Hello, if you are unsure how to follow the guidelines/protocol used in the country you are working in then it may be useful to talk to one of your clinical colleagues who can guide you if you haven't already done this. When I was working in Malawi we used the Ministry of Health Guidelines for CMAM 2012. Based on each assessment and the needs of the child, the following guidelines on feeding management were used:
Ph 1- F75 for 1 or 3 days,
TR- F75 with RUFT (or F-100 if RUFT was not tolerated or the child refused to eat it) for 1, possibly 2 days. It was a difficult phase for the guardian as we encouraged to transfer to RUFT and therefore wean off from or discard F-75. The F-75 was kept in case the child did not tolerate RUFT. One problem was that some guardian tended to offer both and overload the child and made him/her sicker or to give F-75 first then the child would have no appetite for RUTF. Nursing support for the guardian through this phase was crucial. In some cases the child could not tolerate F-100 either so we then reverted back to F-75 and trying again 1 or 2 days later depending on how the child was stable medically. When RUFT was tolerated and accepted then we moved to... Ph 2- RUFT only, for 2 to 4 days.
Length of feeding management for each phase and length of stay in NRU depended on tolerance and child recovery from medical complications. Any new change in feeding management during morning round would be checked for tolerance during afternoon round. If not tolerated, then feeding management would be adapted.
Discharge to OTP was done with RUTF so child had to take RUFT for 1 to 3 days before being discharged. This was one incentive to encourage child to take it. We would always encourage child to drink clean water during or after eating the RUFT as the palatability was sometime an issue for some children.
I hope this helps. All the best.

Hello there,
I will not say this is it and that is that as the treatment protocols may differs from country to country and I don’t know which country protocol you are using now. But I do hope we will agree on the logic behind. The reason why we are providing low calorie diet (F-75) at the very early phase of the treatment is, to stabilize the metabolic system since we already knew that their internal system is not properly functioning. Once you done with your 1st phase treatment and ready to transit the child to the next phase which is transition phase, you need to make sure that the child is taking like a minimum of 75% of the total amount given per feed and the child is really improving. As to me, since most of the children admitted to inpatient are complicated cases I prefer to start with F-100 (I am not saying we cannot use RUTF we can use it for both transition and phase two which is OTP ) and gradually introduce them RUTF . The other option is to feed them alternately so that discharging to outpatient with RUTF will not be a problem.
When I come to your question, as you may know F- 75 cannot be used for transition phase. If the child still refusing high calorie diet (both F-100 and RUTF) you need to return the child to phase- 1 and assess the child for another medical complications which might need urgent action.

thanks

Hello again, I absolutely agree with Sinksar. It is a fine tuning management. The child should be kept on F-75 (Phase 1) until he is ready to be transferred to Transition phase and then Phase 2. The reasons indicated by Sinksar are absolutely right!