The Dual-Phase Approach to Therapeutic Feeding
The World Health Organization (WHO) protocol for treating severe acute malnutrition (SAM) uses a two-phase feeding strategy. It starts with F-75 for stabilization, followed by a transition to F-100 or Ready-to-Use Therapeutic Food (RUTF) for rehabilitation. Proper timing of this transition is vital for recovery.
The Stabilization Phase and the Role of F-75
F-75, providing 75 kcal per 100 ml, is used for the first 2 to 7 days of treatment. Its low osmolality, protein, and electrolyte content help stabilize the patient without overwhelming their system. This phase focuses on preventing hypoglycemia, correcting electrolyte imbalances, managing dehydration, and treating infections and hypothermia. Micronutrient levels are restored, but iron is typically withheld.
Key Criteria for Transitioning to F-100
Transitioning from F-75 to F-100 depends on several clinical indicators of recovery. These include:
- Return of Appetite: The child can and wants to eat, often confirmed by an appetite test.
- Resolution of Medical Complications: Acute illnesses are treated.
- Significant Reduction of Edema: Swelling decreases in edematous malnutrition.
- Clinical Improvement: The patient shows overall better alertness and stability.
The Transition Phase: A Gradual Shift
The switch is gradual, taking 2 to 3 days to help the patient adjust to the higher nutrient load. This involves slowly increasing F-100 (or RUTF) while decreasing F-75 until only the higher-energy formula is used. Total energy intake should be around 100–135 kcal/kg/day.
F-100 and the Rehabilitation Phase for Catch-Up Growth
F-100 (100 kcal and 2.9 g protein per 100 ml) is used in the rehabilitation phase for rapid weight gain, aiming for over 10g/kg/day. Its higher energy and protein help rebuild tissues. RUTF is often used instead of F-100 in inpatient settings due to convenience and safety.
F-75 vs. F-100: A Comparison Table
| Feature | F-75 | F-100 |
|---|---|---|
| Energy Content | 75 kcal/100ml | 100 kcal/100ml |
| Protein Content | 0.9 g protein/100ml | 2.9 g protein/100ml |
| Purpose | Initial stabilization | Rapid catch-up growth and rehabilitation |
| Treatment Phase | Phase 1 (Stabilization) | Phase 2 (Rehabilitation) |
| Duration | Typically 2-7 days | Used until recovery and discharge |
| Metabolic Impact | Low osmolality, low electrolytes to avoid overwhelming the system | Higher nutrient load to drive growth |
Important Considerations During Therapeutic Feeding
Successful feeding requires careful monitoring and adherence to protocols.
- Regular Monitoring: Daily weight and clinical signs tracking are crucial.
- Hygiene and Preparation: Strict hygiene is needed when preparing formulas.
- Outpatient Management: Uncomplicated SAM cases often use RUTF directly in CMAM programs.
- Breastfeeding: Encourage continued breastfeeding alongside therapeutic feeds.
Conclusion: Ensuring Successful Recovery
Knowing when to change from F-75 to F-100 is a key decision guided by WHO protocols. It marks the shift from metabolic correction to catch-up growth. This staged approach, with monitoring and hygiene, is vital for effective SAM treatment and recovery. The WHO Pocket Book of Hospital Care for Children offers detailed guidelines.
