Treatment

Recovery
Nutritional of Acute Malnutrition
Severe and Moderate without Complications
in the Patient

[Link] TREATMENT

A. General Guidelines for the Diet

Special attention must be paid to nutrition, not only because it occupies a place
central in nutritional treatment, but because inadequate diet
it can contribute to the death of the patient with acute malnutrition, particularly
in the first days of treatment.

For dietary treatment in the urgent phase, formulas must be used.

liquids that ensure the girl (or boy) the required protein and energy intake. If
if less than required is given, their malnutrition will worsen; if more is given, the girl(boy)
you can experience a severe metabolic imbalance.

General Guidelines for Starting Feeding

Start the dietary treatment as soon as possible,

when the conditions threatening life have been resolved
of the patient.

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Use a high-quality nutritional liquid formula as a base.
Increase those amounts slowly and gradually.
Administer food frequently and in small volumes,
both day and night.
Avoid fasting, even for a few hours.
Help the patient to eat, but without forcing them.
Continue with breastfeeding. If the patient is breastfeeding
mother must stay in the CRN to breastfeed him.
Supplement the diet with minerals and vitamins.
Do not give iron during the first week
Have patience and show affection to the child, especially to the
feed it.
Do not let the child eat alone, without supervision.
Involve the mother, other relatives, and caregivers in the
recovery of the boy or girl.
Evaluate the patient's progress every day.

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 2. Nutrition in the emergency phase of treatment (for boys and girls
coming from the community without any complications

The same liquid formula can be used for marasmic patients as for
kwashiorkor, paying special attention to the amount of proteins and energy. Table 2
presents examples of formulas that can be prepared depending on availability
food location. (Annex 3).

Table 2 LIQUID FORMULAS FOR NUTRITIONAL RECOVERY (for

the urgency phase of treatment), using different foods ¹

INGREDIENTS
Water
No. Food Cantidad Harina de maíz Azúcar Aceite until
Formula Principal (g ó ml) the rice g² (g) (ml) complete
ml
Milk in
1 dust 35 50 100 --- 1,000
integral
Milk in
2 dust 25 50 100 10 1,000
skimmed
Fresh milk
3 (fluid) 250 50 100 --- 1,000
integral

3
 Incaparina,
4 65 --- 100 15 1,000
flour
5 CSB flour 70 --- 100 10 1,000
Formulas
commercials
6 with protein 85 --- 75 --- 1,000
isolated from
soy, powder.
1. If precooked corn or rice flour is not available, it can be substituted by increasing the amount by 50%.
main food (for example, 52 instead of 35 g of powdered milk) and adding another 25 g of sugar or 10 ml of oil; to the
add more liquid milk, proportionally reduce the water to prepare a total volume of 1,000 ml.
2. If precooked corn or rice flour is not available, it can be substituted by increasing the quantity by 50% of the
main food (for example, 52 instead of 35 g of whole milk powder) and adding another 25 g of sugar or 10 ml of
oil; when adding more liquid milk, reduce the water proportionally to prepare a total volume of 1,000 ml.
Note: The formulas provide: 75 kcal/Kg and 1.3 g of protein/100 ml.

a. Diet management

The treatment should start with a liquid or semi-solid formula giving it

frequently and in small amounts to avoid vomiting and an overload of
intestine, liver and kidneys. To do this, the formula for one day will be divided into 8 to 12 portions.
of similar size, to be administered at intervals of 2-3 hours throughout the 24 hours
(see table 3 for reference of amounts according to the weight of the child).
should avoid fasting for more than 4 hours in all patients, to prevent hypoglycemia and
hypothermia. The volume of the formula should gradually increase according to progress
of weight gain and tolerance to avoid harmful metabolic alterations.

4
Most malnourished children have little appetite at the beginning of treatment. It is
It is necessary to have patience and encourage children to eat all the
foods in each meal, without forcing them and avoiding vomiting.

Whenever necessary, a cup and spoon should be used to give the formula.

A child should never be left in bed with food so that they

inquire on its own (without supervision)

Avoid the use of bags and straws as much as possible.

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 Table 3

Determination of the amount and frequency of formula to be administered in the phase of

urgency of the treatment

Formula volume per feeding time (ml) (contribution of 100kcal/kg/day)

Child's weight (every 2 hours) Every 3 hours Every 4 hours
Libras (12 doses) ml (8 doses) ml (6 shots) ml
4 pounds 20 30 45
0.5 pounds 25 35 50
5 pounds 25 40 55
5.1/2 pounds 30 45 55
6 pounds 30 45 60
6 ½ pounds 35 50 65
7 pounds 35 55 70
7 ½ pounds 35 55 75
8 pounds 40 60 80
8 ½ pounds 40 60 85
9 pounds 45 65 90
9 ½ pounds 45 70 90

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 10 pounds 50 70 95
10 ½ pounds 50 75 100
11 pounds 55 80 105
11 ½ pounds 55 80 110
12 pounds 60 90 120
12 ½ pounds 60 90 125
13 pounds 65 95 130
13 ½ pounds 65 100 130
14 pounds 70 100 135
14 ½ pounds 75 110 145
15 pounds 75 110 150
15 ½ pounds 75 115 155
16 pounds 80 120 160
16 ½ pounds 80 120 160
17 pounds 85 125 165
17 ½ pounds 90 130 175
18 pounds 90 135 180
18 ½ pounds 90 140 185
19 pounds 95 140 190
19 ½ pounds 95 145 195
20 pounds 100 145 200
20 ½ pounds 105 155 205
21 pounds 105 155 210
21 ½ pounds 110 160 215
22 pounds 110 160 220

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 i. Nutrition for the population aged 0-6 months

It is essential to ensure that the mother continues to provide exclusive breastfeeding,

supporting the technique of relactation. (Annex 4) as frequently as possible,
however, it is essential that the formula is given every 2 to 3 hours.

The WHO and UNICEF developed a list of acceptable medical reasons for the use of
substitutes for breast milk. This list for temporary or long-term use of
breast milk substitutes are available both as an independent tool
for health professionals working with mothers and newborns. (Annex 5)
Nutrition for the population of 6 to 24 months.

One should always continue breastfeeding and complement it

nutrition as indicated by the dietary guidelines for children under 2 years old.
Nutritional treatment (formulas) must be provided as a complement.
gradually with other foods, especially those that may be available in
the patient's home. Those foods should be prepared nutritionally, for example
combining cereals (corn, rice, wheat, oats, or products like bread, tortillas, pasta,
sorghum) with animal-based foods (powdered milk, cheese, eggs, chicken, beef
or pork, fish), or with legumes (beans, soy, chickpeas, peas). (Annex 7)

iii. Nutrition for population over 24 months

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 At the beginning of the treatment, girls and boys should be fed every 4
daytime and nighttime hours (6 intakes in 24 hours). Water consumption is not usually a
problem in children over 2 years old because they ask for it when they are thirsty. At this age their
The diet should be balanced, soft in consistency, and based on the Guidelines.
Food for Guatemala.

3. Nutrition during the treatment monitoring phase

The treatment should continue with any of the formulas that appear in the
table 5, prepared with locally available ingredients (Annex 8, of recipes for
prepare the formulas). The amount of formula in each dose is increased by 10 ml (per
For example, if the first dose is 60 ml, the second should be 70 ml, the third 80 ml and
so on and so forth).

When the child has not finished a serving, the same amount should be offered again.
next shot. If the shot runs out, the amount offered in the next shot must
increase by 10 ml. This process must be maintained until some formula is left
after most of the shots. From this moment on, this will be the amount that
Offer the girl (boy) in the following days. Any food that is not to be discarded.
consumed; it can never be used again for the next dose.
Table No. 5

Examples of liquid formulas for nutritional recovery (Monitoring phase of

growth), using different foods¹

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 INGREDIENTS
No. Food Amount Corn flour or Sugar Oil Water up to
Formula Principal (g or ml) rice g² (g) (ml) complete ml
1 Powdered milk, 90 50 100 --- 1,000
whole
2 Powdered milk 70 50 100 20 1,000
skimmed
3 Milk fresh 700 50 100 --- 1,000
(fluid), integral
4 Incaparina, 100 --- 100 30 1,000
flour
5 CSB flour 160 --- 100 --- 1,000
6 Formulas 190 --- 75 --- 1,000
commercials with
isolated protein
soy, powder.
1. Supplement these diets with syrups or drops of multivitamins and minerals at the recommended dose according to the patient's age, or
add 20 ml of the concentrated mineral solution and 150 mg of the vitamin mix described in the Unit to each liter of the diet
2 of the document on Management of the Malnourished Child (published No. MDE/107)
2. If precooked corn or rice flour is not available, it can be substituted by increasing the amount of the main food by 20%.
(for example, 108 instead of 90 g of whole milk powder) and adding another 25 g of sugar or 10 ml of oil; when adding more liquid milk,
proportionally reduce the water to prepare a total volume of 1,000 ml.
Note: The formulas provide: 100 kcal/Kg and 2.8g of protein/100 ml.

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This type of liquid formula should be maintained until the child is in a DE.
above -1 DE according to the weight for height graph. (Annex 2) and be prepared to
continue their feeding at home or on an outpatient basis.

B. Principles of Dietary Treatment

All treatment must be cautious, slow, and with permanent supervision, above all.
during the first days, which is when most patients who are die
treated inappropriately. Figure 6 shows the phases of the treatment.
nutritional, and table 7 the doses of micronutrients.

Table 6

Principles of Dietary Treatment

PHASES STAGE TYPE OF FREQUENCY OF

FEEDING FEEDING
Phase of 75 kcal/kg formulas Formula every 2 or 3
Initial phase emergency of weight. (see annex No. hours
3)
Formulas 100 cal/kg of Formula every 4 hours.
Phase
Monitoring phase weight (see annex No. 8). Food 3 to 5 times
rehabilitation Foods according to age. daily.

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 Table 7 Principles of Treatment with Micronutrients

MICRONUTRIENTS DURATION DOSAGE

First day 50,000 UI
2nd Day 100,000 UI
Vitamin A
2 weeks later 200,000 UI*
First day 5 mg
Folic Acid
From the 2nd to the 30th. 1 mg
From the second week until the
Iron 3 mg/kg
3 months.
Zinc Tablets 10 mg
1 over daily for 6
Micronutrients months from
From the 6th month to <5 years
Sprinkled the second week
of recovery
IMPORTANT NOTE: In case the child is referred from the hospital: before administering the
micronutrients, check if they have already received them. If the child is receiving Chispitas, do not administer.
multivitamin, neither iron nor folic acid.
In table No. 8 are the administration guidelines for vitamin A by age range.

C. Severe Vitamin A Deficiency

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 Patients with acute malnutrition usually have very low body reserves.
retinol deficiencies, even when there are no clinical signs of vitamin A deficiency.

When their tissue synthesis and growth increase in response to a dietary treatment.
suitable, the metabolic demands for vitamin 'A' also increase and the patient
It can develop eye lesions due to a lack of vitamin 'A'.

If there is eye inflammation or ulceration, the eyes should be protected with compresses.
soaked in 0.9% saline solution. Use tetracycline eye drops (1%) four times a day.
day until all signs of inflammation have been resolved.

Atropine eye drops (0.1%) should also be applied and the affected eye or eyes should be bandaged.

The vitamin dose is administered as indicated in table 8, except for girls and
referred children from the hospital:

Table 8

Administration and Dosage of Vitamin 'A'

Time Dosage
Day 1
Under 6 months 50,000 UI
6 to 12 months 100,000 UI

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 Over 12 months 200,000 UI
Day 2 Just like the specific dose according to age
At least 2 weeks later Just like the specific dosage according to age

D. Folic Acid, Iron and Zinc

Iron should be taken orally and never injected. Girls and boys with
moderate or severe anemia should receive iron, 3 mg/kg of body weight per day in two doses
divided into a maximum of 60 mg per day, for 3 months. It is preferable to administer
iron supplements between meals.

In addition, all girls and boys must continue to receive 1 mg of folic acid per day when
They come referred from the hospital. When they are not referred from the hospital, the first day in the
CRN should receive 5 mg of folic acid and then 1 mg per day. After the first phase has been completed
In emergencies, supplementation with 10 mg of Zinc daily is started.

(In the beginning or the first week, iron should not be administered to the child).

E. Use of Formulas F-75 and F-100

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 The F-75 and F-100 are therapeutic formulas specifically designed for the
treatment of severe acute malnutrition. The energy density of these formulas
corresponds to 0.75 Kcal/ml for F-75 and 1 Kcal/ml for F100.

The presentation is in packages of 410g. (F-75) and 458g. (F-100). The detail of the
Ingredients that make it up are presented in Table 1. They are low osmolarity formulas.
as indicated in table 1.

Table 1

Ingredients of the Therapeutic Formulas

F-75 F-100
Skimmed milk powder, fat Skimmed milk powder, fat
vegetable, sugar, maltodextrin, complex vegetable, whey,
vitamin and mineral maltodextrin, sugar, complex
vitamin and mineral.

1. Composición nutricional de las fórmulas F-75 y F-100

The detail of the nutritional composition per 100g and per 100ml.

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From reconstituted formulas to normal dilution, it is detailed in table 2.

Table 2

Nutritional Composition of Therapeutic Formulas

F-75 F-100
Nutrient Per 100g For 1000ml. Per 100g For 1000ml.
Energy 420Kcal 750Kcal 520Kcal 988 Kcal
Protein 5g (4.8%) 9g 15.3g (11.8%) 29g
Carbohydrates 74.07g (71.2%) 133.5g 45.8g (35.2%) 87g
Fats 11.2g (24%) 20g 30.6g (53%) 88g
Lactose ---- 18g ---- 42g
Sodium < 84mg < 150mg < 290mg < 550mg
Potassium 878mg 1570mg 1100 mg 2123 mg
Iron --- < 0.1 mg < 0.2mg 0.64 mg
Football 179mg 320mg 300 mg 579mg
Phosphorus 134mg 240mg 300mg 579mg
Zinc ---- 20.5mg 11mg 21.2mg
Osmolarity ---- 280mOsm/l ---- 320 mOsm/l

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 2. Prescription of Therapeutic Formulas

i.F-75: This formula is used in the emergency or initial phase of

treatment for recovery from severe malnutrition due to being low in
proteins, fats, and sodium but high in carbohydrates.

The urgent phase is estimated to last 5 days during which the objective of
Nutritional treatment focuses on initiating and attempting to stabilize oral intake.
This is considered concluded at the moment when the controls are applied.
vomiting and diarrhea, or when the first 5 days of treatment are completed.

Formula Calculation - For the whole day of F-75

Urgency phase or onset

The amount of formula that the child needs to take per day is calculated according to the child's weight in kilograms, by the following
formula:
Volume formula per day = Child's weight (Kg.) x 120 - 130 ml (see table 4)

Example:

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Girl weighing 7.0 kg
7.0 Kg. x 120 ml. Prepared formula = 840 ml. for the whole day, this is divided by 12 (it is
say consumption every 2 hours) = 70 ml. Therefore
Give 70 ml every 2 hours or 105 ml every 3 hours, in a cup with a teaspoon.
provided every 2 or 3 hours, for 24 hours.
For preparation: Each packet of F-75 contains 410 g, which is dissolved in 2 liters of water. (2000ml)

In marasmic childhood, it started with smaller volumes than childhood with edema.
Example:
If 20cc of formula is going to be given.
1 teaspoon (tsp) = 2.44 grams
1 tablespoon (tbsp) = 6.62 grams

410g of F-75 powder 2000ml of water X grams

20 ml.
X grams = 4.1 g of F-75 powder (table 3).

Table 3
Volume of water Grams of powder Approximate measurements
(in ml) F-75 (Tablespoon tbsp. or teaspoon tsp.)
20 4.1 2 ctas.
30 6.1 1 Cda.
40 8.2 3 cta.
50 10.2 4 cta.
60 12.3 1 spoon + 2 cups

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 70 14.3 2 Cda.
80 16.4 2 tablespoons + 1 teaspoon

90 18.4 2 Cda. + 2 cta.

100 20.5 3 Cda.
110 22.5 3 tablespoons + 1 teaspoon

125 25.6 3 tablespoons + 2 teaspoons

130 26.7 4 Cda.

140 28.7 4 tablespoons + 1 teaspoon.

150 30.7 4 spoons + 2 cups.

On the first day of treatment, the child's tolerance should be monitored, and efforts should be made to ensure they consume.
the amount calculated according to their weight. If the child takes less than the calculated amount, it
it will adjust the amount according to tolerance and will gradually increase until reaching
the desired. The formula should be administered in various forms every 2-3 hours day and night.
Table 4 VOLUME OF F-75 TO ADMINISTER BASED ON WEIGHT
The Boy and the Girl
The daily total can be 120ml/Kg. or 130ml/Kg. depending on the child's tolerance.

Weight of the child Volume of F-75 per intake (ml) Daily total
(kg) Every 2 hours Every 3 hours Every 4 hours (120 ml/kg)
(12 shots) (8 shots) (6 shots)
2.0 20 30 40 240
2.2 25 35 45 264
2.4 25 35 50 288
2.6 30 40 55 312
2.8 30 45 50 336

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3.0 30 45 60 360
3.2 35 50 65 384
3.4 35 50 70 408
3.6 40 55 75 432
3.8 40 60 80 456
4.0 40 60 80 480
4.2 45 65 85 504
4.4 45 70 90 528
4.6 50 70 95 552
4.8 50 75 100 576
5.0 50 75 100 600
5.2 55 80 105 624
5.4 55 80 110 648
5.6 60 85 115 672
5.8 60 90 115 696
6.0 60 90 120 720
6.2 65 95 125 744
6.4 65 100 130 768
6.6 70 100 135 792
6.8 70 100 135 816
7.0 70 105 140 840
7.2 75 110 145 864
7.4 75 110 150 888
7.6 75 115 150 912
7.8 80 120 160 936
8.0 80 120 160 960

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 8.2 80 125 165 984
8.4 85 125 170 1008
8.6 85 130 175 1032
8.8 90 135 175 1056
9.0 90 135 180 1080
9.2 95 140 185 1104
9.4 95 140 190 1128
9.6 100 145 195 1152
9.8 100 150 200 1176
10.0 100 150 200 1200

ii. F-100: This formula is used in the follow-up phase, or next one.
rehabilitation, in which a rapid weight gain is sought. The phase of
recovery begins immediately after F-75, that is, after the phase of
urgency or start.

The F-100 formula can last up to 25 days, or more, or when they arrive.
a normal nutritional status (between +2 and -2 SD) according to the growth charts
WHO annex 2.

For the first 2 days, the amount of F 100 to be prescribed to the child per day will be calculated from the
next way:

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Volume formula per day = Child's weight (Kg.) x 120 to 130 ml

Monitoring Phase:

Formula Calculation for the whole day of F-100

Volume formula per day = Child's weight (Kg.) x 120 - 130 ml.

If the child tolerates the formula well, a gradual increase will be made according to their tolerance.
child

For formula recalculations, the following scheme is suggested:

120-130ml/Kg/day, 150ml/Kg/day, 180ml/Kg/day, and so on, until reaching

200ml/Kg/day at most

Recalculation example:

Child weighs 7.0 kg

7.0 Kg. x 120 ml. Prepared formula = 840 ml. for the whole day Give 70 ml.
every 2 hours or 105ml. every 3 hours, in a cup with a spoon. Provided every
2 or 3 hours, for 24 hours.

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According to the patient's response, the increases may be more frequent in time or more.
aggressive. Once the child has consumed the assigned amount, they can take additional quantities.
extras on demand.

The formula should be administered during the day and night between meals. At this stage, the formula
it can be accompanied by complementary feeding according to the child's age and tolerance.
Special care must be taken to ensure that meal times do not coincide.
solids and formulas, as the child will choose between the two when they must consume both.

3. Preparation of Therapeutic Formulas

Preparation for normal dilution (F-75 = 0.75Kcal/ml and F-100 =

1.0 Kcal/ml.

To prepare the formula, dissolve a packet of formula F-75 or F-100 in two liters of
boiled, lukewarm or cold water and mix until there are no lumps. Each packet of formula
yields 2.3 liters of F-75 and 3.2 liters of F-100. (Table 5)

Special care must be taken in the use of clean and dry utensils, as well as in the
compliance with hygiene standards by the staff for preparing the formulas.

Preparation of F-100 at an energy density of 0.75, to be used in the phase of

transition from F-75 to F-100 in the treatment of severe malnutrition or in the first phase
of treatment in children who present mild or moderate malnutrition without complications.

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Table 5 presents a summary of the quantities needed to achieve the F-100
has an energy density of 0.75.

Table 5

Preparation of Formula F-100 to an Energy Density of 0.75

Amount in powder Amount in water Quantity in formula
1 on 2.8 liters 3.2 liters
½ about 1.4 liters 1.6 liters
¼ about 0.7 liters 0.8 liters

Preparation of therapeutic formulas in individualized treatments

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Table 6 shows the macronutrient contents in therapeutic formulas.
commercial measures.

Table 6
Macronutrient content of therapeutic formulas for commercial measures

Formula Measure Weight Kcal. Proteínas(g) Carbohidratos(g) Fats (g)

g)
Mead 4.39 18.44 0.22 3.28 0.49
F-75 Johnson
Abbott 9.80 41.16 0.49 7.32 1.10
Isocal 20.54 86.27 1.03 15.34 2.30
Mead 3.80 19.76 0.58 1.74 1.16
F-100 Johnson
Abbott 8.36 43.47 1.28 3.83 2.56
Isocal 17.96 93.39 2.75 8.22 5.49

4. Handling of prepared formulas

The prepared F-75 and F-100 formulas have a very short shelf life.
since due to their high nutritional value they decompose quickly.

They must be stored in a covered container and should not remain for more than 2 hours at
ambient temperature (especially in warm climates) or more than 8 hours in refrigeration.

25
The formulas must be refrigerated in a designated area for their handling, free
of food, biological samples or other types of contaminants.

5. Special recommendations

i. Expiration date: With proper storage, the formulas

therapeutics within the envelopes must last at least 18 months after the date of
manufacturing.

ii. Storage of therapeutic formulas: the warehouse must comply with

the following characteristics: cool, dry, clean, and safe place. The boxes must be
stored on pallets.

En los servicios de salud los sobres abiertos deben almacenarse bien cerrados
securing them with a clip, rubber, etc. Inside a clean and closed container (it can be
a can of milk). It is not advisable to empty the contents of the packet into another container.
Once the envelope is opened, it is recommended to use it as soon as possible.

iii. Other recommendations: The therapeutic formulas F-75 and F100 contain
lactose, so its management is contraindicated in cases of diagnosis or suspicion of
lactose intolerance. Likewise, they should be handled with caution in patients with
episodes of diarrhea or severe malabsorption problems. It is important to take into account
the following recommendations:

26
 The formulas do not replace the ORS or other rehydration methods.
The formula does not replace breast milk.
The formulas should be heated or warmed in a water bath, but
NEVER boil to avoid loss of vitamins.
If the formula is in the environment: it should be disposed of after two
preparation hours.
If the formula is in refrigeration: it should be discarded after eight
prepared hours.

F. Adequate Food Intake

For the girl (or boy) to consume adequate amounts of food, it is very important:
The attitude and behavior of the people who feed you or help you eat.
One must have patience and show affection. It should be insisted that the girl or boy
give him what is offered, but do not FORCE him to eat.

The appearance, taste, smell, and texture of food, prioritizing food.

with features that the child likes the most. It should be kept in mind that the
The likes and dislikes of adults are not necessarily the same as those of girls.
children (for example, most adults reject foods with globules of
floating fat, while the girls (or) accept them.)

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 VII. EVALUATION OF PROGRESS

Monitoring of the Nutritional Recovery of the girl and boy

It is necessary to weigh the girls and boys daily to assess their progress and development.
(Annex 14) and keep a record of the children admitted and discharged from the CRN
(Annex 15, 16). To do this it is necessary to

Weigh daily, an average weight gain of 30 is expected.

grams per day.
If you do not gain weight after reaching 250 kcal, investigate other causes (example:
septicemia, the formula is not taken, vomiting, diarrhea, etc.)
Quantify the volume ingested daily
•Take daily temperature curve, measure temperature as
at least twice a day, in the morning and in the afternoon.
Keep track of the number and type of evacuations and vomiting.
The presence of edema should disappear in the first 4-8 days of
dietary treatment, otherwise it should be investigated.
Observe that the child does not show signs of overeating.
(sweating while eating, tachycardia).

When boys and girls are found in the DE ranges above -2 D.E, they are discharged.
and you can continue with your diet in the community.

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 ANNEX Annex 3

Preparations of liquid formulas for nutritional recovery

(For emergency phase)

Recipe 1
Whole powdered milk as the main food
Ingredients
6 ½ level tablespoons of whole milk powder
½ cup of precooked corn flour (Maseca) or rice*
½ cup of sugar
Water to complete 1000 ml

Instructions
Add a cup of water to the powdered milk, stir with a fork, spoon, or whisk (blender if you have one)
until there are no lumps.
2. Add the milk to the pre-cooked corn flour and the sugar little by little and stir with a fork until everything is combined.
well mixed.
3. Finally, add the rest of the water gradually so that everything is well dissolved.

To make rice flour, the rice must be toasted over very high heat until it puffs, then it must be ground until it reaches a fine powder.
fine powder.

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 Recipe 2
Skimmed milk powder as the main food

Ingredients
4 ½ level tablespoons of skim milk powder
½ cup of precooked corn flour (Maseca) or rice*
½ cup of sugar
2 teaspoons of oil
Water until reaching 1000
mlInstructions:
1. Add a cup of water to the powdered milk, stir with a fork, spoon or
blender (if available) until there are no lumps.
2. Add the oil to the precooked corn flour, stir it until everything is mixed.
well mixed.
3. Add the milk to the precooked cornmeal and the sugar gradually and stir.
with a fork until everything is dissolved.
4. Add the rest of the water gradually so that everything is well mixed or
dissolved.

To make rice flour, the rice must be toasted over very high heat until it puffs up, then it must
to be pulverized until having a fine powder.

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 Recipe 3
Whole fresh (liquid) milk as the main food
Ingredients
1 cup of fresh whole pasteurized milk*
½ cup of precooked corn flour (Maseca) or rice**
½ cup of sugar
½ cup sugar
Water until reaching 1000 ml
Instructions:
1. Mix the precooked flour and the sugar in a container.
2. Add the milk to the flour and sugar, stirring with a fork, spoon, or
blender.
3. Add the rest of the water gradually so that everything is well mixed or
dissolved.
If the milk is not pasteurized, boil it for 10 minutes on low heat, constantly stirring without letting it
crusts form on the shores.
To make rice flour, the rice must be toasted over very high heat until it puffs up, then it must
pulverize until you have a fine powder.

Recipe 4
Incaparina as a main food
Ingredients
7 ½ level tablespoons of incaparina (flour)
½ cup of sugar
9 teaspoons of oil

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Water until reaching 1000 ml
Instructions:
1. Add the oil to the incaparina powder, stir it until well combined.
mixed.
2. Dissolve the incaparina in the water.
3. Put the incaparina dissolved in water into a pot, and bring it to a boil over medium heat.
until it boils and stir it constantly.
4. Let it boil for 10 minutes.
5. Once the incaparina is cooked, add the sugar and stir it.

Receta 5
Commercial formula with isolated soy protein as the main food ingredient
Ingredients
¾ cup of commercial formulas with isolated soy protein (powder)
6 ½ tablespoons of sugar
Water to complete 1000 ml

Instructions:
Mix the soy protein (powder) and the sugar in a pot.
2. Gradually add the water and stir it with a fork or whisk until no lumps remain.
This preparation does not require cooking.

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 Recipe 6
CSB flour as the main food
Ingredients
8 level tablespoons of CSB flour
½ cup of sugar
2 teaspoons of oil
Water until reaching 1000
mlInstructions:
1. Mix the flour and the oil in a pot.
2. Slowly add the water and stir it with a fork or whisk until it no longer
there are lumps.
3. Cook the mixture for 20 minutes over low heat
4. Once cooked, add the sugar and stir.

33
 Annex 4
Using relactation technique with supplement

34
35
36
 Annex 5

Acceptable medical reasons for the use of milk substitutes

maternal

CHILDREN'S AILMENTS

Infants who should not receive breast milk or other milk except formula.
Specialized

• Lactantes con galactosemia clásica: se necesita una fórmula especial libre de galactosa.
• Infants with maple syrup urine disease: a special formula free is needed
• of leucine, isoleucine, and valine.
• Infants with phenylketonuria: a special formula free of phenylalanine is required (some is allowed)
breastfeeding, with careful monitoring.

Newborns for whom breast milk is the best feeding option, but that
they may need other foods for a limited period in addition to breast milk

• Infants born with a weight of less than 1500 g (very low birth weight).
• Infants born at less than 32 weeks of gestation (very premature).
• Newborns at risk of hypoglycemia due to a metabolic adaptation disorder, or
increase in glucose demand, particularly for those who are premature, small for the
gestational age or have experienced significant intrapartum stress with hypoxia or ischemia,
those who are sick and those whose mothers are diabetic (5) if the blood sugar does not respond to
optimal breastfeeding or feeding with breast milk.

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 Annex 6
Food guides for children under 2 years old.

Age Recommendations
0-6 months Only breastfeeding both day and night on demand.
First give breast milk and then other mashed foods such as: tortillas, beans,
egg yolk, chicken, fruits and herbs and vegetables so that he learns to eat.
Give mashed foods such as: tortilla with beans, cooked dough with beans, rice
From 6 to 8 months
with beans, bread with beans because they strengthen him.
Add oil to the mashed foods because you like it and it gives you energy.
Serve the food on a plate or in a cup with a spoon.
Continue with breast milk and the previous foods.
9 to 11 months Add meat, chicken or beef liver, or pieces of fish.
Feed him three times a day on a plate.
From 12 to 60 months Remove all the foods that the family eats five times a day, according to
with family
•Delete every day: Grains, cereals or potato, herbs or vegetables and fruit. Tortillas and
beans; one tablespoon of beans for each tortilla.
Remove thick toppings.
At least twice a week an egg or a piece of cheese or a glass of
milk.
At least once a week, liver or meat.

38
 • I continued breastfeeding.
From 12 to 24 months continue with breastfeeding.
Take the child to the nearest health service for a follow-up.
regular (the first, second, and fourth weeks, then once a month for 6
months) and ensure that the child receives:
Vaccine boosters.
Vitamin A every 6 months according to age:
100,000 U.I. for 6-11 months and 200,000 U.I. for 12 to 59 months.
IMPORTANT Continue with iron and folic acid supplementation according to your age:
30 mg of ferrous sulfate for 6-18 months; 60 mg of ferrous sulfate 19-59
months; 5 mg of folic acid for 6-59 months.
Continue weight control (monthly for children under 2 years and every 2 months for those aged 2 to
under 3 years, every 3 months, from 3 to <5 years, every 6 months), so that the mother
know if the boy or girl is growing well or not.

Annex 7

Recipes for preparing vegetable mixtures for girls and boys older than six months

No. Ingredients Procedure

39
 1 1 tablespoon of ground bean Once the bean is cooked, it should be
and strained grind and strain, then sauté with
1 tablespoon of cooked rice half a teaspoon of oil, for
½ teaspoon of oil to be accompanied with rice.
2 2 tablespoons of white bean The bean must be cooked, then
with heat add a tablespoon of dough from
1 tablespoon of corn dough corn in the bean broth and
1 teaspoon of cream It should boil until the dough
it is cooked and served with a
teaspoon of cream.
3 2 Tortillas Undo the omelette in the broth of
1 tablespoon of cream beans and add a tablespoon
2 tablespoons of beans of cream.
4 4 tablespoons of ground beansBoil the banana and mash it.
and strained until does a nipple
¼ of cooked banana accompany it with strained beans and
1 tablespoon of cheese the melted cheese.
5 1 tortilla Prepare a scrambled egg with
1 tablespoon of ground beans a teaspoon of oil and
and strained accompany it with the beans
1 scrambled egg strained and the tortillas fallen apart.
½ teaspoon of oil
6 1 tortilla Accompany the strained beans
1 tablespoon of cheese with a tablespoon of cheese
1 tablespoon of strained and mashed beans with tortilla in
ground pieces.
*Note: If using these recipes for children over one year old, they should be prepared and given with whole foods.

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 Annex 8

Preparations of liquid formulas for nutritional recovery

(Monitoring phase)

41
 Recipe 1
Whole powdered milk as the main food
Ingredients
16 cucharadas rasas de leche en polvo entera
½ cup of pre-cooked corn flour (Maseca) or rice*
½ cup of sugar
Water to complete 1000 ml
Instructions
1. Add a cup of water to the powdered milk, stir with a fork, spoon or
blender until there are no lumps.
2. Add the milk to the precooked cornmeal and the sugar little by little and stir with a
fork until everything is well mixed.
3. Finally, add the rest of the water gradually so that everything is well combined.
dissolved.
To make rice flour, the rice must be toasted over very high heat until it puffs up, then it must...
pulverize until you have a fine powder.

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 Recipe 2
Skimmed powdered milk as the main food
Ingredients
13 level tablespoons of skim milk powder
½ cup of precooked corn flour (Maseca) or rice*
1/2 cup of sugar
2 teaspoons of oil
Water until reaching 1000
Instructions:
1. Add a cup of water to the powdered milk, stir with a fork, spoon, or
blender (if available) until it is smooth.
2. Add the oil to the pre-cooked corn flour, stir it until everything is well combined.
well mixed.
3. Add the milk to the precooked cornmeal and the sugar gradually and stir
with a fork until everything is dissolved.
4. Add the rest of the water gradually so that everything is well mixed.
dissolved.

To make rice flour, the rice must be toasted over very high heat until it puffs up, then it must be...
to be pulverized until having a fine powder.

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 Recipe 3
Whole fresh (liquid) milk as the main food
Ingredients
23 ½ ounces or 3 cups of fresh whole pasteurized fluid milk*
½ cup of precooked corn flour (Maseca) or rice*
1/2 cup of sugar
½ cup sugar
Water until reaching 1000 ml
Instructions:
1. Mix the pre-cooked flour and the sugar in a container.
2. Add the milk to the flour and sugar, stirring with a fork, spoon or
blender, until it has no lumps.
3. Add the water gradually so that everything is well mixed or dissolved.
If the milk is not pasteurized, boil it for 10 minutes over low heat, stirring constantly without
let crusts form on the edges.
To make rice flour, the rice must be toasted over very high heat until it puffs up, then
It should be ground until it has a fine powder.

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 Recipe 4
Incaparina as a main food
Ingredients
¾ cup of incaparina
1/2 cup of sugar
2 teaspoons of oil
Water until reaching 1000
Instructions:
1. Add the oil to the powdered incaparina, stir it until it is well combined.
mixed.
2. Dissolve the incaparina in the water.
3. Put the incaparina dissolved in water in a pot, and bring it to a boil over medium heat.
until it boils and stir it constantly.
4. Déjelo hervir por 10 minutos.
5. Then add the sugar and stir it.

Recipe 5
Commercial formula with isolated soy protein as the main food ingredient
Ingredients
1 ¾ commercial formula cup with isolated soy protein (powder)
6 ½ tablespoons of sugar
Water to complete 1000 ml
Instructions:
1. Mix the soy protein (powder) and the sugar in a pot.
2. Gradually add water and stir it with a fork or whisk until it is no longer
leave lumps.
This preparation does not require cooking.

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 Recipe 6 CSB flour as the main food
Ingredients
¾ cup plus 3 level tablespoons of flour CSB
½ cup of sugar
Water to complete 1000 ml

Instructions:
1. Gradually add water to the flour while stirring with a fork or whisk until no lumps remain.
2. Put the mixture in a pot and simmer for 20 minutes.
Add the sugar and stir.

Annex 14

Evolution of daily progress of the girls (boys) admitted to the Recovery Center

Nutritional

Nombre de la niña o niño: __________________________________Edad:______________

Referred: __________________________________________________________________

Moment Fecha Peso (kg) Talla Edema Nutritional status Profit Evacuation Observations
after the Cm (+, ++, (New standards weight it's per day
income +++) of Growth (g/day)

46
 OMS

Income
Monitoring
Monitoring
Monitoring
Monitoring
Monitoring
High
Mild edema
Moderate edema
Severe edema

Annex No. 15
Registration of Children Entered into the Nutritional Recovery Center

No. Date of Name of the girl or boy Sex Date Age Tall Foot Presents Edema State Origin Responsible
Income (M/F) of o a (+ ) Edema nutritional
status (kg) (cm level (new
not ) Edema standards of
moderate Growth
Edema P/T or L)

47
severe

48
 Annex 16
Registration of Girls (Boys) Graduated from the Nutritional Recovery Center

No. Date of Name of the Girl or Sex

Boy Date of Age Weight Size Nutritional status Observations*
Expense (M/F) birth kg (cm) (new standards of
Growth) P/T or L)

49
Note the conditions under which the child was discharged and where they were referred to:
C/S, Hospital, Outpatient Treatment, or if he/she went home

50
 Bibliographic References

World Health Organization. Breastfeeding, Review of the

experience and recommendations for practice. Geneva 1998.
World Health Organization. Treatment of malnutrition
grave. Manual for doctors and other healthcare professionals
superiors. Geneva. 1999.
Food and Nutritional Security Program. Protocol of
Treatment of Malnutrition at the Recovery Center
Nutritional. Guatemala, October 2001.
World Health Organization. Child Growth Patterns.
Geneva 2006.
World Health Organization, United Nations Fund in
Childhood. Acceptable Medical Reasons for the Use of Substitutes
from Breast Milk. Geneva 2009.
Ministry of Public Health and Social Assistance of Guatemala.
Health Care Standards. Guatemala 2009.