MODULE 4 
                                            FEEDING 
                                             
                                             
                                             
                                             
                                             
                                             
                                             
                                            Training Course on  
                                            Inpatient Management of  
                                            Severe Acute Malnutrition  
                                            (Adapted from the 2002 WHO Training course 
                                            on inpatient management of severe acute 
                                            malnutrition) 
                                             
                                            Children 6–59 Months with SAM 
                                            and Medical Complications 
                                             
                                            March 2012
                                                                                
                                       
                                       
          This modified version of the 2002 World Health Organisation’s Training Course on Inpatient 
          Management of Severe Acute Malnutrition (SAM) is the practical application of the 2010 
          MOH/GHS Interim National Guidelines for Community-Based Management of Severe Acute 
          Malnutrition in Ghana. The training course was modified by the MOH/GHS SAM Support 
          Unit in collaboration with the MOH/GHS Regional SAM Support Teams. USAID/Ghana, 
          FANTA-2 Bridge project, UNICEF/Ghana and WHO/Ghana provided technical and financial 
          support to review and modify the training course. This revised training course is made 
          possible by the generous support of the American people through the support of 
          USAID/Ghana and the Office of Health, Infectious Diseases, and Nutrition, Bureau for 
          Global Health, United States Agency for International Development (USAID), under terms of 
          Cooperative Agreement No. AID-OAA-A-11-00014, through the FANTA-2 Bridge, 
          managed by FHI 360. 
           
           
           
          Illustrations for modules: Susan Kress 
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                                                   
                               Ghana Inpatient Care Training Materials | Module 4. Feeding | March 2012 
                
               Contents 
               Acronyms and Abbreviations ..................................................................................................... i 
               Introduction ................................................................................................................................ 1 
               Learning Objectives ................................................................................................................... 2 
               1.  Prepare F-75 and F-100 Feeds and Learn about RUTF ....................................................... 3 
                       1.1.  Prepare F-75 and F-100 ......................................................................................... 3 
                       1.2.  Ready-to Use-Therapeutic Food ............................................................................ 8 
                       Exercise A ...................................................................................................................... 9 
               2.  Feed the Child with F-75 during Stabilisation ................................................................... 10 
                       2.1.  Determine the Frequency of Feeds ...................................................................... 10 
                       2.2.  Determine the Amount of F-75 Needed per Feed ............................................... 10 
                       2.3.  Record the Child's 24-Hour Feeding Plan ........................................................... 13 
                       2.4.  Feed the Child F-75 Orally or by Nasogastric Tube, if Necessary...................... 13 
                       2.5.  Record Intake and Output on a 24-Hour Food Intake Chart ............................... 15 
                       2.6.  Adjust the Child’s Feeding Plan for the Next Day .............................................. 19 
                       Exercise B .................................................................................................................... 20 
               3.  Feed the Child during Transition ....................................................................................... 29 
                       3.1.  Recognise Readiness for Transition .................................................................... 29 
                       3.2.  Transition Using RUTF (Introduce RUTF Slowly and Gradually) ..................... 30 
                       3.3.  If RUTF Cannot be Given, Transition Using F-100 Slowly and Gradually ....... 31 
                       3.4.  Monitor the Child Carefully during Transition ................................................... 32 
                       3.5.  Record Intake/Output and Plan the Child's Feeds for the Next 24 Hours ........... 32 
                       3.6.   Criteria to Move Back From Transition to Stabilisation Phase .......................... 32 
                       Exercise C .................................................................................................................... 34 
               4.  Feeding on RUTF or Freely with F-100 during Rehabilitation ......................................... 38 
                       4.1.  Feeding during Rehabilitation on RUTF ............................................................. 38 
                       4.2.  Feed Freely with F-100 during Rehabilitation .................................................... 38 
                       4.3.  Encourage the Child to Eat Freely at Each Feed ................................................. 38 
                       4.4.  Record Intake/Output; Determine if Intake of F-100 is Acceptable ................... 39 
                       4.5.  Adjust the Feeding Plan for F-100 as Necessary ................................................. 40 
                       Exercise D .................................................................................................................... 41 
               5.  Plan Feeding for Inpatient Care ......................................................................................... 47 
                       5.1.  Determine a Schedule for Feeding and Related Activities in Inpatient 
                            Care ...................................................................................................................... 47 
                       Exercise E .................................................................................................................... 50 
                       5.2.  Prepare a Daily Inpatient Care Feed Chart .......................................................... 52 
                       Exercise F..................................................................................................................... 54 
               TRAINING COURSE ON INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION                           
               Children 6–59 Months with SAM and Medical Complications 
                               Ghana Inpatient Care Training Materials | Module 4. Feeding | March 2012 
                
                       5.3.  Plan Staff Assignments Related to Feeding Children ......................................... 56 
                       5.4.  Prepare Staff to Do Assigned Feeding Tasks ...................................................... 56 
                       Exercise G .................................................................................................................... 58 
               6.  Management of SAM in Infants under 6 Months .............................................................. 59 
                       6.1.  Breastfed Infants under 6 Months of Age with a (Potential) Lactating 
                            Mother ................................................................................................................. 59 
                       6.2.  Infants under 6 Months without the Prospect of Breastfeeding .......................... 67 
                       6.3.  Infant and Young Child Feeding Support ........................................................... 73 
                       Summary of the Management of SAM in Infants under 6 Months of Age ................. 74 
               Annex A.  F-75 and F-100 Reference Tables .......................................................................... 75 
               Annex B.  Danger Signs for the Management of SAM in Children under 5 in 
                           Inpatient Care ......................................................................................................... 78 
               Annex C.  RUTF Reference Table and Key Messages ........................................................... 79 
               Annex D.  F-100-Diluted (and F-75) Reference Tables for Infants under 6 Months of 
                           Age ......................................................................................................................... 80 
               Annex E.   24-Hour Food Intake Chart .................................................................................... 82 
               Annex F.   Daily Inpatient Care Feed Chart ............................................................................ 83 
               Answers to Short Answer Exercises ........................................................................................ 84 
                
               TRAINING COURSE ON INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION                           
               Children 6–59 Months with SAM and Medical Complications