:06 +0000

From: cfmatrri.sari.ac.uk (Colin Mills)

Subject: Ngonut: WFP/UNHCR energy requirement estimates


Dear Ngonuts,

A full account of the background that led the US Food and Nutrition Board to reccomend 2100 kcal / day for emergency situations ( see Andre Briend's e-mail 17/02/98 and ENN's excellent publication "Field Exchange" Jan,1998,p17) is published in the report:-

"Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations" editors Allen LH and Howson CP Food and Nutrition Board Institute of Medicine.2101 Constitution Ave,NW Washington,DC, 20418.

Prompted by USAID requests for guidance on how to deal with the many conflicting opinions on energy requirements this report, published in 1995, is not only readable but also gives enough detail to help in dealing with situations differing in age profile, general level of physical activity, environmental temperature etc.

In the HANSA Unit here in Aberdeen it has been used regularly when estimating desirable macro- and micronutrient inputs on an energy density basis for besieged communities in Bosnia,Chechnya and elsewhere.


Best wishes,Colin Mills

e-mail; cfmatrri.sari.ac.uk

phone. 0044 1224 868 761 . fax; 0044 1224 716687 .