Sodium levels in F100
Sodium levels in F100 Janet-Marie Huddle 23.07.98
Re: sodium levels in F-100 Andre Briend 24.07.98
Sodium levels in F100 Mike Golden 31.07.98

Date: Thu, 23 Jul 98 11:42:00 UTC

Subject: Ngonut: sodium levels in F-100

From: Janet-Marie Huddle/CANO/WorldVision


In an effort to respond to our need for F-100 for use in emergency

settings, we have been working with a company to produce F-100. The

sodium level for 100g powder based on our calculations is 441mg/100g

dry powder. Will this level of sodium be too high for use with

severely malnourished children? When reconstituted the sodium

concentration would be 1102 mg/Litre of milk.

The maximum level of sodium in the UNCCS specs for F-100 is 290 mg/100

g powder.

Given that the sodium content of 100 g of skim milk powder is approx

500 mg, and skim milk powder forms the bulk of the product, how is it

possible to reduce the sodium content to 290 mg?


thanks for your input, jamo huddle

Date: Fri, 24 Jul 1998 10:44:42 +0200 (METDST)

From: (Andre' BRIEND)

Subject: Re: Ngonut: sodium levels in F-100


Dear Janet,

Skim milk powder does not make the bulk of F100 but only about 42 % of its

dry weight. Check your calculations +++. I suspect there is a mistake in the

formulation you are using.



Dr. Andre' Briend

Date: Fri, 31 Jul 1998 17:35:45 +0100

From: Michael Golden <>

Subject: Ngonut: sodium levels in F100


Dear Jamo,

Yes it does make a difference!

First: The intracellular sodium in all forms of malnutrition is high and,

of course, in oedematous malnutrition the extracellular sodium content is

also high. Brian Wharton showed a long time ago that children with the

sort of sodium intake that comes from "high protein diets" based upon DSM

is associated with heart failure and sudden death, particularly in children

with Kwashiorkor. Heart failure seems to be a particular problem in

Uganda, Burundi, Rwanda and Zaire, although we saw it in Jamaica as well.

John Patrick who was looking at the sodium pump activity described a series

of children with acute sodium associated heart failure. Champ Alleyne

described the effects of sodium infusion (overload) on renal sodium

metabolism and found that the children were unable to increase Na excretion

in response to an Na load. So there is a lot of evidence that these

children are sodium sensitive - it is one of the main reasons for having a

separate oral rehydration solution (ReSoMal) for these children.

Second: even the sodium content of F100 may be to high for the very ill

children when they are first admitted - this is one of the reasons why we

use F75 when the children are first admitted (the other differences between

F100 and F75 are a lower protein content because of the frequent gross

liver disturbance, a higher carbohydrate content because of hypoglycaemia

and a lower fat content because when first admitted many children have a

major fat malabsorption): Having an even higher sodium content than the

present F100 would make it unsuitable for a much higher proportion of the

children. Most of the energy in F100 comes from added fat/carbohydrate

precisely to limit the amount of sodium, iron (and to some extent protein)

that the malnourished child is given.

Third: there are manufacturing specifications for F100. If any product is

made which does not conform to these specifications then it cannot be

called F100. There is effectively one formula: if different manufacturers

change the ingredients to suit market prices of the commodities etc then we

will not know what the children are being given when the term F100 is used.

There is a modification of the original F100 where some of the sucrose is

replaced by dextrimaltose to reduce its osmolality - this is under test in

the refugee camps at the moment, but it should be much better theoretically

and preliminary results confirm this.

I am happy to send the specifications to anyone who requests them or to any

company who is planning to manufacture F100 (which accommodates the change

in osmolality).

Fourth: The formula for F100 is based upon over 30 years of research and

numerous balance experiments, mostly at the TMRU in Jamaica. The diets

were based upon DSM. Since I wrote the draft of the WHO manual, in 1992,

setting out the F100 formula ACF alone has treated about 120,000 patients

with this formula - when the other agencies experience is added we are well

over half a million patients. If the formula is to be changed (for example

substitution of whey protein concentrate for DSM) then it will have to be

formally tested against F100 in properly conducted trials before its use

could be advocated.

Fifth: There are other differences between WPC and DSM apart from the

sodium content. For example, phosphate deficiency is very common in severe

malnutrition and is strongly associated with mortality. One of the great

features of DSM is that it gives plenty of phosphate to replace this

deficit - Calcium also - this means that we do not have to add these

elements to the mineral/vitamin mix - if diets are based upon a different

basic ingredient then all the minerals and vitamins in it will need to be

matched with what we know works. The differences are not large in

Phosphate and calcium content of WPC and DSM - we do not know whether the

differences are important.

There are several products under development which are designed for use in

later recovery which do contain some WPC and these are being formally

tested against F100 - but the results are not yet available.

I hope that this helps - if you have any more detailed questions you could

ask the prospective manufacturer to contact me directly.


Prof. Michael H.N.Golden