By: Michele Goergen
Treatment of severe acute malnutrition without appetite and with medical complications requires specific therapeutic milks adapted to the delicate physiology of malnourished children less than 59 months of age. Use of these milks helps reestablish gut functionality while limiting the risks of refeeding syndrome or other complications.
Recently, there has been a change in packaging and production of these therapeutic milks. Now available in tins, therapeutic milks have improved taste and the milk is less likely to exhibit phase separation when reconstituted. The nutritional value of the milks remains the same. The improvements are due to the fact that producers use different ingredients for the formulation of therapeutic milks (skimmed milk powder rather than whey powder) and also the manufacturing process differs by spray drying. Once opened, therapeutic milk in tins will keep up to 4 weeks, unlike milk in the sachets which has to be used immediately. The new milk packaging will help reduce waste and contamination as was previously common when using milk in sachets.
Now that therapeutic milk in tins is starting to replace sachets in stabilization centers worldwide, it’s important to look at the challenges at health facility level to ensure its proper use, storage and administration.
On a recent deployment to the Kasai region of DR Congo, many of the stabilization centers had started to use the newly packaged milk with good results. Patients reported satisfaction with the taste and tolerance of the product and nurses appreciated that the milk could keep for four weeks and the ease of measuring individual doses.
There were, however, three main challenges identified when observing nurses prepare feeds using the newly packaged F75 and F100.
Challenge #1: Measurement
Though measurement instructions are clearly stated here there were still poor practices identified during measuring of the milk.
When preparing individual doses of the milk, nurses would often estimate, as opposed to measuring exactly, the amount of therapeutic milk that should be mixed with water for reconstitution. For example, if a child requires 120mL of F75, the appropriate measurement would be 5 scoops in 125mL of water. Once this is reconstituted, it should be dosed to 120mL and then given to the infant. In practice, nurses would measure 4 scoops of F75 plus ‘a little’ in 120mL of water. This practice can be dangerous to a malnourished child’s already delicate gastrointestinal system and be more difficult for the child to tolerate feeds. Proper measurement and dosage of milk should be emphasized during trainings on the new milk packaging with case studies for nurses to practice and avoid these errors.
Challenge #2: Similarity to infant formula
Many questions arose on the use of therapeutic milks in maternity for premature or failure to thrive newborns. This is most likely due to packaging similar to infant formula. However, alignment with the manufacturing standards of infant formula does not imply approval to use F75 and F100 as infant formula. Breastmilk is always preferred and prioritized. If infants less than 6 months meet the admission criteria for entry into a stabilization center, national nutrition protocols should be followed for the administration of therapeutic milks. The World Health Organization 2013 “Updates to the Management of Acute Malnutrition in Infants and Children” states in Recommendation 8, that priority should be given to breastfeeding support for infants with MAS and without edema; when this is not possible, commercial infant milks (generic) or F75 (case of edema) or diluted F100 can be administered alone or in addition to breast milk.
Challenge #3: Disposal of the tins
Though it is not recommended to reuse the tins, it is common practice to reuse containers to store food and other items, even for selling in markets. This poses a great danger as any type of milk, medicine, flour or formula can be put in the therapeutic milk containers and mistaken for infant formula. Because of this, it is forbidden to reuse the tins. Each country needs to determine an appropriate recycling or disposal method for the tins that is agreed upon by all partners and communicated to all health facilities. Communication and messaging should be developed with clear disposal methods and reasons why reusing the tins could pose risks if mistaken for formula.