Menu ENN Search

Treatment of severe malnutrition in Tanzania - a problem with ‘scoops’

By Chloe Angood

Chloe Angood has an MSc in Public Health Nutrition and a BA and MA in International Development Studies. She works for the International Malnutrition Task Force, at the Institute of Human Nutrition at the University of Southampton. In the past she has worked for various NGOs, including Viva Network, with whom she spent several years working in Sub-Saharan Africa. Chloe has also worked for ENN on the Infant Feeding in Emergencies programme.

The author would like to acknowledge the hard work of local staff at Muhimbili National Hospital, Morogoro Regional Hospital and Amana District Hospital reflected here. In particular, the author would like to mention Dr Mary Azayo, Dr Jesse Kitundu and the nurses at Makuti B, Makuti A and the general paediatric complex at Muhmbili National Hospital. The author would like to acknowledge the Tanzania Food and Nutrition Centre and WHO Tanzania Child Health Team who are spearheading the work in Tanzania. The author would also like to acknowledge the supervision and support of Professor Ann Ashworth, of the London School of Hygiene and Tropical Medicine and Professor Alan Jackson and Dr Penny Nestel, of the Institute of Human Nutrition at the University of Southampton.

A group of nurses learning how to make F75 and F100

This article describes practical problems in preparing therapeutic milk in a hospital-based setting and makes some suggestions to resolve them.

It is estimated that 3% of children under 5 years are severely wasted in Tanzania1. Severe malnutrition with complications requires inpatient management2. As adequate structures do not yet exist in Tanzania to provide community-based care, uncomplicated cases are also currently treated as inpatients. Significant efforts have been made in recent years by UNICEF, the World Health Organisation (WHO), the Tanzania Food and Nutrition Centre (TFNC) and the Paediatric Association of Tanzania (PAT) to build the capacity of inpatient facilities in Tanzania to manage severe malnutrition. These efforts have included training of selected health staff by WHO and UNICEF and the supply of F75, F100, Plumpy'nut®, weighing scales and length boards to 11 inpatient facilities by UNICEF since October 2006.

In April 2007, a follow-up visit was made on behalf of the International Malnutrition Task Force (IMTF), in association with WHO/UNICEF and the Royal College of Paediatrics and Child Health, to assess progress, particularly at Muhimbili National Hospital (MNH). It was found that although the WHO and UNICEF training had improved doctors' knowledge and prescribing practices at MNH, training had not been adequately transferred to nurses delivering care and the quality of care remained unsatisfactory. The case fatality rate at MNH for October 2006 to April 2007 was 33%.

Programme to improve the inpatient treatment of severe malnutrition in Tanzania

Training in Action

The author, working with University of Southampton and IMTF, was subsequently invited to Tanzania for 6 months to help improve the treatment of severe malnutrition and to support MNH staff through a programme of task-oriented training and supervised practice. This activity was conducted in collaboration with the Child Health Team of WHO Tanzania. Working closely with a paediatrician from MNH, a fourphase programme was developed, described in Figure 1. Input and advice was also received by other staff members of MNH, PAT, WHO, the IMTF and University of Southampton. Parts of the programme were subsequently tested at the regional level, at Morogoro Regional Hospital, where the case fatality rate for February to March 2007 was 50%, and at the district level at Amana District Hospital, with an estimated case-fatality rate of 36%. The knowledge and skills of nurses greatly improved following the training and there were many positive changes in practice at each of the three hospitals.

Preparation of F75 and F100 on the wards

In all three hospitals, UNICEF Tanzania provides boxes of Nutriset-produced F75 and F100 sachets. The sachets are a considerable advantage to staff, as they make feeds easy to prepare and provide children with micronutrients that are otherwise difficult to obtain in Tanzania. To make up one sachet of either F75 or F100, 2 litres of water should be added, to make 2.4 litres of feed. However, in most wards visited, only a few cases of severe malnutrition are treated at any one time, usually two to four children. Furthermore, there is usually no refrigerator, so fresh feeds must be made up every 3 to 4 hours. Therefore making up one whole sachet of F75/F100 (2.4 litres) each time leads to considerable wastage. With a limited country supply of F75 and F100 sachets available, this system is unsustainable.

Feed preparation instructions on the wall in one hospital before the training - these are copied from the Nutriset instructions

To avoid wastage, nurses prefer to make up only the volume of feed required on the ward every 3 hours. In the absence of dietary weighing scales, scoops are a practical way of measuring the right amount of F75/ F100 powder to make up feeds. Nutriset provides a packet of small red scoops inside each box of F75 and F100 to help with exactly this problem. These scoops measure approximately 4g of F100/ F75 powder. The instructions that come with the scoops instruct users to add 20ml water to one scoop of F75 and 18ml water to one scoop of F100. This is potentially a very helpful solution for nurses. However, in practice, the use of these scoops throws up problems.

Problems with the Nutriset 'red scoop'

The following problems were observed in the application of these instructions in Tanzania:

  1. Children are commonly overfed F75. The final volume of 'made up' F75 or F100 is not stated. Nurses commonly assume that the final volume is the same as the volume of water added (e.g. 20ml when making F75, when, in fact, the final volume is 20% higher, i.e. 24ml). If a child is prescribed 100ml F75, nurses using this system will commonly feed the child 120ml. This puts the child at risk of fluid overload.
  2. Nurses find it difficult to calculate the number of scoops to use for different feed volumes. For example, if a child requires 80ml of F75, the nurse must divide 80ml by 24ml to find the number of scoops of powder to use. The answer is 3.3, which must be rounded to 4 scoops. The nurse must then calculate how much water to add by multiplying 4 by 20ml (which is 80ml water). The maths skills of the nurses encountered were generally quite low and all found this calculation to be very complex. Calculations were frequently wrong, leading to risk of either fluid over load (if too much F75 is given) or hypogly caemia (if too little F75 is given). To avoid this calculation, a table is needed showing the volume of water to add to 1, 2 3 scoops etc., and the final volume of reconstituted F75 or F100. But Nutriset does not indicate this final volume per scoop, and so the table is difficult to create.
  3. Miscounting of scoops: When making up feeds, it is very easy to miscount the number of scoops when the number required is above 5. This happens when feed volumes are in excess of 100ml, which is very common. This means that it is all too easy to reconstitute feeds incorrectly.
  4. Difficulties of making up feed for several children: The red scoop is too small when there are more than 10 severely malnourished children, all feeding 2 or 3 hourly. Larger quantities need to be prepared which requires a larger scoop. The big challenge with this method is finding an accurate measure of one quarter/one half of a sachet.

Possible solution to the problem of 'scoops'

The reorganised feeding station with new, clear instructions, after the training

A meeting of the partners was held in October 2007, including representatives from Muhimbili National Hospital, Morogoro Regional Hospital, Amana District Hospital, TFNC, WHO Tanzania, Muhimbili National Hospital, the IMTF and University of Southampton. The above issue of scoops was discussed. It is very difficult to source ready-made, calibrated scoops in Tanzania. Much research was done during the 6 months and no satisfactory solution was found. The possibility of sourcing or making better scoops in Tanzania was considered by the partners, but quickly dismissed due to technical and resource constraints. Instead it was felt by the group that Nutriset should consider adapting the existing red scoop to something more useful that could have international applicability. Specifically, the group would like to request the following from Nutriset:

  1. Much clearer instructions that avoid confusion and miscalculations and that explain how much water to add to each red scoop and the resulting volume of feed. Instructions could include a chart of precalculations for 1, 2, 3 scoops, etc.
  2. A scoop that accurately measures one quarter of a sachet (perhaps a blue scoop for F100 sachets and an orange scoop for F75 sachets to co-ordinate with respective box and sachet colours) with clear instructions that explain how many scoops to use, how much water to add and the resulting volume of feed (instructions should detail how to make one quarter and one half of a sachet).

For more information, contact: Chloe Angood, Institute of Human Nutrition, University of Southampton,

Show footnotes

1United Republic of Tanzania, Ministry of Health and Social Welfare (2006). National Nutrition Strategic Plan 2006/7 - 2009/10. Dar es Salaam: MoH.

2WHO (2003). Guidelines for the inpatient treatment of severely malnourished children. Geneva: World Health Organisation.

More like this

FEX: Updated Nutriset ‘red scoop’ instructions for mixing F75 and F100

Nutriset's F-75 and F-100 therapeutic milks come in sachets of, respectively, 410 g and 456 g. For both products, the full content of one sachet must be mixed with 2 litres of...

FEX: New sachet/carton sizes for F75 and F100 therapeutic milks

Old versus new F100 sachets Substantial changes have been made to the sachet sizes for F-75 and F-100 therapeutic milk as well as to the carton sizes. Therapeutic milks F-75...

en-net: F-75, F-100 packaging

Dear users, what do you consider optimal packaging for F-75, F-100 in terms of size and if measuring scoop is needed or not. Thank you. The decision was made around 4 years...

FEX: New Measuring Scoops for F75 Therapeutic Milk

To respond to frequent requests for measuring scoops for the preparation of small quantities of F-75, Nutriset with the approval of UNICEF, are including measuring scoops in...

FEX: Issue 32 Editorial

The devil is in the detail In this edition of Field Exchange we have a number of field articles that address very detailed programming issues. A field article by ACF deals...

FEX: Response on F-75 and use of measuring scoops

By Mamane Zeilani, Nutriset Mamane Zeilani is Director for International Development and Nutritional Strategies at Nutriset, including product Research and Development Before...

en-net: RUTF

Are simplistic charts for calculation of RUTF ration required per day based on weight recommended by WHO? Most of the RUTF sachets are packed in 92 gms can it be done in 100...

FEX: Letter on local v imported therapeutic milk, by Rebecca Norton and Jean-Pierre Papart (with responses by Mike Golden, Ann Ashworth, Mary Lung'aho and David Sanders)

Recently, ENN was party to an exchange of questions and discussion between field staff and 'experts' relating to decisions on the use of readymade therapeutic products versus...

en-net: THERAPEUTIC MILK - new sachet/carton sizes

Notification from UNICEF supplies (Jan Komrska) Substantial changes have been made to the sachet sizes for F-75 and F-100 therapeutic milk as well as to the carton...

en-net: Treatment of kwashiorkor child

Below is a question received by a field colleagues. Advice will be appreciated. QUOTE: I currently treat in the pediatric ward an 8 year old, 12 kg girl with a miliary Tb and...

en-net: Converting F100 to F75 or making F75 from commercial milk powder

We have a problem of access to one area in Darfur and are asking for feedback on how to either convert F100 to be equivalent to F75 OR how to prepare F75 from locally available...

en-net: The new Therapeutic milk

How can we calculate F-75 and F-100 per caseload ( The new tin packages) or the average amount to be requested per case? While in sachets we could calculate the amount per case...

FEX: Local versus industrially produced therapeutic milks in managing severe malnutrition

By A Ould Sidi Mohamed, M. Diagana, Federica Riccardi, Abimbola Lagunju, Jean-Pierre Papart and Rebecca Norton. A Ould Sidi Mohamed is a paediatrician and chief of the...


Name NUTRISET Tel +33 (0)2 32 93 82 82 Formed 1986 Fax +33 (0)2 35 33 14 15 Director Michel Lescanne Email HQ staff...

FEX: Postscript on local capacity building for treatment of severe malnutrition

Ann Ashworth Hill, Professor of Community Nutrition Public Health Nutrition Unit, London School Hygiene and Tropical Medicine International NGOs usually provide better...

FEX: Foods for the Treatment of Malnutrition

Summary of Conference Presentation At the Dublin conference on Emergency Supplementary Feeding (February 18 to 21, 1997), reported on in the last issue of Field Exchange, Prof....

FEX: Diet and renal function in malnutrition

Summary of presentation1 Supplementary suckling (SS) has revolutionised management of young, malnourished infants Water balance in young, malnourished infants Water is an...

en-net: Use of half strength infant formula instead of F75 Formula

Hi All I am currently working as a Dietitian Advisor to the Samoan NHS. A current practice in the Paediatric ward for infants ranging from about 6 months to 2 years,...

FEX: People in Aid (issue 32)

Sphere training of trainers in Singapore in October 2006 Sphere Audit/Review workshop with CARE Somalia, May 2006 Ms Shafia Khatun, Ms Jolly Khanum, Ms Aklima Parvin,...

en-net: What to do when ReSoMal and CMV not available?

We are having shortages and cannot find in-country sources for some our needed products. The shortage is expected to last until next year. In particular, I need to know how I...


Reference this page

Chloe Angood (). Treatment of severe malnutrition in Tanzania - a problem with ‘scoops’. Field Exchange 32, January 2008. p12.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.