|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
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: briendatext.jussieu.fr (Andre' BRIEND)
Subject: Re: Ngonut: sodium levels in F-100
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 <refugeesatabdn.ac.uk>
Subject: Ngonut: sodium levels in F100
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
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