The patient was admitted into the CCU-Covid-19 unit on 27^th October, 2021 due to history of fever, cough, difficulty in breathing and reduced level of consciousness. He had cold extremities up-to elbows and knees; capillary refill was 6 sec, weak pulses and persistent hypoglycaemia. Medical history revealed that patient was born as pre-term twin with birth weight of 2.8 kilograms. Shortly after birth he was admitted to a new-born unit with neonatal sepsis (NNS). He had history of persistent poor weight gain was previously enrolled in a nutrition program. He also had regressed millstones.

On admission, he weighed 5.5kg, body length was 64cm with z-scores of -3sd (severe acute malnutrition). Prior to admission, patient’s body weight was 5.5kg. The ideal body for eight months old is 8.9 kg.

Baseline laboratory investigations were: Sodium-152 milimoles/L; potassium-1.95mmol/L; Urea 7.2 mmol/L; creatinine- 63.2 umol/l and Haemoglobin leve-7g/dl, random blood sugar-17.5mmol/L. Had nasogastric tube (size F-10) inserted for feeding. Triple serology test was negative. SARS-CoV-2 test was positive after six days of admission in pediatric unit. Computed Tomography (CT) head scan report suggested hypoxic ischemic or brain injury.

On physical examinations, baby had a hollowed look depression under the eyes and triceps had very little space between fingers on touch. He had obvious hollow depressed temple and prominent ribs. On further examination, the patient could not stand without assistance or was able to crawl. He was noted to have delayed milestones. In addition, he afebrile. Oxygen saturation was 98% on room air.

In general paediatric unit, the baby was unable to feed orally and a nasogastric tube feeding was fixed. Bolus of expressed breast milk (EBM) alongside F-75 formula of 100ml every three hours was given for seven days. This was transitioned with kitchen feed (enriched porridge made of sorghum, oil and sugar). The indication for this feed was occasioned by stock-outs of F-100 in the hospital and also lack of suitable commercial formula. This kitchen feed was nutritionally inadequate and it also required dilution into thin liquid to be administered into the narrow bore of paediatric nasogastric tube. Mother did not have adequate production of breast milk for the twin babies immediately after. This necessitated her to initiate complementary feeding at four months. Patient had longstanding history of poor feeding and faltering weight gain. On admission, mother reported depressed production of expressed breast milk.

Based on nutrition assessment data, working nutrition diagnosis formulated was: - Inadequate caloric and nutrients intake due to lack of appropriate feed as evidence by intake of low caloric- nutrients dense kitchen feeds.

A high calorie-high protein diet with appropriate proportion of micronutrients was prescribed. Caloric and nutrients requirements were calculated based on ideal body weight of 8.9kg, with provisions of 95 kilocalories and 2.5g of protein per ideal body weight per day 9. This translated to 846 calories and 22.3 g of protein per day.

There was no suitable paediatric formula that could adequately provide prescribed calories and nutrients. Enteral commercial feeds available in the hospital though they could meet caloric requirements, they exceed protein contents with more than 40% of daily protein needs.

The only enteral feed at disposal by material time which could deliver calories and protein in relatively appropriate amount was fortified blended flour (FBF). It had another advantage in that it had appropriate viscosity for paediatric size F-10 nasogastric tube. This therapeutic feed is commonly used in HIV/AIDS nutrition programs to support children with moderate malnutrition 10. It is a pre-cooked flour made up of maize, sorghum, sugar, soybean oil and fortified with minerals and vitamins 11.

On the first day in the unit, prepared FBF feed from flour amount of 150g was given in bolus of 90mls in every three hours. The mother was requested to express breastmilk and feed the baby first before administration of this therapeutic feed. This provided about 630 calories and 30grams of protein per day 11. An increment of 10ml of the feed was done every day to achieve 120mls per every three hours. In the third day the patient had episodes of loose stool. This necessitated provision of 50 ml bolus of fermented milk which contains live cultures to improve gut flora 12.

On the 5^th day, it was noted that the patient appetite had improved greatly and was not satisfied with volume of feed that was provided. This prompted to an increment of 10ml of FBF per feed to provide a total volume of 150ml per every three hours per day. Total volume was 1200mls per day with 1,050 calories and 50g of protein and good range of micronutrients. The main challenge with this feed was that amount of protein almost tripled when trying to achieve high calories. On day 14^th the patient was transferred to paediatric unit with body weight of 5.6 kg after repeat Covid test was done and it turned negative.

Written informed consent was obtained from the child’s father. Anonymity of the study participant in the case report has been maintained. The case report was approved by Kenyatta National Hospital- University of Nairobi Research Ethics Committee on 30^th August, 2021 under reference number: KNH-ERC/01/PUB/5.

This case report was part of the requirements for completion of a short course training in critical care nutrition offered by India Association Parenteral and Enteral Nutrition (IAPEN) which was funded by Kenyatta National Hospital, Kenya.

Alexander Mbogo developed the concept and did the manuscript writing. Siva Kiran (from IAPEN) provided mentorship in data collection within nutrition care process framework and identification of the journal for publication. Dr. Sophie Ngala provided guidance on manuscript development.