guidelines for integrated management of...

MINISTRY OF HEALTH

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITIONIN UGANDAJanuary 2016

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION

IN UGANDA

MINISTRY OF HEALTH

January 2016

GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA4 JANUARY 2016

Foreword ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 11

Acknowledgements ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 12

Acronyms And AbbreviAtions .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 14

glossAry oF terms .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 16

CHAPTER ONE 19introdUction ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 191.0 OverviewofMalnutritioninUganda .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 191.1 AcuteMalnutritionasaformofunder-nutrition... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 191.2 ComponentsofIntegratedManagementofAcuteMalnutrition(IMAM). ..... ..... ..... ..... . 201.3 PrinciplesofIMAM .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 211.4 PurposeoftheIMAMguidelines .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 221.5 IntegratingIMAMintotheExistingHealthStructureofUganda. ..... ..... ..... ..... ..... ..... . 22

CHAPTER TWO 25commUnity involvement .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 252.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 252.1 StepsincommunityMobilisationandInvolvement ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 26

CHAPTER THREE 31nUtrition Assessment And clAssiFicAtion oF AcUte mAlnUtrition .. .... 313.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 313.1 Wheretheassessment/screeningshouldbedone. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 313.2 NutritionAssessment ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 333.3 Classificationofacutemalnutrition ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 37

CHAPTER FOUR 43SUPPLEMENTARY FEEDING PROGRAMME FOR MANAGEMENT OF MODERATE ACUTEMALNUTRITION ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 434.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 434.1 OpeningandClosingaSupplementaryFeedingProgramme . ..... ..... ..... ..... ..... ..... ..... . 534.2 RequirementsandProcessforSettingUpaSupplementaryFeedingSite . ..... ..... ..... ..... . 54

contents

JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 5

CHAPTER FIVE 59oUtpAtient therApeUtic cAre For the mAnAgement oF AcUte mAlnUtrition with no medicAl complicAtions. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 595.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 595.1 AdmissionCriteriaforOTC .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 605.2 AdmissionprocessandactivitiesinOTC . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 615.3 DischargeProcedures ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 685.4 ProcessandRequirementsforSetting-upanOTC . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 69

CHAPTER SIX 73inpAtient therApeUtic cAre For mAnAgement oF AcUte mAlnUtrition with medicAl complicAtions . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 736.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 736.1 AdmissionCriteria ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 736.2 AdmissionProcess ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 746.2 StabilisationPhase/Phase1 .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 766.4 RehabilitationPhase/Phase2 .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 926.5 CriteriatomovefromPhaseIIbacktotheStabilisationPhase(Phase1) .. ..... ..... ..... ..... . 94

CHAPTER SEVEN 97inpAtient mAnAgement oF inFAnts less thAn siX months with sAm.. .... 977.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 977.1 AdmissionCriteria ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 987.2 StabilizationPhase... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 987.3 MonitoringinfantswithSAM .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1037.4 Infantfeedingcounsellingandsupport ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 103

CHAPTER EIGHT 107emergency nUtrition response .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1078.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1078.1 StepsforEmergencyNutritionResponse ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1088.2 GeneralrequirementsforEmergencyNutritionReliefProgrammes ... ..... ..... ..... ..... ..... 1108.3 ExitStrategyforEmergencyNutritionResponse(ENR) ..... ..... ..... ..... ..... ..... ..... ..... ..... 111

CHAPTER NINE 113nUtrition inFormAtion, edUcAtion And commUnicAtion .. ..... ..... ..... ...1139.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1139.1 NutritionEducationProgramme .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1149.2 CommunicatingNutritionInformation . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1159.3 Proceduresforplanningandfacilitatinganutritioneducationsession .... ..... ..... ..... ..... 1159.4 Conductinganutritioneducationsession .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1169.5 KeyNutritionRecommendations ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 117


CHAPTER 10 121monitoring, sUpervision, reporting And evAlUAtion, QUAlity improvement And sUpply chAin mAnAgement For imAm.... ..... ..... ..... ...12110.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12110.1Keydefinitions .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12210.2MonitoringofIMAMservices.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12210.3 IMAMservicesupervision... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12910.4 Reporting ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12910.5 Evaluation .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 13010.6Qualityimprovementinintegratedmanagementofacutemalnutrition.... ..... ..... ..... ..... 13010.7 Supplychainmanagementforimam .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 136

reFerences ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...138

ANNEXES 141AnneX 1 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...142Equipmentandsuppliesneededforanutritionward/unit .... ..... ..... ..... ..... ..... ..... ..... ..... ..... 142WardEquipment/Supplies. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 142

AnneX 2 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...144TRIAGEOFSICKCHILDREN. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 144

AnneX 3 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1453A:Weight-for-LengthReferenceCarda..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1453B:WEIGHT-FOR-HEIGHTREFERENCECARDa .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1473D:BodyMassIndexreferenceCard .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 153

AnneX 4 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...154PROTOCOLFORTHEINPATIENTMANAGEMENTOFTHESEVERELYMALNOURISHED ..... ..... ..... 154

AnneX 5 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...160TargetWeightforRehydration. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 160

AnneX 6 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...162AntibioticsReferenceCard ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 162

AnneX 7 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...164RecipesforF-75andF-100 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 164

AnneX 8 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...166F-75,F100andRUTFReferenceCards. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 166

AnneX 9: therApeUtic milk reFerence cArds For inFAnts less thAn 6 months with sAm .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1719A:Therapeuticmilkreferencecardsforinfantslessthan6monthswithSAM(stabilizationphase)1719B:TherapeuticmilkreferenceCardforinfantslessthan6monthswithSAMwhoarenotbreastfed(transitionphase). .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 172


AnneX 10.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...17624-HOURFEEDINTAKECHART ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 176

AnneX 11.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...177DAILYWARDFEEDCHART .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 177

AnneX 12.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...178WEIGHTGAINTALLYSHEETFORWARD .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 178

AnneX 13 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...179MONITORINGCHECKLISTS . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 179

AnneX 14 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...182SampleDischargeCard ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 182

AnneX 15.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...184SpecializedNutritiousFoodsSheet ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 184

AnneX 16 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...186CRITICALCAREPATHWAYCHART(-5pages).... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 186

AnneX 17: reFerrAl Forms . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...19417A:CommunityReferralForm .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 19417B:HMIS032:ReferralNote. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 195

AnneX 18 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...196INTEGRATEDNUTRITIONRATIONCARD .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 196

AnneX 19 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...197HealthandNutritionEducationRecordform .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 197

AnneX 20 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...198DOCUMENTATIONJOURNALFORQIACTIVITIES... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 198


List of tabLes* Table1:Gradingofbilateralpittingoedema

Table2:SummaryofClassificationofAcuteMalnutrition

Table3:AdmissioncriteriatoSFP

Table4:SFPRationsandtheirNutritionValue

Table5:Advantagesanddisadvantagesofdryandwetration

Table6:RoutineMedicationsforPatientsinSFP

Table7:TypesofExitsfromSFP

Table8:DischargecriteriafromSFP

Table9:Decision-makingframeworkforopeningaSupplementaryFeedingProgramme1

Table10:GuidanceoncriteriaforclosingSFPs

Table11:RoutineDrugsandSupplementsinOTC

Table12:AppetitetestforRUTF

Table13:EnergyandNutrientCompositionofRUTF(Plumpy’nut)

Table14:TypesandCriteriaforExitfromOTC

Table15:Signsofdehydration

Table16:SummaryofAntibioticsforSeverelyMalnourishedChildren

Table17:RoutineMedicinesandSupplements

Table18:Typesofdischarges,conditionsandactionsfromITC

Table19:KeyNutritionRecommendations

Table20:Toolsusedinmonitoring,supervisionandreportingforIMAMprogram

Table21:Typicaltargetlevelsforcure,mortalityanddefaultingrates

Table22:CoverageneededtoeffectagivenreductioninGAM

Table23:SampleactionplanforimplementationofQIinIMAMServices

Table24:TypesofIMAMsupplies

1


List of figures*Figure1:CoordinationandCommunicationbetweenIMAMcomponents

Figure2:ExistingHealthStructureinUganda

Figure3:StepsinCommunityMobilisationandInvolvement

Figure4:MeasuringMUAC

Figure5:Measuringweightindifferentcircumstances

Figure6a:MeasuringLength

Figure7:ChildrenwithClinicalSignsofSevereAcuteMalnutrition

Figure8:SummaryoftheNutritionAssessmentandClassificationofAcuteMalnutrition

Figure10:LayoutoftheOTCarea

Figure11:WHOTenStepsfortheManagementofSAM(WHO2003)

Figure12:Keepingthepatientwarmlycovered,especiallyatnight.

Figure13:SupplementalSucklingTechnique

Figure14:DecisionTreeforImplementingSelectiveFeedingprogrammes

Figure15:ASchemeforPlanningNutritionEducationProgrammes

Figure16:TheReportingSystemoftheIMAMProgramme

Figure17:WorkPlaceImprovementthrough5-S

Figure18:ThePDSAcycle

Figure19:ProcessFlowofPatientsinOTC

List of boxesBoxA:Measurementsforacutemalnutrition

BoxB:KeyMessagesonSupplementaryFeedingProgramme

BoxC:RequirementsforsettingupSFP

BoxD:DefinitionofSAMwithoutmedicalcomplications

BoxE:KeyMessagesatFirstOTCVisit

BoxF:BasicequipmentandsuppliesforOTC

BoxG:PreparationofReSoMalfromStandardORS

BoxH:F100-Dilutedforinfants


forewordMalnutrition is a significantpublichealthproblemwhich isoftenneglected.The six-part Lancetseriesof2013onmaternalandchildundernutrition,documentedtheup-to-dateevidencejustifyingtheurgentprioritizationofglobalandcountrywidenutritioninterventions.

Management of acute malnutrition drew attention in Uganda from 2003/2004 at the peak ofthe Lord’sResistanceArmy (LRA) insurgency inNorthernUganda.Over the years, improvementofnutritionalstatusofUgandanshasgainedpriorityattheMinistryofHealth(MOH);andtherehasbeendevelopmentofsuccessivestandards,policies,andguidelinesinthisregard,inlinewithevidence-based global recommendations. In response to the need to standardize treatmentguidelines, in 2006, Uganda, with support fromUNICEF and VALID INTERNATIONAL, developedthefirstversionofguidelinesontheIntegratedManagementofAcuteMalnutrition(IMAM)whichcombined existing guidelineswith community therapeutic care (CTC) and integrated aspects oftreatmentofmalnourishedHIV/AIDSchildrenandadults.TheIMAMapproachisacomprehensivestrategywhichcombinesandlinksinpatienttreatment(severewithcomplications)withoutpatientcare (severewithoutcomplications),managementofchildrenwithmoderateacutemalnutrition(wherepossible)andcomprehensivecommunitymobilizationandinvolvement.

InMarch 2010, theMOH launched the IntegratedManagement of AcuteMalnutrition (IMAM)guidelinesthatfurtherincorporatedtreatmentofmalnourishedadolescents,adults,pregnantandlactatingwomen.Theseguidelinesprovidedtheframeworkforensuringappropriatepreventiveinterventions, early identification and treatment of the acutely malnourished. Since thispublication,therehavebeenvariousdevelopmentsandlessonslearntthroughuseoftheguidelinesforexample:(a)Mid-UpperArmCircumferenceisbeingincreasinglyusedtoassesswasting,(b)inNovember2013,theWorldHealthOrganization(WHO)releasednewupdatesonthemanagementofsevereacutemalnutritiontocontributetoimprovedqualityofcarefornutritionandhealthoftheseverelymalnourished(c)ready-to-usetherapeuticfoods(RUTF)arebecomingmoreavailablethrough importation as well as local production and (d) admission criteria into supplementaryfeedingprogrammehasbeenrevisedforpregnantwomen.Asaresult,moreopportunitiesnowexistforearlyidentificationandreferraloftheacutelymalnourishedfortreatment.Similarly,thereareincreasingopportunitiesforearlydischargeoftheseverelymalnourishedfromthehealthfacilitytocontinuereceivingcareinthecommunity.Thisupdatetakesintoaccountthesedevelopments.ThisversionoftheIMAMguidelineswasrevisedandupdatedthroughaconsultativeprocessinvolvinginternationalandnationaltechnicalexperts.

Icalluponallstakeholdersinvolvedinthemanagementofmalnutritiontoapplytheserevisedandupdatedguidelinesandintegratetherecommendationsintotheirprogrammes.HoweverIwouldliketoappealtoallUgandanstobemindfuloftherequirementthatonlytrainedhealthworkersshoulddirectlyadministertheinstructionsintheseIMAMguidelines,astheyarehighlytechnical.OtherstakeholdersmayrefertotheguidelinesforanyotherpurposeotherthantodirectlyimplementIMAM..Whilesomelocaladaptationsmaybemade,theseshouldbedoneincollaborationandwiththeconsentofMoH.TheMoHiscommittedtoensuringappropriateimplementationoftheseguidelines.

Dr.AchengJaneRuthDirectorGeneralofHealthServices


acknowLedgements

TheMinistryofHealthwouldliketoverysincerelythankthefollowingorganisations:TheUnitedNations Children’s Fund (UNICEF), the World Health Organisation (WHO), the World FoodProgramme(WFP),theUnitedStatesAgencyforInternationalDevelopment(USAID),FamilyHealthInternational(FHI360-FoodandNutritionTechnicalAssistance(FANTAIII)Project,ActionAgainstHunger(ACF),MwanamugimuNutritionUnitMulagoHospital,MildMayUganda,BaylorUgandaandtheInternationalBabyFoodActionNetwork(IBFAN-Uganda).Theseprovidedthetechnicalandfinancial supportwhichwassoessential for thedevelopmentof the IntegratedManagementofAcuteMalnutrition(IMAM)guidelines.

Sincere gratitude is extended to all those on the list of contributors for their input throughouttheentireconsultativeprocess..SpecialrecognitiongoestoallthemembersoftheMaternalandChildHealthCluster,SeniorManagementCommittee,HealthPolicyAdvisoryCommitteeandTopManagementCommitteeoftheMinistryofHealthfortheirtechnicalinputinrefiningtheguidelines.

Finally,theMinistryofHealthwishestothankallstakeholdersnotmentionedbyname,whoinonewayoranother,eitherindividuallyorcollectively,contributedtotheproductionofthisrevisedandupdatedIMAMguidelines.

Listofcontributors

locAl consUltAnts

MwanamugimuNutritionUnit,MulagoNationalReferralandTeachingHospital

Dr.ElizabethKiboneka,Dr.EzekielMupereandJollyKamugisha

who technicAl eXperts

WHORegionalExperts Dr.FerimaZerbo,Dr.HanahBekele

MinistryofHealth DrJacentAsiimwe,Dr.K.Ssesanga,AgnesChandiaBaku,SarahNgalombi,SamalieNamukoseBananuka,AlbertLule,JosephOdyek,AgnesAntoniaKiro,LynetteKinconco,PerezKiryaIzizinga,MargieNagawa,EmmanuelAhimbisibwe,

WorldHealthOrganization(WHO) PriscillaRavonimanantsoa,Dr.FlorenceMTuryashemererwa

UnitedNationsChildren’sFund(UNICEF)

NellyBirungi,WilsonKirabira

WorldFoodProgramme(WFP) SiitiHalati,MartinAhimbisibwe,MaryNamanda

MakerereUniversityCollegeofHealthSciences

Dr.JulietAjok,JudithAgaba


who technicAl eXperts

MulagoNationalReferralHospital Dr.VictorMusiime,Dr.LanyeroBetty,SusanAwori,JollyNkayarwa,ScoviaBakesigaki,HanifaNamusoke

MildmayUganda GloriaKirungi

ActionAgainstHunger(ACF) EricSsebunya,

ConcernWorldwide HildaKawuki,JoyceNamitala,JosephMbabazi,MaryNnabagulanyi

WorldVisionUganda JoabTusaasire

BaylorUganda PatrickRichardOkoed

FortPortalRegionalReferralHospital

Dr.EuphrasiaKatutu

MbararaRegionalReferralHospital Dr.FrancisOriokot,NoelKansiime

KabaleRegionalReferralHospital AmosHashakaNdugutse

JinjaRegionalReferralHospital MansurToko

MorotoRegionalReferralHospital SimonOndoga

HoimaRegionalReferralHospital AlbertMugabi

SorotiRegionalReferralHospital ClementinaNyaketcho

AruaRegionalReferralHospital PatrickOyela

MbaleRegionalReferralHospital SirajeKijogo

SPRING KatherineOtim

Igangahospital AdoniaMaganda

Kitgumhospital MiltonPidoOcagiwu

Mityanahospital Kenneth

Apachospital AndrewSilasEwalu

Lacorhospital Dr.RichardNyeko

Kisorohospital MosesMutabazi

Tororohospital BenOkia

MoyoDistricthospital MoteKomaEdema

(FANTA/FHI360) Dr.HanifaBachou,KarenApophiaTumwiine,AhmedLuwangula

USAID/PIN BrianRwabwogo,AugustineKigonya

MSH-STRIDES TuryatembaLivingstone,

EGPAF/RHITES-SW EstherNaluguza

AVSI-SCORE JoanitaNSsebayiga


acronyms and abbreviations AFASS Acceptable,feasible,affordable,sustainableandsafeAIDS AcquiredImmuno-DeficiencySyndromeANC Antenatal CareART AntiRetroviralTherapyBMI BodyMassIndexCBO CommunityBasedOrganizationCCP CriticalCarePathwayCHEWS CommunityHealthExtensionWorkersCHW CommunityHealthWorkerCMV CombinedMineralsandVitaminsCSB CornSoyaBlendDHO DistrictHealthOfficerDHT DistrictHealthTeamDNFP DistrictNutritionFocalPersonDOTS DirectlyObservedTreatmentsENR EmergencyNutritionResponseEPI ExpandedImmunisationProgrammeEPR EmergencyPreparednessandResponseF-100 Formula100F-75 Formula75FBF FortifiedBlendedFoodsGAM GlobalAcuteMalnutritionGFD GeneralFoodDistributionGFD GeneralFoodDistributionGMP GrowthandMonitoringProgrammeHb HeamoglobinHC HealthCentreHIV HumanImmuno-deficiencyVirusHMIS HealthManagementInformationSystemHSSP HealthSectorStrategicPlanHSQI HealthSectorQualityImprovementFrameworkID IdentificationNumberIEC InformationEducationandCommunicationIM IntramuscularIMAM IntegratedManagementofAcuteMalnutritionIMCI IntegratedManagementofChildhoodIllnessesINR IntegratedNutritionRegisterIPs ImplementingPartnersITC InpatientTherapeuticCare


ITC InpatientTherapeuticCareIV IntravenousIYCF InfantYoungChildFeedingIYCF-E InfantYoungChildFeedinginEmergenciesLNS LipidbasedNutrientSupplementMAM ModerateAcuteMalnutritionMCH MaternalandChildHealthMoH MinistryofHealthMUAC MidUpperArmCircumferenceNGO Non-GovernmentalOrganisationNGT Naso-gastrictubeNMS NationalMedicalStoresOPD OutpatientDepartmentOTC Out-PatientTherapeuticCarePCP PneumocystscariniipneumoniaPMTCT PreventionofMother-to-childTransmissionQI QualityImprovementRCT RoutineCounsellingandTestingRNI RecommendedNutrientIntakeReSoMal RehydrationSolutionfortheMalnourishedRUTF ReadytoUseTherapeuticFoodSAM SevereAcuteMalnutritionSF SupplementaryFeedingSFC SupplementaryFeedingCentreSFP SupplementaryFeedingProgrammeSST SupplementalSucklingTechniqueTB TuberculosisTHR: TakeHomeRationsTWG TechnicalWorkingGroupUDHS UgandaDemographicHealthSurveyUNHCR UnitedNationsCommissionforRefugeesUNICEF UnitedNationsChildren’s’FundUTI UrinaryTractInfectionVHT VillageHealthTeamW/L WeightforlengthWFH WeightforheightWFP WorldFoodProgrammeWHO WorldHealthOrganisationYCC YoungChildClinic


gLossary of terms

term deFinition

Client Anyindividual,whetherchildoradultthatisunderanyformofmanagementforacutemalnutrition.Insomeinstancestheyarealsoreferredtoaspatients.

CommunityMobilisation

Communitymobilisationincludescommunityassessment,communitysensitizationandengagement,activecase-findingandreferral,andcasefollow-up.

Defaulted Clientisclassifiedasdefaulteronthethirdconsecutiveabsence(i.e.,threeweeksabsent)(forSupplementaryfeedingprogrammeistwoconsecutiveabsences)

Died PatientdieswhileinCare

DischargedCured Patientmeetsdischargecuredcriteria

Non-Cured Patientdoesnotreachdischargecriteriaafterfourmonths(16weeks)intreatment(medicalinvestigationpreviouslydone)

Oedema+/Grade1

++/Grade2

+++/Grade3

Thisisthereferencefortheclassificationofnutritionoedema.Thegradingof+/++/+++orGrade1,2,3classifiestheoedemarangingfrommoderatetosevere.

SachetsofRUTF ThequantitiesoftheReadytoUseTherapeuticFoodsareusuallymeasuredinsachets.Insomeotherinstances,ithasalsobeenmeasuredinpackets

Shock Adangerousconditionpresentingwithsevereweakness,lethargyorunconsciousness,coldextremitiesandafast,weakpulse

TheABCDconcept Usedforidentifyingseriousillnessorinjuryduringtriagei.e.airway,breathing,circulation/consciousnessanddehydration

Transferredtomoreintensivecare(i.e.fromOTCtoITC)

Patient’sconditionisdeteriorating(accordingtoactionprotocol)

Triage Thewordtriagemeanssorting.Triageisthesortingoutofpatientsintoprioritygroupsaccordingtotheirneedsandtheresourcesavailable


CHAPTER ONEintroduction

1.0 OverviewofMalnutritioninUgandaMalnutritioncanbeeitherunder-nutritionorover-nutrition(obesity).Thisguidelinewillspecificallydealwithacutemalnutritionasaformofundernutrition.Undernutritionistheresultofdeficiencyofprotein,energy,mineralsaswellasvitaminsleadingtolossofbodyfatsandmuscletissues.ItisofamajorpublichealthconcerninUgandathataffectsbothchildrenandadults.Thestatisticsshowthat300,000children(5%nationally)areestimatedtobeacutelymalnourishedandnearly120,000(2%)ofthemhavesevereacutemalnutrition(UgandaDemographicHealthSurvey,2011).TheHIVpandemicinthecountryhasexacerbatedthesituationasmorethan15%ofacutelymalnourishedchildrenpresentingtoinpatientfacilitiesareHIV-positive.Malnutritionisadirectcauseof35-55%ofallchildhooddeaths(WHO,1999,SPHERE2004)andhencetheurgencytopreventandaddressthe problem. Severewasting in children under 5 years in particular is associatedwith a 9-foldincreasedoddsofmortalitycomparedtoahealthychild.

1.1 AcuteMalnutritionasaformofunder-nutritionUnder-nutrition

Under nutrition is categorised as either acute (recent) or chronic (long term). It is caused byinadequate intake or poor absorption of nutrients in the body. There are four forms of under-nutrition: acute malnutrition, stunting, underweight and micronutrient deficiencies. The fourformscanbecategorisedaseithermoderateorseveremalnutritionandcanappearisolatedorincombination,butmostoftenoverlapinoneclientorpopulation.


Under-nutrition is identified through anthropometry (body measurements), clinical signs andbiochemicaltests.Thesemeasurementsarethencomparedtoareferencevaluecommonlyreferredtoasnutritionindices.

Nutritionindicatorsaretheclassificationofspecificmeasuresofnutritionindicesbasedoncut-offpoints.Theymeasuretheclinicaloccurrenceofunder-nutritionandareusedformakingajudgmentor assessment. There are four common nutrition anthropometric indicators : Mid Upper ArmCircumference(MUAC)whichisusedtoassesswasting,weight-for-height(WFH)whichisalsousedtoassesswasting,height-for-age(HFA)whichisusedtoassessstuntingandweight-for-age(WFA)whichisusedtoassessunderweight.

Acute Malnutrition

Acutemalnutritionisarapidonsetconditioncharacterisedbybilateralpittingoedemaorsuddenweightlosscausedbyadecreaseinfoodconsumptionand/orillness.

Note:Itisimportanttointerpretadultoedemawithcautionasitmaynotbenutritionaloedemabutduetosomeunderlyingmedicalcomplaints.

Therearetwoformsofacutemalnutrition:

• Severe acute malnutrition (SAM) which is characterised by the presence of bilateral pittingoedemaorseverewasting.ApatientwithSAMishighlyvulnerableandhasahighmortalityrisk.

• Moderate acute malnutrition (MAM) whichischaracterisedbymoderatewasting.

1.2 ComponentsofIntegratedManagementofAcuteMalnutrition(IMAM)IMAM is an approach to address acute malnutrition and focuses on the integration of themanagementofacutemalnutritionintotheon-goingroutinehealthservicesatalllevels.

InUganda IMAMhas four components:Community, SupplementaryFeedingProgrammes (SFP),Outpatient Therapeutic Care (OTC) and Inpatient Therapeutic Care (ITC) programmes. TheCommunityservicesinvolveearlyidentification,referral,andfollow-upoftheacutelymalnourishedatcommunitylevel.SFPmanagesandtreatsMAMinchildrenof6-59monthsandothervulnerablegroupsthatincludepregnantwomen,lactatingwomenwithinfantslessthan6months,thosewithspecialneedssuchastheelderly.OTCprovideshome-basedmanagementandrehabilitationofSAMpatientsaswellasMAMpatientswithHIV/TBwhohaveanappetiteandnomedicalcomplications.ITCisforthemanagementofSAMwithmedicalcomplications.

Goodcoordinationandcommunicationbetweencommunity,SFP,OTCandITCisessentialtoensurethatpatientsremaininthesystemduringthetreatmentprocessforacutemalnutrition(Figure1below).


FigUre 1: coordinAtion And commUnicAtion between imAm components

To ITC if patient deteriorates

To OTC if client stabilises

COMMUNITY • Mobilisation• Screening and identification of malnourished (Active Case

finding)• Referral of malnourished• Nutrition and health education• Links with other support groups/organizations

Out Patient Therapeutic Care (OTC)

Inpatient Therapeutic Care (ITC)

To ITC if patient deteriorates (SAM with

complications)

Supplementary Feeding Programme (SFP)

To OTC if patient deteriorates (SAM with no complications)

To SFP if recovery

HIV TESTING

1.3 PrinciplesofIMAMThecoreoperatingprinciplesare:

• Maximum coverage and access: Thisaimstoachievethegreatestpossiblecoveragebymakingservicesaccessibletothehighestpossibleproportionofapopulationinneed.Itaimstoreachtheentireacutelymalnourishedpopulation.

• Timeliness: Thisaimstobegincase-findingandtreatmentbeforetheprevalenceofmalnutritionescalatesandadditionalmedicalcomplicationsoccur.

• Appropriate care: Provisionofsimple,effectiveoutpatientcareforclientswhocanbetreatedathomeandclinicalcareforthosewhoneedinpatienttreatment.


• Care for as long as it is needed: Improvingaccesstotreatmentensuresthatclientscanstayintheprogrammeuntiltheyhaverecovered.

• Additionally,IMAMalsoneedstobeeffectiveandsustainable.Bybuildinglocalcapacityandintegratingtheprogrammewithinexistingstructuresandhealthservices,IMAMalsoaimstoensurethateffectivetreatmentremainsavailableforaslongasacutemalnutritionispresentwithinthepopulation.

1.4 PurposeoftheIMAMguidelinesTheIMAMguidelinesspecificallydealwiththeidentification,treatmentandmanagementofacutemalnutrition and are intended to be usedby health andnutrition care providersworking at allhealthcarelevelsinUganda.Theguidelinescanalsobeusedbytraininginstitutionstostandardisetreatmentofacutemalnutritionwithnewgraduates joiningthehealthforce.TheguidelineswillalsohelpNGOs involved innutritionrehabilitationduringemergencies toguideandstandardizetreatmentprotocolsestablishedbyMinistryofHealth.TheguidelinescomplementothernutritionmaterialsdevelopedbyMinistryofHealth.

TheIMAMguidelinesareaimedatcontributingtoimprovedstandardisedtreatment,monitoringandreporting.Theycanalsobeusedasamobilising tool foraddressingacutemalnutritionandstrengtheningcapacities.CompliancewiththeguidelinesshouldcontributetotheoverallreductionofchildmortalityinUganda.

Althoughtheguidelineswillfocusonchildrenunderfiveyears,someinformationspecifictoolderchildren,adolescentsandadults isalso included.There isnosufficientevidencebasedresearchonthetreatmentofadultacutemalnutritiontogointoelaboratedetail,butasevidencebecomesavailable,theguidelineswillbeupdated.

1.5 IntegratingIMAMintotheExistingHealthStructureofUgandaThedeliveryofhealthservices inUganda isbybothpublicandprivatehealth facilitieswith theGovernment of Uganda being the owner ofmost facilities. Public health services are deliveredthroughVHTs,HC IIs,HC IIIs,HC IVs,GeneralHospitals,RegionalReferralHospitalsandNationalReferralHospitals(Figure2).

Facilitiesup toHCIVhave inpatient,outpatientand theatre facilities.TheHC III isanoutpatientdepartment(OPD)facilitywithdeliveryandinpatientfacilitieswhileHCIIisadaycarefacility.AtthevillagelevelaretheVillageHealthTeams(VHT)thatarethelinkbetweenthecommunityandthehealthstructure.


FigUre 2: eXisting heAlth strUctUre in UgAndA

Hospital(National/ regional/ General

Health Centre IV (Sub district)

Health Centre III (In- /outpatient facility, 24hr care)

Health Centre II (Day care /outpatient)

Health Centre I (Village Health Team)

Initially,management of acutemalnutrition has been hospital-basedwith treatment integratedwithin the paediatric ward or within a separate nutrition rehabilitation unit affiliated to thepaediatricward.Thishasbeendonewithminimal communitymobilisationand/or involvement.The IMAM approach aims at broadening the scope of currentmanagement and decentralisingmanagementofacutemalnutritiontolowerlevels(HCIIIandHCII levels)dependingoncapacitywithintheindividualfacility.ThiswillbecombinedwithlinkingwiththeVHTsandothercommunity-levelfiguresaswellaspreventativeprogrammes.


CHAPTER TWO community invoLvement

2.0 IntroductionCommunityacutemalnutritionservicesareacriticalcomponentoftheIntegratedManagementofAcuteMalnutrition(IMAM).Theseservicesshouldbeintegratedintoon-goingcommunityservices.ThecountryisimplementingacomprehensiveVillageHealthTeam(VHT)strategywhichtheIMAMapproachbuildsupon.TheVHTstrategyrequiresthateveryvillagehasVHTmemberswhoworktogethertomobilisecommunitiesforbetterhealth.ThesuccessoftheIMAMdependsonstrongcommunitymobilizationandinvolvementtomaximiseaccessandcoverageofhealthservices.

Community mobilization is defined as a capacity building process through which individuals,groupsororganizationsplan,carryoutandevaluateactivitiesonaparticipatoryandsustainedbasisto improve their health andother needs, either on their own initiativeor stimulatedbyothers(GrabmanH.andSnetro,2004)

Community involvement isdefinedastheactiveparticipationofpeople livingtogether insomeformofsocialorganizationandcohesionintheplanning,operationandcontrolofprimaryhealthcare,usinglocal,nationalandotherresources.Incommunityinvolvement,individualsandfamiliesassume responsibility for their communities’ health and welfare, and develop the capacity tocontributetotheirowncommunities’development(WHO,2004).ThevarioussectorsincommunityinvolvementwillincludebutnotlimitedtoministriesofHealth(MoH),Agriculture,AnimalIndustryand Fisheries (MAAIF), Gender, Labour and Social Development (MoGLSD) and Education andSports(MoES).Thiswillinvolvethestafffromthevarioussectorswhoworkatcommunitylevelse.g.VillageHealthTeams,agricultureextensionworkers,communitydevelopmentworkersandothercommunityresourcepersons.


ThemainaimsofcommunityservicesforIMAMinclude:

• EmpoweringthecommunitybyincreasingknowledgeonacutemalnutritionandIMAM

• Increasingcommunitymobilizationforaccessandserviceuptake(coverage)ofIMAM

• Strengtheningearlycase-findingandreferralofnewacutecases,andfollow-up

• Providinghealth,nutritioneducationandcounselling

2.1 StepsincommunityMobilisationandInvolvementThesummaryofthestepsincommunitymobilisationandinvolvementinIMAMarepresentedinFigure3below.

FigUre 3: steps in commUnity mobilisAtion And involvement

STEP 1: Community Assessment

Theassessmentiskeyindeterminingthefactorsthatarelikelytoimpactonbothservicedeliveryanddemandforservices.Incommunityassessment,thefollowingneedtobeidentified:

• The key community persons, leaders and other influential people and organisations to helpsensitisethecommunitiesonthecomponentsoftheIMAMprogramme;

• Existingstructuresandcommunitybasedorganisations/groups

• Socialandculturalcharacteristicsrelatedtonutrition.

• Formalandinformalchannelsofcommunicationthatareknowntobeeffective

• Attitudesandhealthseekingbehaviours

• Otherexistingnutritionandhealthinterventionsinthecommunity

Theassessmentisconductedbydistricthealthworkers(communityhealthnurse,VHTandmembersofthedistricthealthteam(DHT).

Ongoing Community sensitization and mobilization

Links with other Community Initiatives

Community assessment

Developing messages

Community sensitization

Community training Implementation

On-going monitoring and

supervision

Recording and Reporting


STEP 2: Developing messages and materials

• Develop sensitisationmessages for handbills or pamphlets, local radio as well as television.Meetingswith the community and religious leaders provide essential information about theIMAMServiceaims,methodsandactors.(Table19canprovideguidanceonthemessages).

• Develop a sensitisation plan detailing who and how to sensitise, based on the informationgatheredduringcommunitycapacityassessment.Reviewmessagewithinfluentialpersonsinthecommunitytocheckifitisculturallyappropriatebeforedisseminatingit.

STEP 3: Community Sensitization

• Engagethecommunityandotherpartnerswithcommunity-basedprogrammestodiscusstheproblemofmalnutrition,causesandpossiblesolutions.

• IntroduceandnegotiateontheadoptionofIMAMasanapproachtothemanagementofacutemalnutritionintheircommunities.

• Agreeonwhatneedstobedone;therelevantgroups,organisationsandstructurestobeinvolvedinIMAM;anddiscussclearrolesaswellasresponsibilities.

• Once services for the management of SAM have started, continue the dialogue to addressconcerns,maintainchangesinbehaviourandsharesuccessstories.

STEP 4: Community Training

• TheDHTshavearesponsibilitytoensurethattheidentifiedcommunityvolunteersaretrainedon identification,referralandhowtodisseminatemessageseffectively.RefertotheavailabletrainingpackagessuchasVHTTrainingPackage.

STEP 5: ImplementationCase-Finding and Referral

• Activecase-findingisimportanttoensurethatclientswithSAMareidentifiedearlybeforethedevelopment of severemedical complications. Identified clients are referred to the nearesthealthfacilityforfurtherassessmentandappropriatemanagement.

Theidentifiedcommunityhealthproviderswill:

• Screen for acute malnutrition at various contact points (house to house visits, communitymeetings, health facilities/outreachprogrammes, and at other opportunities) using theMid-upperarmcircumference(MUAC)andpittingoedema,forallclientgroups.

• Identifyandrefermalnourishedclientsappropriately.

Follow-up of Patients with Acute Malnutrition Patientswithacutemalnutritionontreatmentrequirefollow-upastheyareatanincreasedriskofdiseaseanddeath.Theyshouldbemonitoredtoensuresustainedimprovementintheircondition.

Followupshouldensureeffectivelinkagebetweenthecommunityandhealthfacilities.Itshouldentailthefollowing:


• Conducting home visits of malnourished clients for follow up as determined by the healthprovider

• Followinguponabsentordefaultingpatients

• Givingfeedbacktohealthproviders

• Linkingclients/patientstolivelihood/safetynetprogrammesavailableinthecommunity

STEP 6: On-going Community Sensitisation and Supervision

• This mainly involves constant dialogue, in which the communities periodically voice theirviews and suggest alternative coursesof action. This entails regularmeetings (monthly and/orquarterly)withkeycommunityrepresentatives,healthstafffromthenearesthealthfacility,beneficiariesandotherpartnerstodiscussdifferentaspectsoftheprogrammesuchas:

o Reviewingtheselectionandmotivationofvolunteers;

o Thecommunity’sperspectiveoftheprogrammewhichmayincludeidentifyingnewbarrierstoaccess;and

o Jointsolutionstoproblemslimitingtheimpactoftheprogramme.Thispromotescommunityownershipofprogrammedevelopmentandimplementation.

STEP 8: Recording and Reporting

• One of the key responsibilities of the VHTmembers is tomaintain records of screened andreferredcommunitymembers;thehealtheducationsessionsconducted;aswellastheanalysisandsubmissiontohealthfacilities.


Contact points at health facility level:

• Immunisationcentres

• YoungChildclinics(YCC)

• HIV/AIDS/TB,cancer,

• MotherBabyCarePoint/AntenatalCare(ANC)andpostnatalclinics.

• Outpatientdepartments

• Inpatientclinicsorwards

• Othercareandsupportclinics

CHAPTER THREE nutrition assessment and

cLassification of acute maLnutrition

3.0 IntroductionForearlydetectionandmanagementofacutemalnutrition,nutritionassessmentshouldbedoneatallcontactpointsandspecialattentiontocommunitieswithhighriskofmalnutritionincludingpregnantandlactatingmothers,children,HIV/AIDS,TB,cancer,andotherchronicconditions.

3.1 Wheretheassessment/screeningshouldbedoneAcutemalnutritioncanbeidentifiedthroughnutritionalscreeningand/orassessmentatdifferentcontactpoints.

Contact points at community level:• Day-to-dayorhouse-to-house

• Duringmasscampaigndays

• IntegratedChildhealthdays

• Integratedoutreaches

• Schoolsandcommunityprogrammesandothers.


TheMidUpperarmCircumference(MUAC) measurement andWeight-for-Height(WFH) indexareusedtoassesswasting,aclinicalmanifestationofacutemalnutrition,reflectingtheclient’scurrentnutritionalstatus.MUACinvolvesmeasuringthecircumferenceoftheclient’sleftmid-upperarm.MUACisabetterindicatorofmortalityriskassociatedwithacutemalnutritionthanWFHz-score(WorldHealthOrganisation[WHO]standards).MUACassessmentisusedforchildrenolderthan6monthsofage,pregnantandlactatingwomen(6monthspostpartum)andadultswhocannotstand.

ThewFh indexshowshowachild’sweightcomparestotheweightofachildofthesameheightandsexintheWHOstandards.AWFHstandarddeviationbelow-2z-score

ofthemedian(WFH<-2z-score)oftheWHOstandardsindicateswasting.

TheBody Mass Indexisusedasameasureofacutemalnutritionforadults(18yearsandabove)whoarenotpregnantorlactating(6monthspostpartum).Forpregnantandlactatingwomen(andotheradultswhocannotstand)MUACisused.

Bilateral pitting oedemaisaclinicalmanifestationofacutemalnutritioncausedbyanabnormalinfiltrationandexcessaccumulationofserousfluidinconnectivetissueorinaserouscavity.Bilateralpittingoedema(alsocalledkwashiorkor)isverifiedwhenthumbpressureappliedontopofbothfeetforthreesecondsleavesapit(indentation)inthefootafterthethumbislifted.

Measurements for acute malnutrition

boX A


3.2 NutritionAssessmentNutritional assessment is a comprehensive evaluation to determine the nutrition status of anindividual.Thiscanbedonethroughtakinganthropometryaswellastakingmedicalanddietaryhistory;performingclinicalexamination,and laboratorytests. Itshouldbedonebyaskilledandknowledgeableworkerinnutrition.

Anthropometry

This refers to thephysicalmeasurementofbodyparts in comparison to reference standards. Itincludesbutnotlimitedtothefollowingmeasurements:

• Mid-Upper-ArmCircumference(MUAC)incm;

• Body WeightinKgandroundingofftothenearest0.1kg(100g);

• Length (forchildrenbelow2yearsorlessthan87.0cm)or height (forchildrenabove2years, or 87.0 cm or more, adolescentsandadults)in cmroundingofftothenearest0.1cm;

Steps in anthropometryConduct Triage(seeannex2)tofasttrackseriouslyillpatients.

Triageisthesortingoutofpatientsintoprioritygroupsaccordingtotheirneedsandtheresourcesavailable.

Determine ageDeterminethepatient’sagefromrecordssuchastheChildHealthCard/MotherChildPassportorrecallbythemother/caregiver.

Measure MUAC • Ruleoutbilateralpittingoedema

• MeasuretheMidUpperArmCircumferenceonthelessactivearm(commonlyleftarmoftheclient).Tolocatethecorrectpointformeasurement,flextheclient’selbowto900.

• Locatethetipoftheshoulder(acromion)andelbow(olecranon)ontheleftflexedarmasshowninFigure5.

• Determinethemid-pointbetweenthetipoftheshoulderandtheelbow

• PlacetheMUACtapearoundthemiddleoftheleftupperarm(thearmshouldbehangingdownthesideofthebodyandrelaxed).

• ReadthemeasurementfromthewindowoftheMUACtapewithouttighteningorlooseningit.

• RecordtheMUACtothenearest0.1cmandthecolourcode(Green,Yellow,Red).

• Repeatthemeasurementtoensureaccuracy


FigUre 4: meAsUring mUAc

Measure weight

• MakesuretheweighingscaleiscalibratedtoZerobeforeeachmeasurementistaken.

• Clientsshouldbeweighedwithminimumofclothingandnojewellery.

• Theweightreadingshouldbedoneassoonastheindicatoronthescalehasstabilised.

• Weightisrecordedtothenearest0.1kg(100g).

Note: Weighing scales should be standardised after every 100 measurements using a known weight.

FigUre 5: meAsUring weight in diFFerent circUmstAnces

Figure 5c: weighing a child who cannot stand Figure 5a: weighing a child up

to 25kg

Figure 5b: Weighing a child who can stand


Measure Length/Height

• Childrenwhoareshorterthan87.0cm(orlessthan2years)aremeasuredwhilelyingdown;tallerchildren(equaltoormorethan87.0cmorolderthan2years)aremeasuredwhilestanding.

• Makesurethechildisbarefootandhasnoheadgear

• Makesureshoulderblades,buttocksandheelstouchthesurfaceofthelength/heightboard;kneesshouldbefullystraightandarmsstretchedonthesides;andneckshouldbestraightwitheyeslookingstraightaheadwiththeheadpiece/footpieceplacedfirmlyinposition.

• Themeasurementisreadtothenearest0.1cm.

Note: If a child is less than 2 years old will not lie down for a measurement of length, measure the standing height and add 0.7 cm to convert it into length. If the child aged 2 years and older cannot stand measure the recumbent length and subtract 0.7 cm to convert it to height

FigUre 6A: meAsUring length

FigUre 6b: meAsUring height

How to take length of children < 87cm

How to take height of children > 87cm standing


Take Medical and dietary history

• Obtainpatientinformationincludingage,sexandpossiblerecentalterationinbodyweight

• Checkthepatient’s/clienthealthrecordandaskthecaregiveraboutanymajorhealthissueswhichcanhavenutritionalimplications

• Askaboutfeedingpractices.

Perform Clinical Examination

Thisentailsboththegeneralaswellasthesystemicevaluationofthepatient,fromheadtotoe,withemphasisonsignsofvisibleseverewasting,bilateralpittingoedema(Figure7),andmedicalcomplications(hypothermia,hypoglycaemia,cornealulcerations,verysevereanaemia,dermatosis,heartfailure,dehydration/shock,severeinfections,shockandIMCIdangersigns).

FigUre 7: children with clinicAl signs oF severe AcUte mAlnUtrition

Bilateral pitting oedema

Oedemaisswellingfromexcessfluidinthetissuesandcanbeseeninthefeet,lowerlegsandarms.Inseverecasesitisgeneralized.Oedemacausedbyacutemalnutritionoftenpresentswithspecialcharacteristics:

• Itisbilateralpitting(leavesadepressiononpressureappliedforatleast3-5seconds)

• Doesnotchangewithtimeofthedayorposture

Note: If the swelling is only in one foot, it may just be a sore or infected foot

Oedemaiscommonlygradedasshowninthetable1below:

b: child with bilateral pitting oedemaa: child with visible signs of severe wasting


tAble 1: grAding oF bilAterAl pitting oedemA

observAtion grAde

Nooedema (0)

Bilateralpittingoedemainbothfeet(belowtheankles) +/(Grade1)mild

Bilateralpittingoedemainbothfeetandlegs,(belowtheknees)handsorlowerarms

++/(Grade2)moderate

Bilateralpittingoedemaobservedonbothfeet,legs,arms,face +++/(Grade3)severe

Note: It is important to interpret oedema with caution as it may be a sign of underlying medical condition (e.g. nephritic syndrome, severe anaemia, high blood pressure, other renal or heart conditions) or physiological changes such as in pregnancy. A clinician should take detailed history, physical examination and where possible biochemical tests

Dermatosis

Dermatosisoftheskiniscommonamongchildrenwithoedema.Dermatosiscanbecategorizedas:

• +Mild:discolorationorafewroughpatchesofskin

• ++moderate:multiplepatchesonarmsand/orlegs

• +++severe:flakingskin,rawskin,fissures(openingsintheskin)

Eye signs

Childrenwithseveremalnutritionmayhavesignsofeyeinfectionand/orvitaminAdeficiency.

• Bitot’s spots –superficialfoamywhitespotsontheconjunctiva(whitepartoftheeye).TheseareassociatedwithvitaminAdeficiency.

• Pus and inflammation (redness)aresignsofeyeinfection.

• Corneal clouding is seenasanopaqueappearanceof thecornea (the transparent layer thatcoversthepupilandiris).ItisasignofvitaminAdeficiency.

• Corneal ulceration isabreakinthesurfaceofthecornea.ItisasignofseverevitaminAdeficiency.

3.3 ClassificationofacutemalnutritionAcutemalnutritioniscategorizedasmoderateorsevere.Itcanbeclassifiedusingcutoffs,z-scoresand/orbilateralpittingoedema(Table2below)


tAble 2: sUmmAry oF clAssiFicAtion oF AcUte mAlnUtrition

Age cAtegory

nUtritionAl indicAtor

moderAte AcUte MALNUTRITION (MAM)

severe AcUte MALNUTRITION (SAM)

Infantslessthansixmonths

WeightforLength(WFL)

Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)

Lessthan-3z-score(<-3SD)

Bilateralpittingoedema

Nobilateralpittingoedema Presenceofbilateralpit-tingoedema

Childrenfrom6to59months

WeightforLength/Height(WFL/H)



MUACcutoff Greaterorequalto11.5cmandlessthan12.5cm(≥11.5cm&<12.5cm)

Lessthan11.5cm(<11.5cm)



*Childrenandadolescentsfrom5yearsto19years

BMIforage Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)


MUACcutoff 5tolessthan10yearsGreaterorequalto13.5cmandlessthan14.5cm(≥13.5cm&<14.5cm)


10tolessthan15yearsGreaterorequalto16.0cmandlessthan18.5cm(≥16.0cm&<18.5cm)


15tolessthan18yearsGreaterorequalto18.5cmandlessthan21.0cm(≥18.5cm&<21.0cm)




*Adults BMI Greaterorequalto16andlessthan17kg/m2(≥16and<17kg/m2)

Lessthan16kg/m2 (<16kg/m2)




Age cAtegory

nUtritionAl indicAtor

moderAte AcUte MALNUTRITION (MAM)

severe AcUte MALNUTRITION (SAM)


Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutmedicalcauses)

*Pregnantwomenandlactatingmotherswithinfantlessthan6months




Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutphysiological/medicalcauses)

*Elderly60yearsandabove

MUACcutoff Greaterorequalto16.0cmandlessthanorequal18.5cm(≥16.0cm&≤18.5cm)



Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutphysiological/medicalcauses)

*Sphere 2011

SAM can be uncomplicated or complicated. Uncomplicated SAM is for children 6months and above, adolescents and adults who have no medical complications.AppetitetestisessentialandshouldbeperformedforSAMpatientswithoutmedicalcomplications because anorexia or poor appetite is considered to reflect severedisturbanceofmetabolism.ThetestwilldifferentiatecomplicatedfromuncomplicatedSAMforpatientshavingSAMwithoutmedicalcomplications(refertochapterfive-OTCfordetails).


FigUre 8: sUmmAry oF the nUtrition Assessment And clAssiFicAtion oF AcUte mAlnUtrition Algorithm

nutrition assessment

§ Check for bilateral pitting oedema

§ Measure MUAC,

§ Measure weight and length/height and for children interpret the growth curve.

§ Determine the WFH for children less than 5 years

§ Determine the BMI for age for children 5 to19 years

§ Determine the BMI for adults

§ Assess for medical complications

Moderate acute malnutrition (MaM)

No bilateral pitting oedema

WFL/H/BMI- for- age ≥ –3 and < –2 z-score

Adults: BMI ≥16 & <17

Or

MUAC

6 to 59 months: ≥ 11.5–< 12.5 cm

5 to <10 years: ≥ 13.5–< 14.5 cm

10 to < 15 years: ≥ 16.0–< 18.5 cm

15 to <18 years: ≥ 18.5 & < 21.0 cm

Adults 18years and above: ≥19 - < 22.0 cm

Pregnant/Lactating women: ≥19 - < 23.0 cm

Elderly 60 years and above: ≥ 16.0cm - ≤ 18.5cm

Severe acute malnutrition (SaM)

Bilateral pitting oedema (any grade)

Or

WFL/H/BMI for age < –3 z-scores (see annex 3)

Adults: BM I <16

Or

MUAC

6 to59 months: < 11.5 cm

5 to <10years: < 13.5 cm

10 to <15 years: < 16.0 cm

15to <18 years: < 18.5 cm

Adults 18years and above: <19.0 cm

Pregnant/Lactating women: <19.0 cm

Elderly 60 years and above: < 16.0cm

SAM with medical complications

OR bilateral oedema +++ OR infant less than 6 months (manage in ITC).

SAM with no medical complication

Passes appetite test on RUTF, (manage in OTC)

For all MAM manage in SFP

aSSESSMEnT CLaSSIFICaTIOnCLaSSIFICaTIOn anD

aCTIOn PLan

Encourage and counsel on good nutrition

no acute Malnutrition

Weight gain parallel to or greater than the median growth curve

WFL/H ≥ –2 z-scores

OR MUAC

6-59 months: ≥ 12.5 cm

5 to <10 years: ≥ 14.5 cm

10 to <15 years: ≥ 18.5 cm

15 to <18 years: ≥21.0 cm

Adults 18 years and above: > 22.0 cm

Pregnant/Lactating: women: ≥ 23.0 cm

Follow up every 1- 2

weeks.

Follow up every 1-2

weeks.


CHAPTER FOUR suPPLementary feeding

Programme for management of moderate acute maLnutrition

4.0 IntroductionSupplementary Feeding (SF) is the provision of nutritious food in addition to the regularmealstoclientswithoratriskof moderateacutemalnutrition(MAM) inspecifiedgroups(particularlyyoungchildren,pregnantwomen,breastfeedingmothersandtheelderly)andforaspecifiedperiodoftime. Supplementary FeedingProgram (SFP) involves theprovisionof nutritious food aswellasotherservices(routinemedication,nutritionandhealtheducation,HIVcounsellingandtestingamongothers).SFPpreventsdeteriorationofpatientswithMAMtoSAM,providesacontinuumofcaretopatientsdischargedfromInpatientTherapeuticCare(ITC)andOutpatientTherapeuticCare(OTC).SFPisparticularlyimportantinemergencysituations.

Therearetwomechanismsthroughwhichfoodmaybeprovided:

GeneralFoodDistribution(GFD)orSelectiveFeedingProgrammes(SFPs)

• TheGeneralfoodrationsinpractice,rarelyprovidesufficientfoodtoallowforcatch-upweightgainforthosealreadymalnourished

• SFPsarethereforea“safetynet”forthosewhosefamiliescannotcopeandarenotsustainedbythegeneralration


TherearetwotypesofSFP:blanketandtargetedsupplementaryfeeding.

blanket sFpaimsatprovidingsupplementaryfoodrationtoallmembersofaspecifiedatriskgroupforadefinedperiodregardlessoftheirnutritionalstatus.Blanketsupplementaryfeedingisprovidedwhentheprevalenceofacutemalnutritionishigh(GAMrate>15%withthepresenceofaggravatingfactors)andgeneralfooddistributionisinadequate.Itaimsatpreventingfurtherdeteriorationofthegroups’nutritionalstatusandreducesMAM.

Targeted SFP provides nutritional support to individuals of MAM. It generally targets childrenunderfiveyears,malnourishedpregnantandbreastfeedingmothers,andothernutritionallyatriskindividuals.ItaimsattreatmentofMAM.

SFPmaybeimplementedthrougha largenumberofdecentralizedsites.ThesearelocatedatornearthesitesforOTC,andshouldbewithinaday’swalk(roundtrip)forthebeneficiary.ThishelpsfacilitatereferralsbetweenSFPandOTC.SFPshouldhavestronghealth/nutritioncounsellingandeducationactivitiesaswellaslinkagestolivelihoodprogrammes(refertoChapterNine)

Supplementaryfoodcanbedistributedaswetrationsason-sitefeedingordryrationsastakehome.

AdmissionCriteriaintoSFP(seeTable3)

PatientswhomeetthefollowingcriteriashouldbeadmittedtoSFP(Table3)

tAble 3: Admission criteriA to sFp

Age cAtegory nUtritionAl indicAtor Admission criteriA





Bilateralpittingoedema Nobilateralpittingoedema


BMIforage Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)

MUACcutoff 5 to less than 10 yearsGreaterorequalto13.5cmandlessthan14.5cm(≥13.5cm&<14.5cm)

10 to less than 15 yearsGreaterorequalto16.0cmandlessthan18.5cm(≥16.0cm&<18.5cm)

15 to less than 18 years Greaterorequalto18.5cmandlessthan21.0cm(≥18.5cm&<21.0cm)


*Adults BMI Greaterorequalto16andlessthan17kg/m2(≥16and<17kg/m2)


Age cAtegory nUtritionAl indicAtor Admission criteriA







MUACcutoff Greaterorequalto16.0cmandlessthanorequal18.5cm(≥16.0cm&≤18.5cm)


Admission Process in SFP

ThefollowingstepsareimportantduringtheadmissionforSupplementaryfeedingservices.

FigUre 9: steps And Flow oF Activities At An sF site

EXIT

rCT

ENTRy

aWaITInG arEa

TriageHealth and nutrition

education

BanTHrOPOMETrIC

arEa

CCLInICaL

aSSESSMEnT

DrEGISTraTIOn

POInT

E DruG DISPEnSInG

arEa

FFOOD DISTrIBuTIOn arEa

Food distributionHealth and Nutrition Education

raTIOn PrEParaTIOn arEa


STEP 1: Triage ( see annex 2) and Nutrition/Health Education

• Conduct triage to fast-track seriously illpatients(seeAnnex1fordetails )

• Identify referred patients from thecommunity,ITC,orSFP.

• Give sugar water solution (1 roundedteaspoon of glucose/sugar in 50 ml water=3 tablespoonsof sugarwater)ororal10%dextrose (Refer to ITC on how it can bereconstituted) to any patients with SAMsuspectedtobeatriskofhypoglycaemiaandreferimmediatelytoITC

• Conduct health and nutrition education tocaregivers/orpatientsnotseriouslyill.

STEP 2: AnthropometrySTEP 3: Clinical assessmentNote: Steps 2 and 3 will follow the same procedure as described in chapter three.

Assessallpatients(newandfollow-up)attendingOTC. Inaddition,theclinicianshould:

• Review the previous treatment for patientsreferred/transferred from other clinics toavoid overdose of routine medicines (seesectionontreatmentprotocol)

• Ensurethattheycontinuewiththetreatmentstartedonearlier

• Patients on treatment for HIV/AIDS, TBshouldbecounselledtocontinuewiththeirmedication.

• Those diagnosed after admission toSFP should be referred to appropriateprogramme/health facility for treatment,careandsupport.

step4: Explain to the patient that he/she ismoderately acutely malnourished. Explainhow the SFP intervention functions andwhenthepatientshouldreturntothehealthcentre.ExplainwhythepatientisbeingadmittedintheSFPandwhenhe/shewillexittheprogramme.

Preparation of ReSoMal from standard ORS:• Water-2litres

• WHO-ORSone-1litrepacket

• Sugar-50g

• 40mlMineralmixsolution*orCombinedmineralsandVitamins (CMV) (20mls-1redscoopmixedin18mlsofboied,colledsafewater)

*Themineralmixsolutionmaybepreparedbythehospitalpharmacy.

Alternatively, a commercial product, calledCombined Mineral Mix (CMV), maybeused.

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step 5: Registerpatient informationintheIntegratedNutritionRegister(INR)refertoAnnex......(IntegratedNutritionRegister).

step 6:Fillouttheintegratednutritionrationcard.(Annex18)

step 7:Dispenseroutinemedicationsasshownintable6

step 8:Conducthealthandnutritioneducationanddispensefoodration,includingdemonstrationoffoodsupplementpreparationifrequiredandgivereturndate.

Step 9: Linkpatienttoanyexistinglivelihoodprogrammeswithinthecommunity

step 10:Compile,summariseandsubmitreports

Supplementary Foods and Ration SizeSupplementaryfoodsmustbeenergydense,highinproteinandrichinmiconutrients,culturallyappropriate,easilydigestibleandpalatable.

Readytousesupplementaryfoodsusuallyprovide500kcalperpersonperdayonassumptionthattheydonotshareandareinsmallquantities.

Thesupplementarydryrationshouldprovidefrom1,000-1,200kcalperpersonperdayand35–45gramsofproteininordertoaccountforsharingathome.Itshouldbedesignedtoprovide10-13%ofthetotalenergyfromproteinand30-40%totalenergyfromfat.Wetrationshouldprovide500-700Kcaland15-25gramsofprotein.2

Theserationsmaybegivenonaweeklytomonthlybasisdependingonthesupplementaryfoodtype,programdesignandcontext.

Therearespecializednutritiousfoodsthatcanbeusedforthedifferenttargetgroups.Theseinclude:

• Fortifiedblendedfoods(Cornsoyblend(CSB),supercerealplusandsupercereal).

• Lipidbasednutrientsupplement(LNS)suchassupplementaryplumpy

Lipid Based Nutrient Supplement (LNS)

• Targetgroup:Children6-59months

• Keyingredientsinclude:Peanuts,sugar,whey,vegetableoil,milk,soyprotein,cocoa,vitaminsandminerals

• Nutrientprofile(92g)

o 500kcal,

o 13gprotein(10%),

o 31gfat(55%).

o Containsessentialfattyacids,

o Meets recommended nutrient intake (RNI) and protein digestibility corrected amino acidscore(PDCAAS)

2 WHO.Guideline:Updatesonthemanagementofsevereacutemalnutritionininfantsandchildren.Geneva:WorldHealthOrganization;2013.2UNHCR,guidelinesforselectivefeeding:UnitedNationsHighCommissionforRefugees


Fortified Blended Foods Super Cereal Plus

• Targetgroup:Children6-59months

• Keyingredientsinclude:Corn/wheat/rice,soya,milkpowder,sugar,oil,vitaminsandminerals

• Nutrientprofile(200g-includesprovisionforsharing)

o 787kcal,

o 33gprotein(17%),

o 20gfat(23%).



Corn Soy Blend CSB/Super Cereal

• Targetgroup:PregnantandLactatingWomen,MalnourishedindividualsonART/DOTS

• Keyingredientsinclude:Corn/wheat/ricesoya,vitaminsandminerals

• Nutrientprofile(200-250g-includesprovisionforsharing)

o 752-939kcal,

o 31-38gprotein(16%),

o 16-20gfat(19%).



tAble 4: sFp rAtions And their nUtrition vAlUe

TAkE-HOME RATIONS ON-SITE RATIONSExampleTHR1

ExampleTHR2

ExampleTHR3

ExampleOn-Site1

ExampleOn-Site2

ExampleOn-Site3

FBF(g) 250 200 125 100Soy-basedRUSF(g) 92*FortifiedBiscuits(g) 125FortifiedVegetableOil(g) 25 20 10 10Sugar(g) 20 15 10 10nUtritionAl vAlUesEnergy(Kcal) 1300 1000 500 573 630 530Protein(g) 45 36 13 18 23 18Fat(g) 40 32 33 21 17.5 16

THR: Take Home Rations Source: IMAM WFP-UNHCR-SFP guidelines, 2009


Bothdryrations(takehome)andwetrations(on-sitefeeding)haveadvantagesanddisadvantagesasillustratedintable5below.

tAble 5: AdvAntAges And disAdvAntAges oF dry And wet rAtion

type oF rAtion

AdvAntAges disAdvAntAges

Dryration • Possibilityformotherstoparticipateinmealpreparation

• Nutritionandhealtheducationpossible

• Abletocheckchildrenandensuretheyeattheirmeal(Sharingtherationandmisuseoffoodislimited)

• Trainingpersonnelinfoodpreparationandhygieneisdone

• Bringingstaffandbeneficiariestogetherpossible

• Noguaranteethatthebeneficiarywilleatthewholeration

• Lackofmonitoringofuseoftherationinhomes

• Difficulttoholdhealtheducationsessionsandtohavecollectivedemonstrations

• Largeamountoffoodrequired

Wetration • Possibilityformotherstoparticipateinmealpreparation

• Nutritionandhealtheducationpossible

• Abletocheckchildrenandensuretheyeattheirmeal(Sharingtherationandmisuseoffoodislimited)

• Trainingpersonnelinfoodpreparationandhygieneisdone

• Bringingstaffandbeneficiariestogetherpossible

• DisruptionoffamilytasksduetodailypresenceatSFC

• Increasedriskoftransmissiblediseases

• Largestaffrequirement

• Largeconstructionneeds

• PossibilitythatfoodtakenattheSFCwillbeasubstituteforthatinthehome

Treatment protocols in SFP

Theseinclude:

• SupplementationwithvitaminAonadmission*(onlyiftheyhavecomedirectlytoSFPoriftheyhavenotreceivedanyVitaminAsupplementationinthelast30days).

• Treatmentofallchildrenforworminfestation(Deworming)

• Measlesvaccinationforallchildrenbetweenninemonthsandfifteenyearsofage

• Supplementation of iron and folic acid on admission. These should be administered amongpatientswithsignsofanaemiaandinpregnantwomen.(Refer to Table 6)


tAble 6: roUtine medicAtions For pAtients in sFp

medicAtion when Age prescription dose

VitaminA* Onadmissionifnotreceivedintheprecedingmonth

6monthsto1year<6monthsnotbreastfed

100000IU

50000IU

Singledoseonadmission

>1yearofage 200000IU

Albendazole

OR

Onadmissionifnotreceivedinthepreceding6months

<1year Donotgive

1-2years>2years

200mg400mg


Mebendazole**(Givenonlyifalbendazoleisnotavailable)

Onadmission <1year Donotgive

1-2year>2years

250mg500mg


Iron:Giveonlywithsignsofanaemiaordiagnosedwithanaemia

OneachSFPvisit Children<10kg 30mg ½tabdaily

Children≥10kg 60mg 1tabdaily

FolicAcid Onadmission Children<1yearChildren>1year

2.5mg5mg

Singledosedaily

Measles****vaccination

OnadmissionifnorecordofreceivingPreviously

≥9monthsand<15years

Vaccine Once if not receivedthevaccinationyet

CotrimoxazoleHIV-positiveandexposedpatients(Antibioticcover for PCP prophylaxis)

Dailydosetocontinue

Dosedependantonbodyweight

DifferentstrengthsofCotrimoxazole(RefertoTable11

Oncedailybutcontinueindefinitelyasprophylaxis.

*Do not give if patient received within the previous 6 months. However it can be provided if the patient has eye signs of Vit A deficiency, has/had measles in the last 3 months3

** Dose can be given again after 3 months if signs of re-infection appear.

***Pregnant and lactating women should attend the Antenatal Care / Post-Natal Care for Iron/folic Acid supplementation

****Follow National immunization guidelines for measles vaccination

3


Follow-Up of a Patient in SFP

ThefollowingshouldbedoneateachvisitoftheSFP

• Reviewtheregularityofattendanceanddiscusswithcaregiverthereasonsforanyabsence

• Anthropometry:Takeweight,height/lengthandMUACmeasurementstoassessprogress.StaticweightorweightlossmayrequirereferraltoOTCifadmissioncriteriaaremet.

• Doamedicalassessmentandreferfortreatmentifrequired.

• Conductgrouphealthandnutritioneducation.

• Assessthesupplyofthesupplementaryfood

• Assessthereadinessfordischargeaccordingtodischargecriteria

• Linkthepatienttofoodsecurityandlivelihoodprograms

Exit Criteria from SFP

ApatientcanexitfromSFPeitherasadischargeortransfer

Dischargesinclude:cured,defaulters,non-respondentsanddeaths.

tAble 7: types oF eXits From sFp

type oF eXits description

TransfertoOTC/ITC Staticweight for height orMUAC orweight loss for two consecutivevisits)and/ormedicalcomplications(i.e.notrespondingtotreatment)

Nonresponse For 3months* and have not reached the target weight for height orMUACwithoutaggravatingconditionslikemalaria,diarrhoea,etc

Defaulter Patientsmissingtwoconsecutivevisits

Dead Patientsdiedwhileontheprogramme

Cured AttainedWFHorBMI forAgeZ score>-2SD,BMI foradultsabove19years>18.5Kgm-2ornormalMUACcutofffortherespectiveagecategory.RefertoTable8forthecutoffsforthevariousagegroups.


tAble 8: dischArge criteriA From sFp

Age cAtegory nUtritionAl indicAtor eXit criteriA



Greaterorequalto-2z-score(≥-2SD)

MUACcutoff Greaterorequal12.5cm(≥12.5cm)



BMIforage Greaterorequalto-2z-score(≥-2SD)

MUACcutoff 5tolessthan10yearsGreaterorequalto14.5cm(≥14.5cm)

10tolessthan15yearsGreaterorequalto18.5cm(≥18.5cm)

15tolessthan18yearsGreaterorequalto21.0cm(≥21.0cm)


*Adults BMI Greaterorequalto17kg/m2(≥17kg/m2)

MUACcutoff Greaterorequalto22.0cm(≥22.0cm)








*SPHERE2011

4.1 OpeningandClosingaSupplementaryFeedingProgramme

Opening a Supplementary Feeding Programme

AdecisionaboutwhethertoopenSFPsshouldtakeintoconsideration;malnutritionrates,contextualfactors,publichealthpriorities,availablehuman,materialandfinancialresourcesandtheobjectivesoftheimplementerasdetailedinTable9.Thedecision-makingframeworkneedstobeusedrelativetolocalcircumstances.


TABLE 9: DECISION-MAkINg FRAMEWORk FOR OPENINg A SUPPLEMENTARy FEEDINg progrAmme4

Finding Action reQUired

Malnutritionrate(GAM)≥15%or 10–14%plusaggravatingfactors

Serious situation:

• Generalrations(unlesssituationislimitedtovulnerablegroups)• Blanketsupplementaryfeedingforallmembersofvulnerable

groups,especiallychildren,pregnantandlactatingwomen• Therapeuticfeedingprogrammeforseverelymalnourished

individuals

Malnutritionrate(GAM)10–14%or 5–9%plusaggravatingfactors

Risky situation (alert):

• Nogeneralrations,but• TargetedSupplementaryfeedingforindividualsidentifiedas

malnourishedinvulnerablegroups• Therapeuticfeedingprogrammeforseverelymalnourished

individuals

Foodavailabilityathouseholdlevel<2100kcalperpersonperday

Unsatisfactory situation:

• Improvegeneralrationsuntillocalfoodavailabilityandaccesscanbemadeadequate

Malnutritionrate(GAM)under10%withnoaggravatingfactors

Acceptable situation:

• Noneedforpopulationinterventions• Attentiontomalnourishedindividualsthroughregular

communityservices

Aggravating factors can include:

• Worseningofthenutritionalsituation

• Foodavailabilityathouseholdlevellessthanthemeanenergyrequirementof2100kcal/person/day

• Thegeneralfooddistribution(GFD)isbelowmeanenergy,proteinandfatrequirements

• Crudemortalityratemorethan1per10000perday

• Epidemicofmeaslesorwhoopingcough

• Highprevalenceofrespiratoryordiarrhoealdiseases.

4.2 RequirementsandProcessforSettingUpaSupplementaryFeedingSiteTheSFPcanbeimplementedatasitewithinahealthfacilityorcommunity,providedthefollowingrequirementsareinplace:

• Trainedserviceproviders(refertoBoxC)

• Functionalanthropometricequipment

• Stockcontrolsystems

• MonitoringandReporting(M&R)tools

4 WHO(2000).TheManagementofNutritioninMajorEmergencies,Geneva:WHO


• Information,EducationandCommunicationmaterialsandjobaidsforhealth/nutrition

• Continuoussupplyofsupplementaryfood

• Safeandsecureplaceforstoringenoughsupplementaryfoodtolastatleasttwomonths

• Routinemedications

When to Close a Supplementary Feeding Programme

Theclosure/exit strategy shouldbeplanned fromthebeginningof theprogramme.Steps takenandthefinaldecisionshouldalwaysbemadeinconsultationwithallstakeholders.Populationlevelassessmentofnutritionstatusshouldbepartofthedecisiontocloseaprogramme.

CriteriaforclosingblanketandtargetedSFPsaresummarizedinTable10

tAble10: gUidAnce on criteriA For closing sFps

blAnket sFp tArgeted sFps

• GeneralFoodDistribution(GFD)isadequateandismeetingplannedminimumnutritionalrequirements.TheGFDshouldalsohaveaspecificfoodthatmeetstheminimumnutritionalrequirementsforyoungchildren.

• Prevalenceofacutemalnutritionis<15%withoutaggravatingfactors.

• Prevalenceofacutemalnutritionis<10%withaggravatingfactors.

• Diseasecontrolmeasuresareeffective.

• GFDisadequate(meetingplannednutritionalrequirements).

• Prevalenceofacutemalnutritionis<10%withoutaggravatingfactors.

• Controlmeasuresforinfectiousdiseasesareeffective.

• Deteriorationinnutritionalsituationisnotanticipated,i.e.seasonaldeterioration.

Thedurationof ablanket SFPdependson the scale and severityof thedisaster, aswell as theeffectivenessoftheinitialresponse5.Attheendofthisperiodifthesituationisstillpoor,eitherblanketfeedingcouldbecontinuedortargetedfeedingcouldreplacetheprogrammetoensurethatthemostvulnerablearetreated.

Targeted SFP canbeclosedwhentheprogrammehaslessthan30beneficiariesandtheseshouldcompletetreatmentwhilethenewcasesshouldbereferredtootherservicessuchashealthcentresorhospitalsand/orlivelihoodprogrammes.Inunstableandinsecuresituationstheprogrammemaybemaintainedasa‘safetynet’.

Whenfeasibleandappropriate,agradualprocessofhandoverandintegrationintolocalprimaryhealth services, community health programmes like safe motherhood, HIV/ AIDS, PD Hearth,immunization,integratedmanagementofchildhoodillnesses(IMCI)shouldbeundertaken.

5 Initialplanningtimeframesgenerallyanticipateadurationof3monthsforablanketSFP.

NOTE• In a non emergency situation where there is no SFP, there should be routine nutrition and health

education, routine practical food demonstrations, routine medications, HIV counselling and testing and follow ups to prevent deterioration of MAM to SAM.

• Link to food security and livelihood programmes


ThefollowingaretherequirementsthatshouldbeputintoconsiderationwhensettingupaSFP.(i) key Staff • In-chargeofthecentre• RecordsAssistant• Nurse/PublicHealthNurse• Nutritionist• DomesticAssistant• StoreKeeper• SocialWorker

• Supportstaff(Securityguardsandcleaners)(ii) Location

• Presenceofawatersource:Thewatersourceshouldbenearbyforhandwashing,cleaningequipmentandthewatershouldbesafefordrinking.

• Closetoahealthfacility:Thewalkingdistanceshouldbe2hoursorlessonfoot;

• Capacityofthesite:Thenumberofbeneficiariesshouldnotbetoolarge

(iii) Structure• Asuitableexistingstructure,preferablyata

healthfacilityor,existingstructuressuchasahouse,school,church,underatreeetc.Ifnoneoftheseisavailable,constructasimplefencedstructurebigenoughtocontainroomforregistration,andtakinganthropometric

measurements,1shelterforwaitingwherehealtheducationsessionscouldalsobeheldandadistributionroom

• Toiletorlatrineswithawatersourcenearbyforhandwashing

(iv) Equipment and basic supplies

Basic equipment:Weighingscalesforchildrenandadults,Heightboard,MUACtapes(childandadult),Calculator,furniture,sourceofheat,cookingequipment,mixingequipmentsuchasbowls,spoonsandladles.

Basic supplies/items: IntegratedNutritionRationcard,Referralforms,Dailyscreeningtools,IntegratedNutritionRegister(INR),stockcards,RegisterforGrowthPromotionMonitoring(atcommunityandhealthfacilitylevels),ListofOutpatientandinpatienttreatmentsites,EssentialmedicinesasrequiredintheroutinemedicalprotocolforSFP,Thermometer,Timewatch,Scissors,Foodrations,Hygieneandsanitationsupplies,Information,EducationandCommunicationmaterialsforhealth/nutritioneducation,dozingcharts,rationdistributionchartsandjobaids(WeightforHeightz-scoretables,BMIforagez-scoretables)

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(v). Storage facilities• Asolidstructurewithconcreteand

cementedfloor,wellventilatedandprotectedfromdampness,rodentsandpestsandsecurefromtheft

• Thestoragecapacityhastobesuitableforthequantitytobestoredi.e.1tonneoffoodstufftoabout2m³ofspace

• Thefacilitiesshouldbeeasilyaccessibletotrucksatalltimes

• Fooditemsshouldbestackedonpallets.

(vi). Determining quantity and frequency of delivery of suppliesThiswilldependon:

• Typeofsupplementaryrationtobegiven

• Numberofbeneficiaries

• Distancebetweenthecentralwarehouseandthesupplementaryfeedingcentre

• Availabilityofvehicle(s),fuelanddriver(s)

• Typeofvehicle(truck,pick-up);and

• Weatherandterrain

(vii). Security measures and procedures in place for transporting logistics and supplies.

1. Loadingthevehicleatthecentralwarehouse

• Thequantitiesnecessaryforeachcentreshouldbeestablishedinadvance,basedonthestockremaininginthecentreandtheestimatedneedsoftheperiod.

• Thestorekeepershouldrecordthequantityrequestedfor,signit,andsoshouldthedriverwhenthevehicleisloaded.Thisshouldalsoberecordedonthestockcardsforthecentralwarehouse

2. Destinationtothecentre

• Atrusteddriverandasaferouteshouldbeusedforthistaskinordertoavoidtheft

3. Deliverytothecentre

• Thefoodsdelivered(quantities,stateofthesacks,etc.)shouldbenotedinadeliverynoteandsignedbythedriverandthesupervisorofthecentre

• Thedeliverynoteshouldthenbecheckedbythesupervisoryteam,thencomparedwiththatofthewarehouse

• Thedeliverymustbedoneinthepresenceofthesupervisorofthecentre.


CHAPTER FIVE outPatient theraPeutic care

for the management of acute maLnutrition with no medicaL

comPLications

5.0 IntroductionOutpatienttherapeuticcare(OTC)isaimedatprovidinghome-basedtreatmentandrehabilitationforSevereAcuteMalnutrition(SAM)patientswhohaveanappetiteandnomedicalcomplications.OTCalsoaimsattimelydetectionofacutemalnutrition,referral,andearlytreatmentbeforeonsetofmedicalcomplications.Follow-upoftheenrolledpatientsisalsoacrucialpartofmanagement.

OTCcanfunctioneitherasastaticormobileservice.StaticOTCservicesshouldbeconductedinasmanyhealthfacilitiesaspossible(withsufficientcapacityinplace)andshouldbeintegratedintoroutineservicedelivery.Similarly,mobileOTCservicesshouldbeintegratedintoroutineoutreachservicese.g.,inemergencysituationsandotherwise.Thisensuresgoodaccessandcoveragesothatasmanyacutelymalnourishedpatientsaspossiblecanaccesstreatmentwithinaday’swalkfromandbacktotheirhomes.


AfullyfunctionalOTCshouldhavethefollowinginplace:

• ServiceproviderstrainedinIMAM

• Up-to-dateIMAMguidelines

• Functional anthropometric equipment(weighing scales, height boards, MUACtapes),monitoringandreportingtools.

• Appropriate Information, Education andCommunication materials for examplecounselling tools, and IMAM Job Aids forhealth/nutritioneducation.

• AdequatesupplyofRUTF

• Routinemedications

• ServicestoscreenforHIVandTB.

RequirementsforOTCarelistedinBoxF.

5.1 AdmissionCriteriaforOTCAll patients who meet the following criteriashouldbeadmittedandtreatedinOTC(seeBoxDandTable2)

• SAMwith no medicalcomplications,clinicallywellandalert,andwithappetite(abilitytoeattheReadytoUseTherapeuticFood[RUTF])

• Discharges for ITC irrespective of theiranthropometry

Note: For the success of the IMAM services, the home conditions or environment should be conducive6 and caregiver willing to treat at home.

6 MayincludeGoodWater,SanitationandHygiene,(WASH)practices,childcaringpractices,andfoodsecurity

Definition of SAM without medical complicationsThepatienthasappetiteforRUTF,clinicallywellandalert.ANDForChildrenBilateralpittingoedema(+/Grade1or++/Grade2)ORWFL/HorBMIforage<–3z-scoresORMUAC6to59months:<11.5cm5to<10years:<13.5cm10to<15years:<16.0cm15to<18years:<18.5cmForadultsBilateralpittingoedema(+or++)ORBMI<16ORMUAC<19.0cmPregnant and LactatingWomen with anInfantlessthansixmonthsMUAC<19.0cm

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5.2 AdmissionprocessandactivitiesinOTCThelayoutoftheOTCareashouldbewellplannedtoensureasteadyflowofpatientsaswellasorganisedprovisionofcomprehensivehealthandnutritionservices(Figure 10).

FigUre 10: lAyoUt oF the otc AreA

Note: This layout is for a stand alone OTC. However, these activities can be integrated into existing outpatient clinics e.g., OPD, YCC, MCH, TB clinics, HIV/ART clinics, , etc.

STEP 1: Triage (Refer to annex 2)

• Conducttriagetofast-trackseriouslyillpatients

• Identifyreferredclients/patientsfromthecommunity,ITC,orSFP.

• Give50mlsof10%glucoseorsugarsolution (1 teaspoonofglucoseorsugar in50mlof safewater)toanypatientswithSAM,suspectedtobeatriskofhypoglycaemia

• Conducthealthandnutritioneducationtocaregiversof/orpatientsnotseriouslyill.

Steps 2 and 3 will followthesameprocedureasdescribedinchapter three. Assessallpatients(newandfollow-up)attendingOTC. Inaddition,theclinicianshould:

• Review the previous treatment for patients referred/transferred from other clinics to avoidoverdoseofroutinemedicines(Table11)

• Ensurethattheycontinuewiththetreatmentstartedearlier.

PatientsontreatmentforHIV/AIDS,TBshouldbecounselledtocontinuewiththemedication.ThosediagnosedafteradmissiontoOTCshouldbereferredtoappropriateprogramme/healthfacilityfortreatment,careandsupport.

Dispensing Medicine & RUTF

Qualified persons Registered &

Counseled on HIV Testing

RUTF test amount served to client Fails if does not

complete/Passes if completes amount

Clinical Assessment/ Immunization update

Anthropometric measurements

TRIAGE Nutrition & Health

GENERIC FLOW OF ACTIVITIES IN OTC

2) Anthropometry Area

3) Clinical Assessment

1) Waiting Area

5) Registration and counsellingin OTC4) Appetite Test 6) Dispensing


tAble 11: roUtine drUgs And sUpplements in otc

condition to be mAnAged DRUg/SUPPLEMENT WHEN/FREqUENCy

Hypoglycaemia 10%glucose/sugarsolution Once,atthetriage

Bacterialinfections Amoxicillin Twicedailyfor5-7days(accordingtobodyweight)

Firstdosetobestartedonadmissionundersupervisionofthehealthworker.

Explainhowtocompletetreatmentathome.

Measles(checkChildHealthcard:Ifnotalreadyvaccinated)

Vaccinateif≥9monthsupto5years

Onadmissionsingledose

Malaria(doBloodSmearorRDT) Anti-malarials Treataccordingtonationalprotocolsiffoundtobehavemalariaparasites.

VitaminAdeficiency(CheckforsignsofvitaminAdeficiencyastheconditionofeyescandeteriorateveryrapidly.

Ifcornealulcerationispresent,refertoITC

• DonotgiveVitaminAtopregnantwomen

• DonotgivevitaminAroutinelytolactatingmothersexceptwherethereisclinicaldeficiency(seechapter9)

• DonotgivevitaminAroutinelytoanypatientonRUTF

VitaminAcapsule

0-6months-50,000IU

6-12months-100,000IU

>12months-200,000IU

Shouldbegivenonlyonce at dischargefromOTCandundersupervisionofthehealthprovider.

Anaemia(checkforsignsofanaemiaanddorelevantinvestigations)

IronandFolicAcid-5mg Treataccordingtocause.

Helminthicinfection(worminfestation)

Mebendazole:

1-2years:250mg

>2years:500mg

ORAlbendazole:

1-2years:200mg

>2years:400mg

Atsecondvisit


STEP 4: Perform the appetite test with RUTF

Ensurethatmother/caregiverandchildwashhandswithcleanwaterandsoap.Assesspatient’sappetitebygivingasmallamountofRUTF(Table12).MalnourishedchildrenmayrefusetotakeRUTF because they are in an unfamiliar/strange environment. If so, the mother/caregiver andhealthworkershouldmovethechildtoacomfortablesettingandslowlyencouragethechildtoeattheRUTF.Provideenoughsafedrinkingwaterforthepatient.PatientswhopasstheappetitetestshouldbeconsideredforadmissiontoOTC.

Patientswhofailtheappetitetestshouldbesentbacktotheclinicianforreassessment.

tAble 12: Appetite test For rUtF

WEIgHT (kg) sAchets oF rUtF

<4 <1/4

4.0 – 6.9 >1/4

7.0 – 9.9 ½

10.0 – 14.9 ½-¾

15.0 – 29.9 ¾-1

≥30.0 >1

STEP 5: Registration and Counselling in OTC

• Recordthepatient intheIntegratedNutritionRegister(INR)asperpatientcategory(e.g.newadmissions,relapses,)

• ExplainthereasonsandpurposeforadmissiontotheOTCandexpectedtreatment,careandsupport.

• CalculatetheamountofRUTFtobegiventothepatient(RefertodosingchartforRUTFinAnnex:8)andrecordontheintegratednutritionrationcard.

• Counselcaregivers/patientsonkeymessages(RefertoBoxE)

• Linkcaregivers/patientstootherprimaryhealthcareservicesorinitiatives(e.g.,YCCorgrowthmonitoring programme, HIV/TB, VHT, livelihood programmes, etc.) as may be needed orrequired.

• Counsel caregivers/patients to return for scheduled follow-upvisits toenablemonitoringofprogress. Depending on the OTC site’s schedule and the ability of the patient to return orcaregivertobringinthechild,weeklyorbi-weeklyfollow-upsessionsshouldbescheduled.

• Askthecaregiver/orpatienttoreturnforeachOTCfollow-upsession,andtheimportanceofcompliancewiththisisexplained.


key Messages at First Visit 1. RUTFisbothafoodandmedicineforseverely

malnourishedpatientsonly.Itshouldnotbeshared

2. Give small regular meals of RUTF andencouragethepatienttoeatoften(ifpossibleeightmealsaday)

3. NevermixtheRUTFwithotherfoods.Mostcereals and beans contain anti-nutrientsand inhibitors of absorption thatmake thespecial nutrients in theRUTF that the childneedstorecoverunavailableforthechild.IfotherfoodsaregiventheyshouldbegivenataseparatetimefromtheRUTF

4. For children who are still breastfeeding,always breastfeed before offering RUTF.Continuetobreastfeedregularly

5. AlwaysofferthepatientplentyofsafewatertodrinkwhiletakingRUTF.

6. Ensurethepatient’shandsarewashedwithcleanwaterandsoapbeforeeating.

7. Keep food clean and covered, includingsachets of RUTF which should be rolled upfrom the opened end and kept in a cleancoveredcontainer

8. Ifa patienthas diarrhoea,continueto feedwith RUTF. Offer frequent meals in smallquantitiesifthepatient’sappetiteisreduced

9. Malnourished patients get cold quickly.Therefore, always keep them covered andwarm

10. If the patient develops a reaction to RUTF,discontinue use and take to the nearesthealthfacilityfortreatment.

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Step 6: Dispense medication and RUTF

DispensingofRUTFandOTCmedicationsshouldbeintegratedwithinthefacilitydispensingsystem.

PatientsadmittedtotheOTCshouldreceivetheprescribedRUTFaswellasroutineandappropriatemedication(Table11)

RUTF in Management of Severe Acute Malnutrition in OTC RUTF is an energy and nutrient-dense pre-packed paste designed for the treatment of acutemalnutrition.Therationgiventoapatientisbasedonhis/herweightandtheintakerequirementofbetween175and200kcal/kg/day.RUTFisdose-relatedandshouldbegivenonprescription.

Composition of RUTF

• Hasacaloricvalueof500kilocalories(kcal)per92gofproduct

• Contains25%peanutbutter,26%milkpowder,20%oil,27%sugar,2%combinedmineralsandvitamins(CMV).

Benefits of using lipid based RUTF

• Itiseasytocalculatethequantityrequiredforeachbeneficiarybasedonweight

• Itdoesnotrequirepreparationorcooking

• Patientcanjustopensachetandeatdirectly

• Doesnotneedtobedilutedwithwater.Thiseliminatestheriskofcontamination.

• Canbeusedathomewithsupervisionfromthehealthfacility

• Reduces on the number of staff necessary or needed for preparation and distribution oftherapeuticfood

• ItreducestheneedforITCadmission

• RUTFhasalongshelflife

• Itdoesnotrequirerefrigeration

Nutrient Composition of RUTF (plumpy’ nut)The energy and Nutrient Composition of Guidelines for Integrated Management of AcuteMalnutritioninUganda

Plumpy’nutisshowninTable13.


TABLE13: ENERgy AND NUTRIENT COMPOSITION OF RUTF (PLUMPy’ NUT)

nUtrient per 92g sAchet nUtrient per sAchet 92g

Energy 500kcal VitaminA 840mcg

Proteins 12.5g VitaminD 15mcg

Lipids 32.86g VitaminE 18.4mg

Calcium 276mg VitaminC 49mg

Phosphorus 276mg VitaminB1 0.55mg

Potassium 1022mg VitaminB2 1.66mg

Magnesium 84.6mg VitaminB6 0.55mg

Zinc 12.9mg VitaminB12 1.7mcg

Copper 1.6mg VitaminK 19.3mcg

Iron 10.6mg Biotin 60mcg

Iodine 92mcg Folicacid 193mcg

Selenium 27.6mcg Pantothenicacid 2.85mg

Sodium <267mg Niacin 4.88mg

How to Administer RUTF• Washhandswithcleanrunningwaterandsoap

• TheRUTFshouldbegiventothepatientinsmallamountsandfrequently(e.g.½sachet*8timesperday)providedthatthedailyamountisaccordingtoprescription.

• AlwayshavesafedrinkingwaternearbywheneverthepatientiseatingRUTF.

• MakesurethatthepatientconsumesandfinishestherecommendedRUTF.RUTFshouldnotbegivenatthesamesittingwiththefamilypot.

• Anutritiousmealmadefromlocallyavailablefoodscangraduallybeintroducedasthepatient’shealthimproves.

• ChildrenshouldbesupervisedwhiletheyconsumetheirRUTFandmeals.

Allergic Reactions to RUTF:Althoughitisunlikely,thereisaminimalriskofapatienthavinganallergicreactiontothepeanutbutterinRUTF.ItisimportanttoaskforhistoryofallergytotheRUTFingredients.

Theallergymaycausereactionsintheformof:• Skinchanges:hives,Rashes

• Bodyswelling,

• Shortnessofbreath,

• Anaphylacticshock.

Ifthepatientdevelopsanyofthesesymptoms,discontinueadministeringRUTF.Thepatientshouldbetreatedforallergicreactionatthenearesthealthfacilityimmediatelyandpharmaco–vigilanceformfilledappropriately.


Exit Process and Discharge CriteriaThepatientcanexitascured,non-respondent,dead,transferredanddefaulted.Table14showsthecategoriesandcriteriaforexitfromOTC.

tAble 14: types And criteriA For eXit From otc

cAtegory oF dischArge

dischArge criteriA Action

Cured* • WFL/Hor≥-2z-scores(6-59months)

• BMI-for-age≥-2z-scores(5-19years)

• BMI>18kg/m2(adults>18years)

• AND• Nobilateralpittingoedema

for2weeks• ClinicallywellandalertORMUAC:• ≥12.5cm(6monthsto

<5years)• ≥14.5cm(5to<10years)• ≥18.5cm(10to<15years)• ≥21.0cm(15to<18years)• >22.0cm(pregnantand

lactatingwomenwithinfantlessthan6months)

• ≥22.0cm(Adults)AND• Nobilateralpittingoedema

for2weeks• Clinicallywellandalert

• RecordinINRas“Cured”.• Linkcaregivers/patientstoother

primaryhealthcareservicesorinitiativesatFacility/orcommunity:o YCCorGrowthMonitoring&

Promotion(GMP)programmeo SFPorotherLivelihood

programmeswhereavailableo HIV/AIDS/TBcareandtreatment

services

Non-Respondent • Hasnotreacheddischargecriteriaafterthreemonths(fourmonthsfortheHIV/TBpatients)

• RefertoITCforre-evaluationIfHIV/TBstatusisknown:• Assessonacase-by-casebasisand

takeactionafterdiscussionwiththepatient’sHIV/TBtreatmentprovider

Defaulted • Absent(notreportedorfollowed-upinthecommunity)for2consecutivevisits

• Makeafollow-uphomevisittoassesssituationtosupportthefamilyinmonitoringthepatientprogress

• Onreturn,thepatientmayre-enterOTCifhemeetstheadmissioncriteria




• Followthecriteriaforregisteringthepatientasare-admissionusingthenumberpreviouslygiven

TransferredtoITC • ConditionhasdeterioratedandrequiresITC

• Notrespondingtotreatment

• Fillareferralslipwithinformation(includingmedicines)andthereasonfortransfer

• RecordinINRas“transferredtoITC”

Transfertoothermedicalservices

• Ifpatient’sconditiondeterioratesneedingattentionforothermedicalservices

• Fillareferralslipwithinformationincludingmedicinesandthereasonfortransfer

• RecordinINRas“transferredtoothermedicalservices”

TransfertootherOTC

• PatienttransferredtoothernearbyOTCsorasrequestedbycaregiver

• UseareferralformandstatereasonsfortransfertoanotherOTC

• RecordinINRas“transferredtootherOTC”

Died • Diedwhileonprogramme • RecordinINRas“died”

Note: *If the patient meets the above criteria and has spent a minimum of four weeks in the programme (a minimum of three visits to OTC including the initial visit) and a maximum of 90 days

5.3 DischargeProcedures• Thankthecaregiver/orpatientontheroleshehasplayedonensuringrecoveryofthepatient

• Whentheclienthasattainedtheappropriateexitcriteria,dischargeon last ration(at least1weekssupply)andlinktolivelihoodprogramandcomplementarynutritionservices(Table14)wherethereisnoSFPortransfertoSFPifavailable.

• RecordthedischargeoutcomeintheINRandtheintegratednutritionrationcard.

• Advisethecaregiver/orpatientongoodnutritionandcaringpractices.

• Advisethecaregiver/orpatientto immediatelygotothenearesthealth facility ifpatienthasinabilitytoeatorhasanyofthefollowingsignsandsymptoms:

o Noappetiteo Vomitingo Lethargicorunconsciouso Convulsionso Bilateralpittingoedemao Losingweighto Highfevero Diarrhoeaorfrequentwaterystoolsorstoolswithblood

o Difficultorfastbreathing


5.4 ProcessandRequirementsforSetting-upanOTCProcess for Setting-up an OTC

• Identify theneed for setting-up anOTC (for example, highGAMand SAM rates, aggravatingfactors)throughconductinganeedsassessment

• Identifyotherstakeholdersincludingpartners

• Mobilizeresourcesincludingfinancial,human(knowledgeableandskilled),space,equipments,supplies,andtools

• Mobilize,sensitizeandinvolvethecommunity

• SelectionofOTCsite

• MaketheOTCfunctional

• CreatinglinkageswithinIMAMnetwork

• Monitoring,reporting,supervisionandevaluationoftheprogramusingexistingstructures.

Requirements for setting-up an OTCLocation

• OTCservicesshouldbeintegratedwithintheexistingHealthFacilityinfrastructure

• MobileOTCshouldbeintegratedwithinotheroutreachprogrammes.

• Thesiteshouldhavethefollowing:

o Ashadeandadequatespacetoserveasawaitingareaforthebeneficiariestoseat(Triage,Heathandnutritioneducation)

o Cleanwaterandsoapforhandwashing

o Safedrinkingwaterforconductingappetitetest

Human resource Theseinclude:

• AnIn-charge,nutritionist,dispenser,recordsassistant,threenurses,onehealtheducator,onehealthassistant,oneporter,securityguard,storekeeper,andmedicalsocialworkerdependingonthelevelofthehealthfacility.

• Thesepersonnel shouldhavebeen trainedon integratedmanagementof acutemalnutritionpackage.Someofthesestaffmaybealreadyemployedatthehealthfacilitiesandifso,thereisnoneedforrecruitingmore.However,whereallpositionscannotbefilledthenthereshouldbetaskshifting.

Equipment and supplies

• EquipmentandsuppliesforOTCaredescribedinBoxF.

• Theequipmentshouldbefunctionaltoensureaccuracyofthemeasurements

• Some of the equipment should be routinely calibrated and standardized according to themanufacturer’sinstructions.


• Suppliesshouldbeorderedthroughroutinesupplychainmanagementsystem

• Goodsupplychainmanagementpracticessuchastimelyorderingandaccurateforecastingofsuppliesshouldbeobservedtopreventstock-outsandoverstockingthatmayleadtolossessuchasexpiryofsupplies,damagesamongothers

Storage facilityThestorageperiodfornutritioncommoditiesisusuallylessthanthreemonthsandnotmorethan12months

Thebasicfacilityrequirementsshouldinclude:

• Adequatestoragespacewithspaciouswalk-ways

• Adequatelightingandventilation

• Protectionfrominsectsandrodents

• Clean,dryandrainproofstorageroom

• Securedstoragearea,withlockandkeyandaccesstoonlyauthorizedpersons

• First-expiryfirst-out(FEFO)andfirst-infirst-out(FIFO)principleobserved

• Freefromdirectsun-heat

• Medicinesandsuppliesstoredonpalletsawayfromfloorsandwalls

Data collection tools and Job aidsThetoolsinclude:

• INR,integratednutritionrationcards,tallysheets,HMISreportingforms(Monthlyandquarterly)

Jobaidsmayinclude:

• Counsellingcards,RUTFdosingandappetitetestchart,admissionanddischargecriteriachart,routinemedication charts,WFL/Hand BMI for- age-z-score reference charts, BMI referencecharts

guidelines and IEC MaterialsOTCshouldhavethemostupdatedversionofthefollowingguidelinesforpurposesofreference:

• IntegratedManagementofAcuteMalnutrition(IMAM)

• InfantandYoungChildFeeding(IYCF)

• IntegratedManagementofChildhoodIllnesses(IMCI)

• Micronutrientsupplementation

• Maternalnutritionand

• GrowthMonitoringandPromotion(GMP)

Similarly,IECmaterialsshouldbeharmonizedwiththeguidelines.

StaffshouldbecontinuouslyupdatedontheuseoftheseguidelinesandIECmaterials.


Basic equipment and supplies for OTCBasic equipment• Salter/hangingscaleandweighingpants• Electronicstandingscale• MUACtapes(childandadult)• Heightboard• Calculator• Thermometer• Clock• Scissors

Basic supplies• IntegratedNutritionRegister• IntegratedNutritionRationcards,• Tallysheets• Reportforms/books,• Communityreferralslip• HMIS032healthfacilityreferralnote• RoutinemedicationsforOTC• RUTF• IMAMguidelines• Safewater• Sugarorglucose• Weightforlength/heightz-scorecharts• BMIcharts/wheels• BMIforagez-scorecharts• JobAids(RUTFAppetitetest,Dosingcharts,

MUACandBMIcut-offs,listofinpatientandoutpatienttreatmentsites)

• IECmaterials• Folderfiles• RUTF• Cleanwaterandsoapforhandwashing• Jugandcups• Jerrycansforstorageofdrinkingwater• Wastedisposalbins• Benches/chairsandtables• RCTkitforHIVtesting• RDTstripsformalaria• Foodandcookingdemonstrationmaterials

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CHAPTER SIXinPatient theraPeutic care for management of acute maLnutrition with medicaL

comPLications

6.0 IntroductionIn-patient Therapeutic Care (ITC) is for management of Severe Acute Malnutrition (SAM) withmedicalcomplications.Itcanbeprovidedinaspecialisedunitinahealthfacilityorinachildren’swardatahealthfacilitywith24-hourcare.ThepurposeofITCistoconcurrentlyprovidemedicalandnutritionaltherapy,inadditiontootherformsofcare(psychosocial,stimulation,playtherapyandinvolvingthemother/caregiverincare).(refertoannerx4onProtocolforITC)ITCconsistsoftwophases;stabilisation(phase1)andtransitionandrehabilitation(phase2).

6.1 AdmissionCriteriaAllpatientsunderthecircumstancesbelowshouldbeadmittedandtreatedinITC.

• PatientswithSAMwithanyofthefollowingmedicalcomplications:

o Hypoglycaemia

o Hypothermia(<35°Caxillaryand35.50Crectal)

o Infections

o Severedehydration

o Shock

o Verysevereanaemia

o Cardiacfailure

o SevereDermatosis

o Cornealulceration


• PatientswithSAMandanyofthefollowingIMCIdangersigns:

o Anorexia,noappetite

o Intractablevomiting

o Convulsions

o Lethargy,notalert

o Unconsciousness

o Inabilitytodrinkorbreastfeed

o Highfever(>39°Caxillaryand38.5°Crectal)

6.2 AdmissionProcess

STEP 1: Triage (Refer to Annex 2)

• Conducttriageandfast-trackseriouslyillpatientsforassessmentandcare

• Identifyreferredpatientsfromthecommunity,OTC,otherITC,orSFPandothercontactpoints

• Givesugarwatersolution(1roundedteaspoonofglucose/sugarin50mlwater(3tablespoonsofwater)ororal10%dextrosetoanypatientswithSAM,suspectedtobeatriskofhypoglycaemia

• ExplaintheadmissionprocesstothemotherorcaretakerofpatientswithcomplicatedSAMandcomfortthem

• Advisethemotherorcaregivertohandlethepatientgently

STEP 2: Re assess to confirm referred cases

• DetermineageofthepatientbasingonPatientHealthCard/MotherChildPassportorrecallofthecaregiver.

• Checkforthepresenceofbilateralpittingoedema

• MeasureMUACforchildren6monthsandabove,adultsincludingpregnantwomenandpatientswhocannotstand

• Takeweightofthechild

• Takelengthmeasurementforchildrenlessthan2years(<87.0cm)orheightmeasurementforchildrenolderthan2years(>87.0cm),adolescentsandadults.

• Classifythenutritionstatus(seeFigure8).

STEP 3: Clinical Assessment

• Assessthepatient’smedicalconditionthroughhistorytakingandphysicalexaminationtoidentifyanymedicalcomplicationsthatmayrequireinpatientcare.Thisentails:

o Takingrelevantmedicalhistory(currentandpastillnesses,drugs,medicationsetc).

o Taking dietary history/feeding practices in terms of variety, amount and frequency,preparation,hygienepractices,active/passivefeeding

o Conductingaphysicalexamination(bothgeneralandsystemic).


o Conducting basic relevant investigations (Hb, blood sample for malaria, stool analysis,urinalysis,chestx-ray(absenceoftheseinvestigationsshouldnotdelayadmission).

o HIV testing should be done in all patients according to Provider Initiated Testing andcounselling

o Recordingallthefindings

Management Process

On admission the patient should be managed in the stabilisation phase and transferred torehabilitation/OTCwhenthemedicalcomplicationshaveimproved.

The general Principles for Routine Care (The 10 steps)

Step1:Treat/preventhypoglycaemia

Step2:Treat/preventhypothermia

Step3:Treat/preventdehydration

Step4:Correctelectrolyteimbalance

Step5:Treat/preventinfections

Step6:Correctmicronutrientdeficiencies

Step7:Startcautiousfeeding

Step8:Achievecatchupgrowth

Step9:Providesensorystimulationandemotionalsupport

Step10:Preparefordischarge/transfertoOTC

Figure11showsthephasesandtimeframeformanagementofSAMpatientsinITC.


FIgURE 11: WHO TEN STEPS FOR THE MANAgEMENT OF SAM (WHO 2003)

10 Steps Stabilization Phase Days1-2

Transition Days3-7

Rehabilitation Phase/otc Week2-6

1. Treat/PreventHypoglycaemia

2. Treat/PreventHypothermia

3. Treat/PreventDehydration

4. CorrectElectrolytes

5. Treat/PreventInfections

6. CorrectMicronutrients

7. StartCautiousfeeding

8. Achievecatchupgrowth

9. Providesensorystimulationandemotionalsupport

10. Preparefordischarge/transfertoOTC**

*Ironisgivenafter2daysonF100,ifpatientistakingRUTF,ironshouldnotbegiven

**Prepare to transfer to OTC during transition if OTC services are available or discharge afterrehabilitationphase

6.2 StabilisationPhase/Phase1Managingmedical complications is critical during the first 48 hours of admission in ITC. If notpreventedortreatedappropriatelyandpromptlythiscanleadtoahighdeathrate.Thecommonmedical complications are hypoglycaemia, hypothermia, infections, severe dehydration, shock,cardiacfailure,severedermatosisandverysevereanaemia.

Iffeasible,childreninthestabilisationphaseshouldbephysicallyseparatedfromthechildreninthetransitionandrehabilitationphasesandfromchildrenwithotherdiseases.Adultscanbemanagedontheparentwards(e.g.TB,cancerwardsetc)

Treatment and Prevention of hypoglycaemia

Hypoglycaemia is blood glucose less than 3mmol/l or 54mg/dl. Perform a blood glucose test(Dextrostix,Glucostixorlabtest)onadmissionbeforegivingglucoseorfeedingifpossible.

Causes of hypoglycaemia

Inadequate intake of food:malnourishedchildrenmayarriveatthehospitalhypoglycaemiciftheyhavebeenvomiting,toosicktoeatoriftheyhavehadalongjourneywithoutfood,waitingtoolongforadmissionoriftheyarenotbeingfedregularly.

Signs of hypoglycaemia:

• Lethargy,limpness,lossofconsciousnessorconvulsions

• Semiconsciouswiththeeyespartlyopened

• Drowsiness(theonlysignbeforedeath)

• Hypothermia(axillarytemp<35°C,rectal<35.5°C)

+/-Iron*NoIron


Treatment of hypoglycaemia

Ifbloodglucoseisloworhypoglycaemiaissuspected,takeimmediateaction;

• Ifpatientisconscious:

o Give50mlof10%glucoseorsugarsolution(1roundedteaspoonofglucose/sugarin50mlsafewater=(3tablespoonsofsafewater),orallyorbynasogastrictube(NGT)

o ThenfeedF75every30minutesfortwohoursgivingone-quarterofthetwo-hourfeedeachtime(RefertoAnnex8fortheamounttogive).Providethetwo-hourlyfeedsdayandnight.

o Alwaysgivefeedsthroughoutthenight

• Ifpatientislethargic,unconscious,orconvulsing,:

o Give intravenous(IV)sterile10%glucose(5ml/kg), followedby50mlof10%glucoseorsucrosebyNGT,thengiveF75asabove(two-hourfeeds,dayandnight).Ifonly50%glucosesolution isavailable,diluteonepart to fourparts sterileboiledwateroronepartof50%glucoseto9partsof5%glucosetomakea10%solution

o Takeanotherbloodsampleafter2hoursandcheckthepatient’sbloodglucoseagain.

o Ifbloodglucoseis3mmol/lorhigher,changeto2hourlyfeedsofF75.

o Ifbloodglucoseisstillbelow3mmol/l,ensureantibioticshavebeengivenandcontinuetogiveF75everyhalfhour.

o Continuetomonitorthelevelofconsciousnessandbloodglucoselevel.

Prevention of hypoglycaemia

Ifapatient’sglucoseisnotlowandpatienthasnoclinicalsigns;

• FeedchildrenstraightawaywithF75andthenevery2-3hoursdayandnight.

• Encouragemothers/caregiverstowatchforanydeterioration,helpfeedandkeeppatientwarm

Treatment and prevention of hypothermia

Hypothermiaislowbodytemperatureofbelow35°C(axillary).Severelymalnourishedchildrenareatgreaterriskofhypothermiathanotherchildrenandneedtobekeptwarm.Thehypothermicpatienthasnothadenoughcaloriestowarmthebody.Ifthepatientishypothermicheisprobablyalsohypoglycaemic.Bothhypothermiaandhypoglycaemiaaresignsthatthepatienthasaserioussystemicinfection.Allhypothermicchildrenshouldbetreatedforhypoglycaemiaandforinfectionaswell.

Treatment of hypothermia

• Keepwarm:useindirectheat(nottooclosetothebody).

• Have themotherhold the childbyputting the childon themother’s /caregiver’sbare chest(Kangarootechnique/skintoskincontact).

• Keepthepatientcoveredincludinghishead.

• FeedF752hourly


• Monitorandrecordthetemperatureevery30minutesduringthefirsthour,theneveryhouruntilimprovementisregistered.

• Keeptheroomwarmespeciallyatnight

Note: Do not use hot water bottles due to the danger of burning fragile skin.

Prevention of hypothermia

• Keepwarmbyclothing,covertheheadandlegsaswell),coveringwithawarm/survivalblanket,andorputtingthechildonthemother’s/caregiver’sbarechest (Kangarootechnique/skin toskin)andcoveringbothofthem.

• Thecareproviderorcaregivershouldwarmtheirhandsbeforetouchingthepatient

• Avoidexposureduringexaminationandbathing

• Keep the patient dry. e.g. promptly change patient’s clothes and bedding and child’s wetnappies,anddrythepatientthoroughlyafterbathingandavoidprolongedmedicalexaminationandweighing

• Maintainroomtemperatureat25°Cto36.5°Candavoiddraughtsaswellaskeeppatientsawayfromwindowsanddoors

Monitoring for hypothermia

• Takebodytemperatureevery2hours.Stopre-warmingwhenitrises>36.5°C(taketemperaturehalfhourlyifheaterisused).

• Ensuringthepatientiscoveredatalltimes,especiallyatnight

• Checkbloodglucoseleveli.e.checkforhypoglycaemiawheneverhypothermiaisfound

Note: If a low-reading thermometer is unavailable and the patient’s temperature is too low to register on an ordinary thermometer, the healthcare provider should assume the patient has hypothermia.

FigUre 12: keeping the pAtient wArmly covered, especiAlly At night.

Treatment/ Prevention of Dehydration

Dehydrationoccurswhenapatientusesorlosesmorefluidthanwhatistakeninsuchthatthebodydoesnothaveenoughwaterandotherfluidstocarryonitsnormalfunctions.Itiscausedmostlybydiarrhoea,vomiting,excessivesweatingandinabilitytodrink.


Preparation of f ReSoMal from standard ORS:• Water-2litres

• WHO-ORSone-1litrepacket

• Sugar-50g

• 40mlMineralmixsolution*orCombinedmineralsandVitamins (CMV) (20mls-1redscoopmixedin18mlsofboied,colledsafewater)

*Themineralmixsolutionmaybepreparedbythehospitalpharmacy.

Alternatively, a commercial product, calledCombined Mineral Mix (CMV), maybeused.

Signs of dehydration

It is often difficult to determine dehydrationstatus inapatientwithSAMastheusualsignsof dehydration such as lethargy, sunken eyes/anterior fontanel,may be present and yet thepatient may not be dehydrated. Dehydrationtends to be over diagnosed and its severityover-estimated in children with SAM. This isbecause it is difficult to estimate accuratelythe dehydration status of children with SAMusingclinicalsignsalone.Therefore,healthcareprovidersshouldaskthemotherorcaregiverifthepatienthashadrecentandfrequentwatery diarrhoea or vomitingratherthansmallmucoidstools commonly found in severemalnutritionbut which do not cause dehydration. If so,assumedehydrationandgiveReSoMal.

ReSoMal is Rehydration Solution forMalnutrition.ItisamodificationofthestandardOralRehydrationSolution(ORS)recommendedbyWHO.ReSoMal contains less sodium,moresugar, andmorepotassium than standardORSand is intended for severely malnourishedpatientswithdiarrhoea,exceptifprofuseliquiddiarrhoea (e.g. cholera). It should be givenby mouth or by nasogastric tube. ReSoMal isavailable commercially in some places, but itmay also be prepared from standardORS andsomeadditionalingredients(SeeBoxG)

Note: Do not give standard ORS to severely malnourished children, except in case of profuse liquid diarrhoea.

It is useful to look for the usual signs ofrehydration (Refer to Table 15) as they canbeusedtodetectimprovementduringrehydration.

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tAble 15: signs oF dehydrAtion

lethArgic Alethargicpatientisnotawakeandalertwhenheshouldbe.Heisdrowsyanddoesnotshowinterestinwhatishappeningaroundhim.

restless, irritAble Thepatientisrestlessandirritableallthetime,orwheneverheistouchedorhandled.

Absence oF teArs Observewhetherthepatienthastearswhenhecries.

sUnken eyes Theeyesofaseverelymalnourishedpatientmayalwaysappearsunken,regardlessofthepatient’shydrationstatus.Askthemotherifthepatient’seyesappearunusual.Photographs6,30,and31(inthePhotographs booklet)showsunkeneyes.

dry moUth And tongUe

Feelthepatient’stongueandtheinsideofthemouthwithaclean,dryfingertodetermineiftheyaredry.

thirsty SeeifthepatientreachesoutforthecupwhenyouofferReSoMal.Whenitistakenaway,seeifthepatientwantsmore.

skin pinch goes bAck slowly

Usingyourthumbandfirstfinger,pinchtheskinonthepatient’sabdomenhalfwaybetweentheumbilicusandthesideoftheabdomen.Placeyourhandsothatthefoldofskinwillbeinalineupanddownthepatient’sbody,notacrossthebody.Firmlypickupallthelayersofskinandtissueunderthem.Pinchtheskinforonesecondandthenrelease.Iftheskinstaysfoldedforabrieftimeafteryoureleaseit,theskinpinchgoesbackslowly.(Note: The skin pinch may always go back slowly in a wasted patient.)

Note: • A non-oedematous patient can present with some signs of dehydration that would normally

be found in dehydrated non-malnourished patient, e.g. sunken eyes, slow skin pinch, etc. It is important to take history and determine if there has been recent fluid loss (recent diarrhoea or vomiting)

• A non-oedematous patient with very visible veins is not dehydrated

• In very rare circumstances an oedematous patient with recent frequent watery diarrhoea or vomiting may become dehydrated- be extremely careful when diagnosing this.

• A patient with loose mucoid non watery diarrhoea is NOT likely to be dehydrated and does NOT need rehydration therapy

• Although patients with oedema have a high body fluid volume they may be dehydrated as a result of further loss of fluid from the intravascular space.


Treatment of dehydration

Inboththeoedematousandnon-oedematousSAM,themarginofsafetybetweendehydrationandover-hydrationisveryNARROW.Hence,careandcautionmustbetakeninmakingadecisiononhowtoavoidover-hydrationandcardiacfailure.

Adecisionmustbetakenon:

• Howtorehydrate(route,choiceofsolution,amount,rateofrehydration)

• Whattomonitorduringrehydration

Fluidmanagement should be done cautiously. It is important to determine the patient’s targetweight(seeannex5)beforegivingReSoMalasfollows:

Ifknown,usetheweightofthepatientbeforeepisodeofdiarrhoeaastargetweight

Ifnotknown,takethepatient’sweightbeforegivingReSoMal.Calculatetheminimumat2%andmaximumat5%ofthatweight.Addthefigureobtainedtotheweightofthepatientandusethatastargetweight

• Ifthechildisbreastfeeding,encouragethecaregivertocontinue.

• GiveReSoMalslowly,sincetoomuchfluidtooquicklycancauseheartfailure.ThebestwayofgivingReSoMalisbycup.NGTcanbeusedforgivingReSoMalatthesamerateifapatientistooweaktotakeorally.NGTshouldbeusedinweakerorexhaustedpatients,thosewhovomit,havefastbreathingorpainfulmouthsores.IVfluidsshouldnotbeusedtotreatdehydrationexceptinshock.Theoralrouteispreferredas,thepatient’sthirstyhelpstoregulatetheamountgiven.

• ItisessentialtostopgivingReSoMalwhenthepatientreachesthetargetweight.Forchildren,startwithReSoMal5ml/kgevery30minutesfortwohours,orallyorbyNGT,thenReSoMal5-10ml/kg/hourforthenextfour-to-10hours,alternatingwithF75everyhour.

a) Monitoring patients on ReSoMal

• Monitor all patients taking ReSoMal for signs of hydration (improvement), over-hydration(complication)andshock(worsening),every30minutesforthefirsttwohours;thenhourlyuntilhe/sheimproves.

• Closelymonitor for signsofover-hydration.Thesignsofexcessfluid (over-hydration) includeincreasingrespiratoryandpulserates,increasingoedemaandpuffyeyelids.Ifthesesignsoccur,stop fluids immediately and reassess after one hour. Monitor the progress of rehydration:Observethepatientevery30minutesfortwohours,thenhourlyforthenextthree-to-10hours,recording:

o Pulserate(slowingrate)

o Respiratoryrate(slowingrate)

o Feelingofthirst(lessthirstifrehydrationworking)

o Passingurineandurinefrequency

o Stool/vomitfrequency

o Lesslethargicandmorealert


• Signsofimprovinghydrationstatus

o Lesslethargic

o Lessthirsty

o Skinpinchnotasslow

o Slowingofrapidrespirationandpulserates

o Passingurine

Note: Although these changes indicate that rehydration is proceeding, many severely malnourished children will not show these changes even when fully rehydrated.

Ifapatienthasthreeormoreoftheabovesignsofimprovinghydrationstatus,stopgivingReSoMalroutinelyinalternatehours,insteadofferReSoMalaftereachloosestoolasdescribedbelow:

• Forchildrenlessthan2years,give30-50mlaftereachloosestool,children2yearsandolder,give100mlaftereachloosestool.

Atthesametimeasthepatientgainsonweightduringrehydration,theremustbeanimprovementinclinicalsignsandsignsofdehydrationshoulddisappear.Ifthatisnotthecase,thendiagnosisofdehydrationwasfalseandReSoMalmustbestopped

Prevention of dehydration

Apatientwithcontinuingwaterydiarrhoeashouldbe fedwithF75.TheapproximatevolumeofstoollossesshouldbereplacedwithReSoMal.Asaguide,give30-50mlofReSoMalifapatientisagedlessthan2yearsor100mlsifaged2yearsorolderaftereachwaterystool.

Note: It is common for patients with SAM to pass many small unformed stools. These should not be confused with watery stools and do not require fluid replacement.)

Case with profuse liquid diarrhoea

In case of profuse liquid diarrhoea (e.g. cholera), ReSoMal should not be given and should bereplacedbyWHOlowosmolarityORSwithoutchangingtheamountandfrequency.

Management of shock

Shock is a dangerous condition presentingwith severeweakness, lethargy or unconsciousness,coldextremitiesandafast,weakpulse.Itiscausedbydiarrhoeawithseveredehydration,severehaemorrhage, burns, cardiac failureor septicaemia. There is a decrease intissueperfusion andoxygendeliveryduetosevereinfectionandsepsis.

ApatientwithSAMisconsideredtohaveshockifhe/sheislethargicorunconsciousandhascoldhandsaswellaseither:

• Slowcapillaryrefill(>3seconds);

• Weakorfastpulse;or

• Absenceofsignsofheartfailure(refertoSectionbelowoncardiacfailure)


Septic shock

Insepticshock,superficialveins,suchastheexternaljugularandscalpveinsaredilatedratherthanconstricted.Asshockworsensthepatientdevelopskidney,liver,intestinalorcardiacfailure.Whenapatientreachesthisstage,survivalisunlikely.

Shockfromdehydrationandsepsisarelikelytoco-existinpatientswithSAM.Theyaredifficulttodifferentiateonclinicalsignsalone.Childrenwithdehydrationwill respondto IVfluids,whereasthosewithsepticshockandnodehydrationwillnotrespond.

Ifthepatientmeetsthecriteriaofshockdescribedabove,applythefollowing:

• Giveoxygen.

• Givesterile10%glucose5ml/kgbyIV

• Keepwarm

• GiveoneoftheIVfluidsasdescribedbelow(15ml/kgover1hour).

o Half-strengthDarrow’ssolutionwith5%glucose(dextrose)

o Ringer’slactatesolutionwith5%glucose*

o 0.45%(half-normal)salinewith5%glucose*

Note: *If either of these is used, add sterile potassium chloride (20mmol/l)

• If respiratoryandpulse ratesareslowerafteronehour, thepatient is improving.Repeat thesameamountoffluidforonehourandcontinuetocheckrespiratoryandpulserateeverytenminutes.

• If respiratoryandpulse rates increase, stop the IV. Thenassume that thepatienthas septicshock.MaintaintheIVlinewithfluidat4ml/kg/hrwhilewaitingforblood.

• Givebloodtransfusion.Beforegivingblood,stoptheIVfluidsandanyoralfeeds.Giveadiuretic(Frusemide1mg/kg).Givewholefreshbloodat10ml/kgslowlyoverthreehours.Incaseofsignsofheartfailure,givepackedcellsinsteadofwholebloodasthesehaveasmallervolume.

• Givebroadspectrumantibiotics(seedetailsinsectionofantibiotics)

• Reducephysicaldisturbance;NEVERtransferpatientasstressleadstodramaticdeterioration)

Manage very severe anaemia

Anaemiaisalowconcentrationofhaemoglobinintheblood.Verysevereanaemiaisahaemoglobinconcentrationof<4g/dl(orpackedcellvolume<12%).Verysevereanaemiacancauseheartfailureandmustbetreatedwithabloodtransfusion.Asmalnutritionisusuallynottheonlycauseofverysevereanaemia,itisimportanttoinvestigateotherpossiblecausessuchasmalariaandintestinalparasites(forexample,hookworm).

If it isnotpossible to testhaemoglobin, relyonclinical judgment.Forexample, judgebasedonpalenessofgums,palms,lipsandinnereyelids.


Transfusing a patient with severe acute malnutrition with very severe anaemia (Hb <4.0 g/dl)

1. Lookforsignsofcongestiveheartfailuresuchasfastbreathing,respiratorydistress,rapidpulse,engorgementofthejugularvein,coldhandsandfeet,cyanosisofthefingertipsandunderthetongue.

2. Getbloodready. If therearenosignsofcongestiveheart failure,give10ml/kgwhole freshblood.Iftherearesignsofcongestiveheartfailure,givepackedcells(5–7ml/kg)insteadofwholeblood.

3. Transfuseslowlyover3hours

4. StopalloralintakeandIVfluidsduringthetransfusion.

5. Give a diuretic tomake room for the blood. Frusemide (1mg/kg, given by IV) is themostappropriatechoice.

cardiac Failure

Cardiacfailureistheinabilityofthehearttopumpsufficientlytomaintainbloodflowtomeettheneedsofthebody.Thecommoncauseofcardiacfailureleadingtosuddendeathishypervolemiaduetoover-hydration,over-feeding,bloodtransfusionandhighsodiumdiet.Severemalnutrition,severeanaemia,andseverepneumoniaareamongothercauses.

Itisthereforeimportanttowatchoutforsignsofcardiacfailureduringstabilisationandtransition.Theseinclude:

• Clinicalsignsofdeteriorationwithincreasingweightgain

• Increasingorreappearanceofoedema

• Suddendifficultyinbreathing

• Fastbreathingis50breaths/minin2–12monthsold,40breaths/minifabove1year

• Acuteincreaseinrespiratoryrateby≥5breath/min,especiallyduringrehydration

• Increasingpulseratesof25beats/minalongwithconfirmedincreaserespiratoryrate

• Prominentsuperficialandneckveins

• Coldhandsandfeet

• Cyanosis(bluediscolourationoffingers,toesandunderthetongue)

• Tendernessdevelopingovertheliver

• Acutefallinhaemoglobinconcentration

• Severepalmpallor.

Note: Heart failure and Pneumonia are clinically similar and can be difficult to differentiate.

Ifthepatientgainsweightbeforetheonsetofrespiratorydistress,diagnoseheartfailure

b) Treating Congestive Cardiac Failure

• Positiontheindividualtoanuprightsittingposition

• Giveoxygen

• Stopallfluidsandfeedsuntilcardiacfunctionimproves

• Administerdiuretic(Frusemide1mg/Kg).Thisistoreducefluidandleavewayforblood,and

• Digoxinandcardiotonicsnotoftenadvisedduetothestateofhypokalaemia.


c) Monitoring a patient in cardiac failure

Closemonitoringofapatientincardiacfailureisessentialduringtreatment.ImportantparametersshouldbetakenfrequentlyandrecordedintheCriticalCarePathwayForm(Annex16)

Theseinclude:• Pulseratesevery30minutes

• Respiratoryratesevery30minutes

• Anassessmentoftheengorgementoftheneckvein

• Anassessmentoftheliversizeandtenderness

• Oxygenflowing

d) Preventing congestive cardiac failure in severe malnutrition

• Feedcautiously,onlygivetheprescribedamountoffeeds

• Avoidbloodtransfusionandonlytransfuseifpatientisveryseverelyanaemic(Hb<4g/dl)asdescribedabove.

• Rehydratecautiously

o GiveIVfluidsonlyincaseofshock

o Changetooralrehydrationassoonaspatientregainsconsciousness(SeedescriptionforIVfluidsabove)

o Giveappropriatesolution(ReSoMal)thatcontainslowsodiumcontentandhighpotassium,andgiveappropriateamounts

Manage Acute Abdomen (paralytic ileus) Septicshockcancomplicateothersystemsincludingthegut,causinggastricdilatationthatpresentwithsuddenabdominaldistension,absentbowelsoundsandintestinalsplash.Paralyticileuscanoccurasaresultofautonomicdisruption,concomitantischaemiaorasaresultofacomplicationofhypokalaemia,abdominaltraumaorsepsis.

Management of acute abdomen associated with shock

• Keepthepatientonnilbymouth

• Giveoxygen

• GiveIVfluids

• PassNGTifindangerofaspiration

• Aspiratecontentsofstomachandrinsewithisotonicclearfluid(5%dextroseor10%sucrose-50mlintostomachandgentlyaspirateallbackagain.Repeatuntilthefluidisclear.

• Introducesugarwater(10%sucrose)intothestomachat5ml/kg.Leaveitinforonehour.

• Aspirateandmeasurethevolume.Ifitislessthantheamountpreviouslyintroduced,returntothestomach.

• GiveBroadSpectrumAntibiotics(Intramuscular(IM)orIV)

• Stopalldrugsthatmaybecausingtoxicity(e.g.metronidazole)

• GivesingledoseofMagnesiumsulphate(2mlof50%solution).

• GivefluconazoleororalNystatintocleargastricandoesophagealcandidiasis

• Keeppatientwarm.


NOTE: If patient is unconscious, give IV glucose and monitor carefully for 3 hours without any other treatment

Signs of improvement includeachangein intestinalfunction,decreaseinabdominaldistension,visible peristalsis, return of bowel sounds and decreasing volume of gastric aspirate. If patientimproves,startgivingsmallvolume(halftheamount)ofF75byNGT.

If no improvement is recorded after 3 hours, putup IV infusionwithfluid containing adequatepotassium.

YoucanaddSterilePotassium(20mmol/L)toIVsolutionsthathavenopotassium.

give AntibioticsGiveallseverelymalnourishedchildrenantibiotics forpresumed infection.Givethe firstdoseofantibioticswhileotherinitialtreatmentsaregoingon,assoonaspossible.

Antibiotic recommendationswould bebasedon the local patternsof resistance. The importantprincipleisthatallseverelymalnourishedchildrenshouldbegivenappropriateantibiotics.

Select antibiotics and prescribe regimenSelectionofantibioticsdependsonthepresenceorabsenceofcomplicationsaspreviouslydescribed(seesummarytablebelowfordetailsandannex6(antibioticreferencecard))

tAble 16: sUmmAry oF Antibiotics For severely mAlnoUrished children

iF: give:

NOCOMPLICATIONS Amoxicillin oral:25mg/kgevery12hoursfor5daysoruntilreferralforoutpatientcare.

WITHCOMPLICATIONS

(shock,hypoglycaemia,hypothermia,dermatosiswithrawskin/fissures,respiratoryorurinarytractinfections,orlethargic/sicklyappearanceetc)

gentamicin1IVorIM(5mg/kg),oncedailyfor7days,plus:

Ampicillin IVorIM(50mg/kg),every6hoursfor2days

Followedby:Amoxicillin Oral: 25 mg/kg,every12hoursfor5days

If resistance to amoxicillin and ampicillin, and presence of medical complications:

Seedetailsofdrugusebelowthedrugkit(supportmaterial):

Inthecaseofsepsisorsepticshock:IMcefotaxime (Forchildren/infantsbeyondonemonth:50mg/kgevery8to12hours)+oralciprofloxacin (5to15mg/kg2timesperday).

Ifsuspectedstaphylococcalinfections:Add:cloxacillin (12.5to50mg/kg/dosefourtimesaday,dependingontheseverityoftheinfection).

If a specific infection requires an additional antibiotic, ALSO give:

Specific antibiotic aredirectedonthedrugkit(seesupportmaterials).Refertothenotesofthedrugkitforsevereacutemalnutritionwithmedicalcomplications.

1Ifthepatientisnotpassingurine,gentamicinmayaccumulateinthebodyandcausedeafness.Donotgivetheseconddoseuntilthepatientispassingurine.2Ifamoxicillinisnotavailable,giveampicillin,50mg/kgorallyevery6hoursfor5days.


Manage Corneal Ulceration

Cornealulcerationisabreakinthesurfaceofthecornea(eye’ssurface).Theeyemaybeextremelyredorbleeding,orthepatientmaykeeptheeyeshut.Cornealulcerationisverydangerous.Ifthereisanopeninginthecornea,thelensoftheeyecanextrude(pushout)andcauseblindness.

Check for corneal ulceration.

Touchtheeyesextremelygentlyandaslittleaspossible.Iftheeyesareclosed,waituntilthepatientopenshiseyestocheckthem.

Ifthepatienthascornealulceration,givevitaminAandinstillonedropofatropine(1%)eyedropsimmediately.

TreatalsowithhighdoseofvitaminA(seesectionbelow)ifthepatienthas:

• VisibleclinicalsignsofvitaminAdeficiency(bitot’sspots,cornealclouding,xerosis)

• Signsofeyeinfection(pusinflammation)or

• Measlesnoworinthepastthreemonths

Foreyeinfectiongivegentamicin(0.3%)eyedrops

Manage Dermatosis

Dermatosis refers to any skin disease or condition especially one that is not characterized byinflammation.Dermatosisisgradedasmild(+),moderate(++)andsevere(+++)

Ifthepatienthasonlymildormoderatedermatosis,useregularsoapforbathing.

If the patient has severe (+++) dermatosis, bathe for 10 to 15 min/day in 0.01% potassiumpermanganatesolution.Sponge thesolutionontoaffectedareaswhile thepatient is sitting inabasin.

Ifthepatienthasseveredermatosisbutistoosicktobebathed,dab0.01%potassiumpermanganatesolutionorgentianviolet.

Applybarriercreamtorawareasusingointmentssuchaszincandcastoroilointmentorpetroleumjellyandparaffingauzedressing.Fordiaperareascolonisedwithcandida,usenystatinointmentorcreamafterbathing.Candidiasisisalsotreatedwithoralnystatinorotherrecommendedantifungal.

Micronutrient Supplements

Vitamin A supplementation

Patients with severe acute malnutrition should receive 5000 IU daily recommended intakethroughoutthetreatmentperiod.Thisshouldbeprovidedeitherasanintegralpartoftherapeuticfoodsoraspartofamulti-micronutrientformulation.

ChildrenwithsevereacutemalnutritiondonotrequireahighdoseofvitaminAasasupplementif they are receiving F-75, F-100 or ready-to-use therapeutic food that complies with WHOspecificationsorvitaminAispartofotherdailysupplementsunlesstheyhaveconditionsdescribedalreadyabove(seesectionontreatmentofcornealulcerations).


ChildrenwithsevereacutemalnutritionshouldbegivenahighdoseofvitaminA(50000IU,100000IUor200000IU,dependingonage)onadmission,onlyiftheyaregiventherapeuticfoodsthatarenotfortifiedasrecommendedinWHOspecificationsandvitaminAisnotpartofotherdailysupplements.

Folic Acid supplement

FolicacidisavitaminoftheBcomplexthatisimportantfortreatingandpreventinganaemiaandrepairingthedamagedgut.Eachchild,exceptinfantslessthan6months,shouldbegivenalargedose(5mg)onDay1andasmallerdose(1mg)onsubsequentdays,unlessthepatientisreceivingF-75andF-100orifthefeedscontainCMV(CombinedMineralVitaminMix).

Multivitamin supplement

IfCMVisusedinpreparingfeeds,thenthefeedswillincludeappropriatevitamins,otherwisegivemultivitamindropsdaily(notincludingiron).

Other Specific Cases

HIV/AIDS

ChildrenwithHIV/AIDSandsevereacutemalnutrition:

• Whoqualifyforlifelongantiretroviraltherapyshouldbestartedonantiretroviraldrugtreatmentas soon as possible after stabilization ofmetabolic complications and sepsis. This would beindicated by return of appetite and resolution of severe oedema.HIV-infected childrenwithsevereacutemalnutritionshouldbegiventhesameantiretroviraldrugtreatmentregimens,inthesamedoses,aschildrenwithHIVwhodonothavesevereacutemalnutrition.

• Whoarestartedonantiretroviraldrugtreatmentshouldbemonitoredclosely (inpatientandoutpatient)inthefirst6–8weeksfollowinginitiationofantiretroviraltherapy,toidentifyearlymetaboliccomplicationsandopportunisticinfections

• ShouldbemanagedwiththesametherapeuticfeedingapproachesaschildrenwithsevereacutemalnutritionwhoarenotHIVinfected

• ShouldreceiveahighdoseofvitaminAonadmission(50000IUto200000IUdependingonage)andzincformanagementofdiarrhoea,asindicatedforotherchildrenwithsevereacutemalnutrition, unless they are already receiving F-75, F-100or ready-to-use therapeutic food,whichcontainadequatevitaminAandzinciftheyarefortifiedfollowingtheWHOspecifications.

• Inwhompersistentdiarrhoeadoesnotresolvewithstandardmanagementshouldbeinvestigatedto exclude carbohydrate intolerance and other infective causes,whichmay require differentmanagement,suchasmodificationoffluidandfeed intake,orantibiotics.Foranyothercaretreatment,refertothenationalHIV/AIDStreatmentguidelines.

malaria

Ifthepatient’stestispositive,treataccordingtothenationalprotocol.

Monitor other danger signs

Watchcarefullyanypatientwithaninfectionsuchaspneumoniaorsepsis,earinfection,orurinarytractinfection(UTI)foroccurrenceofthesignsbelow:


• Anorexia(LossofAppetite)

• Changeinmentalstate(forexample,becomesLethargic)

• Jaundice(yellowishskinoreyes)

• Cyanosis(tongue/lipsturningbluefromlackofoxygen)

• Difficultbreathing

• Difficultyfeedingorwaking(drowsy)

• Abdominaldistension

• Newoedema

• Largeweightchanges

• Increasedvomiting

• Petechiae(bruising)

• Alertaclinicianifanyofthesedangersignsappear.(Seeannex8forsummaryofdangersigns)

Feeding in Phase I: Stabilization

Feedingisobviouslyacriticalpartofmanagingsevereacutemalnutrition;however,feedingmustbestartedassoonaspossiblewithF75(seerecipesofpreparingF75inAnnex7)cautiouslyandinfrequentsmallamounts.Iffeedingbeginstooaggressively,oriffeedscontaintoomuchproteinorsodium,thepatient’ssystemsmaybeoverwhelmed,andthepatientmaydie.

Determinefrequencyandamountoffeeds

On the first day, feed the patient a small amount of F-75 every 2 hours (12 feeds in 24 hours,includingthroughthenight).Nightfeedsareextremelyimportanttopreventhypoglycemia.

The front of the F75 reference card ( see annex8) of is for severely malnourished children with no oedema, or with mild or moderate oedema.

The reverse side is only for children admitted with severe (+++) oedema.)

Therecommendedamountforachildwithnooedema/oedemagrade+and++is130ml/kg/dayofF75.Ifoedemais+++,therecommendedamountis100ml/kg/day(seeAnnex8fortheamountoffeedtogiveaccordingtothepatient’sweight).

After the first day, increase the volume per feed gradually so that the patient’s system is notoverwhelmed.Givelessfrequentfeeds(every3hoursorevery4hours).

Eachpatient’sfeedingplanshouldberecordedona24-HourFeedIntakeChart(Annex10)

Older children, adolescents and adults should receive the same F75 milk formula as children.Encourageadolescentsandadultstotakethisformulamilkalone.

Feeding methods

Twofeedingmethodsarerecommended:oralorbyNGT.


Oral Feeding

Duetomuscleweaknessandslowswallowing,theriskofaspirationpneumoniaishighespeciallyformalnourishedchildren.Therefore,greatcaremustbetakenwhilefeeding.PreferablyuseacupandasaucerwhenfeedingchildrenwithSAM.

Caution:

• Never leave the child to feed alone (ensure supervised feeding)

• The patient should never be force-fed; should never have his/her nose pinched, and should never be laid on the back to have the milk poured into his/her mouth.

• Encourage breastfeeding on demand between formula feeds. Ensure that the patient still gets the required feeds of F-75 even if breastfeeding

Feeding by Naso-gastric Tube (NgT)

Itmaybenecessarytouseanasogastrictube(NGT)ifthepatientisveryweak,hasmouthulcersthatpreventdrinking,orifthepatientcannottakeenoughF-75bymouth.Theminimumacceptableamountforthepatienttotakeis80%oftheamountoffered.Ateachfeed,offertheF-75orallyfirst.UseanNGtubeifthepatientdoesnottake80%ofthefeed(i.e.,leavesmorethan20%)for2or3consecutivefeeds.NGfeedingshouldbedonebyexperiencedstaff.DonotplungeF-75throughtheNGtube;letitdripin,orusegentlepressure.

Ifthepatientdevelopsaharddistendedabdomenwithverylittlebowelsound,give2mlofa50%solutionofmagnesiumsulphateIM.

Feeding children who have vomiting

Ifthepatientvomitsduringorafterafeed,estimatetheamountvomitedandofferthatamountoffeedagain.Ifthepatientkeepsvomiting,offerhalftheamountoffeedtwiceasoften.Forexample,ifthechildissupposedtotake40mlofF-75every2hours,offerhalfthatamount(20ml)everyhouruntilvomitingstops.

Providecontinuedcareatnightbecausemanydeathsinseverelymalnourishedchildrenoccuratnight.

Important things not to do and why

Donot givediuretics to treatoedema. Theoedema is partlydue topotassiumandmagnesiumdeficienciesthatmaytakeabout2weekstocorrect.Theoedemawillgoawaywithproperfeedingincludingamineralmix containingpotassiumandmagnesium.Givingadiureticwillworsen thechild’selectrolyteimbalanceandmaycausedeath.

• Do not give iron during the initial feeding phase. Addirononlyafterthechild has been on F-100 for 2 days (usually during week2).Asdescribedearlier,givingironearlyintreatmentcanhavetoxiceffectsandinterferewiththebody’sabilitytoresistinfection.

• Do not give high protein formula (over1.5gproteinperkgbodyweightdaily).Toomuchproteinin the first days of treatmentmaybe dangerous because the severelymalnourished child isunabletodealwiththeextrametabolicstressinvolved.Toomuchproteincouldoverloadtheliver,heart,andkidneysandmaycausedeath.


• Do not give IV fluids routinely. IVfluidscaneasilycausefluidoverloadandheartfailure inaseverelymalnourishedchild.

BesurethatpersonnelintheemergencytreatmentareaofthehospitalknowtheseimportantthingsNOTtodo,aswellaswhattodo.

Transition

ThisphaseisdesignedtopreparepatientsforPhaseIIorOTC(rehabilitation/catchupgrowth).

How to Recognize Readiness for Transition:

Lookforthefollowingsignsofreadiness:

• Returnofappetite(easilyfinishes3-4hourlyfeedsofF75

• Reducedoedemaorminimaloedema

In settings where RUTF is provided as a therapeutic food in rehabilitation phase:

OncechildrenarereadytomoveintotherehabilitationphaseperformacceptancetestforRUTF(table12)andtheyshouldtransitionfromF-75toready-to-usetherapeuticfoodover2–3days,astolerated.Therecommendedenergyintakeduringthisperiodis100–135kcal/kg/day.

give RUTF slowly and gradually

TwoapproachesfortransitioningchildrenfromF-75toready-tousetherapeuticfoodaresuggested:

• Startfeedingbygivingready-to-usetherapeuticfoodasprescribedforthetransitionphase(seeannex8).Letthechilddrinksafewaterfreely.Ifthechilddoesnottaketheprescribedamountofready-to-usetherapeuticfood,thentopupthefeedwithF-75.Increasetheamountofready-to-usetherapeuticfoodover2–3daysuntilthechildtakesthefullrequirementofready-to-usetherapeuticfood,or

• Givethechildtheprescribedamountofready-to-usetherapeuticfoodforthetransitionphase.Letthechilddrinksafewaterfreely.Ifthechilddoesnottakeatleasthalftheprescribedamountofready-to-usetherapeuticfoodinthefirst12hr,thenstopgivingtheready-to-usetherapeuticfoodandgiveF-75again.Retrythesameapproachafteranother1-2daysuntilthechildtakestheappropriateamountofready-to-usetherapeuticfoodtomeetenergyneeds.

Childrenwithsevereacutemalnutritionwhopresentwitheitheracuteorpersistentdiarrhoea,canbegivenready-to-usetherapeuticfoodinthesamewayaschildrenwithoutdiarrhoea.Ifachildisbreastfeeding,encouragethemothertocontinue.

If the RUTF is not available or if the child does not accept it, give F100:

Thetransitionisspreadoverthreedays,duringwhichtheF-100isadministeredaccordingtothefollowing:

First48hours(2days):GiveF-100every3-4hoursinthesameamountsofF-75thatwerebeinggiven.Donotincreasethevolumefor2days.ThenonDay3:Add10mlateachmealuntilthechildfinisheshismeal.Ifthechilddoesnotfinishameal,offerthesameamountforthenextmeal;ifhe/shefinishesthen,furtherincreasethenextmealby10ml.Continueuntilthechildleavesabit


ofmostofhismeals(usually,whenthevolumereachedaround30ml/kgpermeal).Ifthechildisbeingbreastfed,encouragemotherstobreastfeedbetweenF-100rations.

In inpatient settings where F-100 is provided as the therapeutic feed in the rehabilitation phase:

ChildrenwhohavebeenadmittedwithcomplicatedsevereacutemalnutritionandareachievingrapidweightgainonF-100shouldbechangedtoready-to-usetherapeuticfoodandobservedtoensurethattheyacceptthedietbeforebeingtransferredtoanoutpatientprogramme

F100 should never be given to take home.

Providing medical treatment in the transition phase

Continuetheroutinemedicaltreatment(Table16)andrecordontheCriticalCarePathway(CCP).GiveanyspecificmedicaltreatmentprescribedandrecordontheCCP.

Monitor the patient carefully during transition

Inthetransitionphase,individualmonitoringofpatientsisdoneevery4hours.Checkthepatient’srespiratoryandpulserateandcallaclinicianforhelpifanydangersignsoccur.

Criteria for Transfer from Transition back to Stabilization phase

Allpatientswhodevelopsignsofmedicalcomplicationsshouldbereturnedtostabilizationphase.Thesignsinclude;• Lossofappetiteandnottaking80%ofthemeasuredfeeds

• Increasing/developmentofoedema

• Medicalconditionsnotimprovingorjustdeteriorating

• Anysignsoffluidoverload

• Significantre-feedingdiarrhoeasothatthereisweightloss

Criteria for Transfer from Transition to OTC or Phase II

• Goodappetite(ifthepatientpassestheacceptancetestandtakesmorethan80percentofthedailyrationofRUTF)

• Reducedoedemato++/Grade2or+/Grade1ornooedema

• Medicalcomplicationshavebeenresolved

• Clinicallywellandalert

6.4 RehabilitationPhase/Phase2ApatientprogressingtotherehabilitationphaseonRUTFcanbedischargedfromITCtoOTCifavailable.

RefertoOTCwhenthepatientistakingtheentireamountofRUTFproposedduringtransition(atleast150kcal/kg/day).

Beforeleaving,themother/caretakershouldreceivearationofRUTFcoveringtheneedsofthechildforonetotwoweeksandshouldbeinformedofthereferralsiteclosesttowherehelives.


If no programme for outpatient management of severe acute malnutrition is available:

Duringrehabilitation,thepatientisexpectedtogainweightrapidly,andtheamountofF-100givenshouldbeincreasedasthechildgains.Ifnopossiblereferralforoutpatientcare,feedfreelywithF-100duringrehabilitation,toanupperlimitof220Kcal/kg/day(seeannex8foramounts)

Medications in Rehabilitation phase/Phase 2Thepatientshouldcontinuetoreceiveanyprescribeddrugsandcompletethecourse.

RoutinemedicinesandsupplementsshowninTable17shouldfollowthescheduleasprescribed.

tAble 17: roUtine medicines And sUpplements

medicAtion WHAT TO gIVE / USE FreQUency

Ironsupplement FerrousSulphate300mgs/day(3mgelementalFe/kg/day)

2divideddoses

do not give iron iF the child receives rUtF

Note:Evenifthepatientisanaemic,heshouldnotbegivenironuntilheisrecoveringandhasbeenonF-100fortwodays(i.e.aftertwodaysoftransition).Ifgivenearlier,ironcanhavetoxiceffectsandreduceresistancetoinfection.

De-worm7 Mebendazole>1year:500mg

Albendazole≥1year:200mgs

Albendazole>2years:400mgs

Measlesimmunisation8

9months(upto5years)ifnorecordthatithasbeengivenbefore

Singledoseafter2daysonF-100orRUTF

Singledoseassoonasthechildisstable

Monitoring During Phase II Individualmonitoringof the recoveringchild in rehabilitationphase isdonedaily.The followingparametersshouldbemonitoreddailyandrecordedontheCCP:

• Bodytemperature,pulseandrespirationrate

• Weight,whichshouldbeplottedontheweightchartoftheCCP(RefertoAnnex16).

• Oedema

7 ReportoftheWHOInformalConsultationontheuseofPraziquantelduringPregnancy/LactationandAlbendazole/MobendazoleinChildrenunder24months

8 ManagementofsevereMalnutrition:Amanualforphysiciansandotherhealthworkers,WHO1998


• Vomitingordiarrhoea

• Refusaltofeed

• Clinicalexamination.

• Length/heightorMUACatdischarge

6.5 CriteriatomovefromPhaseIIbacktotheStabilisationPhase(Phase1)If a patient develops any signs of a medical complication, he should be referred back to thestabilisationphase.

Failure to Respond during Rehabilitation phase

Somepatientsmayfailtogainweightduringrehabilitation.Suchpatientsshouldbere-evaluatedinvestigatedandtreatedappropriately

Criteria for discharging children 6 – 59 months from treatment

Childrenwithsevereacutemalnutritionshouldonlybedischargedfromtreatmentwhentheir:

• Weight-for-height/lengthis≥–2Z-scoreandtheyhavehadnooedemaforatleast2weeks,or

• Mid-upper-armcircumferenceis≥12.5cmandtheyhavehadnooedemaforatleast2weeks.

Criteria for discharging patients 5 years and above

• RefertoTable2forMUACandBMIcut-offsand

• Theyhavehadnooedemaforatleast2weeks.

Theanthropometricindicatorthatisusedtoconfirmsevereacutemalnutritionshouldalsobeusedtoassesswhetherapatienthasreachednutritionalrecovery,i.e.ifmid-upper-armcircumferenceisusedtoidentifythatapatienthassevereacutemalnutrition,thenmid-upperarmcircumferenceshouldbeusedtoassessandconfirmnutritionalrecovery.Similarly,ifweight-for-length/heightisusedtoidentifythatapatienthassevereacutemalnutrition,thenweight-for-length/heightshouldbeusedtoassessandconfirmnutritionalrecovery.

Childrenadmittedwithonlybilateralpittingoedemashouldbedischargedfromtreatmentbasedonwhicheveranthropometricindicator,mid-upperarmcircumferenceorweight-for-length/heightisroutinelyusedinprogrammes.

Percentage weight gain should not be used as a discharge criterion

give general discharge instructions

Inadditiontofeedinginstructions,mothers/caregiverwillbetaught:

• Howtocontinueanyneededmedicationsathome

• Signstobringthechildbackforimmediatecare(Refertodangersigns)

• Whenandwheretogoforplannedfollow-up:-at1week,2weeks,1month,3months,and6months;-thentwiceeveryyearuntilwhenthechildis3yearsold.

• Whereandwhenachildshouldbetakenforgrowthmonitoringandpromotiononmonthlybasisupto2years

• Whentoreturnfornextimmunization.


• WhentogotothehealthcentreforvitaminAanddeworming(every6months);

• Howtocontinuestimulatingthechildathomewithplayactivities.

IfapatienthastobetransferredtoOTC,thefollowingactionsshouldbetaken:

• Completeareferralsliptooutpatientcare,includingasummarysectiononmedicalinterventionandtreatmentgiventothepatient.

• Informthemother/caregiverwhereandonwhichdaytogoforoutpatientcare

• Givemothers/caretakerskeymessagesonRUTFandbasichygiene.

• Themother/caregivershouldalsobegiveninstructionsformedicationsathome

• Informthemother/caregivertoreturnthechildonappearanceofanydangersigns.

Ifearlydischarge (before reaching -2SD) isunavoidable,and there isnoprogrammeforOTC, itiscriticaltomakespecialarrangementsforfollow-up(homeandspecialcarevisitsbysocialandhealthcare)(SeedischargecardinAnnex14)

Ensureadequatearrangementsforlinkingthecaregiverandpatientwithappropriatecommunityinitiativesandforfollow-uphavebeenmadesuchassupplementaryfeeding,foodsecurity,socialprotection,safetynets,etc.

tAble 18: types oF dischArges, conditions And Actions From itc



Cured • Acutemedicalconditionshavebeenresolved

• Thepatientiseatingwell(caneatfamilyfoods)

• Nobilateralpittingoedemafortwoweeks

• Clinicallywellandalert• WFL/H≥-2z-scores(infants,

childrenandadolescents)• MUAC≥12.5cm(children6to59

months)

• TransfertoSFPifaccessible/availableforfollowuponceeverymonthforthreemonths

• Referforfollow-upatclosesthealthfacilityandcommunity

• Linktotheavailablelivelihoodprogrammes

• ForHIV-positiveclients,ensureongoingtreatmentthroughanHIVtreatmentprogramme

TransfertoOTC • Noworryingmedicalcondition• Passedappetitetest• InTransitionPhaseandtakingRUTF• Oedemaifpresenthasreducedto

+/Grade1or++/Grade2

• TransfertonearestfunctionalOTCifavailable

Died • Diedwhileonprogramme • Completefileandcardappropriately

Defaulted • Absentfortwoconsecutivedays • Mayre-entertheITCifpatientmeetstheadmissioncriteria

• Re-admitwiththeoldregistrationnumberandinvolvetheVillageHealthTeamforfollow-upduringhomevisits,ifavailable.


CHAPTER SEVEN inPatient management of infants

Less than six months with sam

7.0 IntroductionSevereacutemalnutritionin infantswhoarelessthan6monthsofageisdefinedas;weightforlength<-3Z-scoreorpresenceofbilateralpittingoedema.

Infantslessthan6monthsoldwithSevereAcuteMalnutrition(SAM)shouldalwaysbetreatedinaninpatientunituntildischarge.TheobjectivesofITCareto:

• improveorre-establish,effectiveexclusivebreastfeedingbythemother

• providetemporaryorlonger-termappropriatetherapeuticfeedingfortheinfants;and

• Providenutrition,psychological,andifneededmedicalcareforthecaregivers.

Infantslessthan6monthsmaybecomemalnourishediftheyhaveneverbeenbreastfedorbeenonlypartiallybreastfed.Therearealsoothercausesofmalnutritioninthisagegroupwhichmayberelatedtoeitherthemotherorthechild.


7.1 AdmissionCriteria• Weight-for-lengthlessthan-3Z-scores

• Anypittingoedema

• Recentweightlossorfailuretogainweight

• Ineffectivefeeding(attachment,positioningandsuckling)directlyobservedfor15-20minutes,ideallyinasupervisedseparatearea

• Anymedicalorsocialissueneedingmoredetailedassessmentorintensivesupport(e.g.disability,depressionofcaregiver,orotheradversesocialcircumstance)

• Anyseriousclinicalconditionormedicalcomplicationasoutlinedforinfants6monthsofageorolderwithsevereacutemalnutrition

• Anyinfantswhohavebeenidentifiedtohavepoorweightgainandwhohavenotrespondedto nutrition counselling and support (IMCI) should be admitted for further investigation andtreatment

• AnyinfantwithageneraldangersignasdefinedbyIMCIshouldbeadmittedforurgenttreatmentandcare

Severelymalnourishedyounginfantsneed:

1. Diagnosisofmedicalcomplicationsandtreatmentifanyarefound.

2. Warmthtotreatandpreventhypothermia.

3. Initialre-feeding(formetabolicstabilization)whichmayrequiremilkfeedsinadditiontobreastmilk,orwhereaninfantisnotbreastfedinsteadofbreastmilk.

4. Feedingforcatch-upgrowth(nutritionrehabilitation).

5. Continuousmonitoringofweightandfeedintake.

6. Follow-uptoreducetheriskofbecomingmalnourishedagain.

Note: Low birth weight infants are not usually severely wasted or oedematous and so are unlikely to meet the criteria for SAM. Therefore, they should be managed according to the WHO guidelines specifically for “Low birth weight babies”.

7.2 StabilizationPhase

Medical management and micronutrient supplementation

Infantswhoarelessthan6monthsofagewithsevereacutemalnutritionshouldreceivethesamegeneralmedicalcareasinfantswithsevereacutemalnutritionwhoare6monthsofageorolder:

• Infantswith severe acutemalnutritionwho are admitted for inpatient care should be givenparenteral antibiotics to treat possible sepsis and appropriate treatment for other medicalcomplicationssuchastuberculosis,HIV,surgicalconditionsordisability;

• Infantswithsevereacutemalnutritionwhoarenotadmittedshouldreceiveacourseofbroad-spectrumoralantibiotics,suchasamoxicillin,inanappropriatelyweightadjusteddose


Feeding during stabilization

• TheFeedingapproachforinfantswhoarelessthan6monthsofagewithSAMshouldbeprioritizeestablishing,orre-establishing,effectiveexclusivebreastfeedingbythemotherunlessunderdifficultcircumstances (orphaned,abandoned,medical reasons). Ifan infant isnotbreastfed,supportshouldbegiventothemothertorelactate.

• InfantslessthansixwithSAMshouldalsobeprovidedasupplementaryfeed:

o Supplementarysucklingapproachesshould,wherefeasible,beprioritized.

o Forinfantswithsevereacutemalnutritionbutnooedema,expressedbreastmilkshouldbegiven,and,wherethisisnotpossible,commercial(generic)infantformulaorF-75ordilutedF-100(seeBoxG)maybegiven,eitheraloneorasthesupplementaryfeedtogetherwithbreastmilk.

o Forinfantswithsevereacutemalnutritionbutnooedema,expressedbreastmilkshouldbegiven,and,wherethisisnotpossible,commercial(generic)infantformulaorF-75ordilutedF-100maybegiven,eitheraloneorassupplementaryfeedtogetherwithbreastmilk.

• Forinfantswithsevereacutemalnutritionandoedema,infantformulaorF-75shouldbegivenasasupplementtobreastmilk.

• Supportthemothertobreastfeedevery2to3hoursforatleast20minutes.

• InfantslessthansixwithSAMshouldnotbegivenundilutedF-100atanytime(owingtothehighrenalsoluteloadandriskofhypernatraemicdehydration).

• Ifthereisnorealisticprospectofbeingbreastfed,theinfantsshouldbegivenappropriateandadequatereplacementfeedssuchascommercial(generic)infantformula,withrelevantsupporttoenablesafepreparationanduse,includingathomewhendischarged.

• Inadditionassessmentofthephysicalandmentalhealthstatusofmothersorcaregiversshouldbepromotedandrelevanttreatmentorsupportprovided

Feeding an infant less than six months of age with SAM with prospect to breastfeed

The main objective is to restore effective exclusive breastfeeding. During the initial phase oftreatment,breastfeedingmustbecomplementedwith infantformulaorcommercialtherapeuticmilk,whilestimulatingtheproductionofbreastmilk.

If the infant is able to suckle:

Theinfantshouldbebreastfedasoftenaspossible.Encouragethemothertobreastfeedtheinfantatanytime,assoonastheinfantwants,betweenshotsofmilksupplement.

o Halfanhourtoanhourafterfeeding,givetherapeuticmilkusingasupplementalsucklingtechnique(SST)(seesectionbelow).

o Thetherapeuticmilkshouldbegiven2to3hourly(seeannex9foramounts).

• Donotincreasetheamountoftherapeuticmilkiftheinfantisregularlygainingweight.

Iftheinfantlosesweightorhasastaticweightonthreeconsecutivedays,buttakesallfeedsandcontinuestobehungry,add5mlmoreateachfeed.


Feeding Procedure:

• During breastfeeding, ensure goodpositioning and good attachment of theinfanttoensureefficientsuckling.

• Use the SST to stimulate breast milkproduction. If this is not possible, give themilk supplement with a cup and a sauceror nasogastric tube (using gravity but notpumping).

Note: Only feed with an NGT when the infant is not taking sufficient milk by mouth

The supplemental suckling technique

The SST is recommended to re-establishbreastfeedingaswellastoprovidemaintenanceamounts of therapeutic feeds for severelymalnourished infants. This method involvesthe infant suckling the breast while taking asupplement(therapeuticfeed).Thetherapeuticfeed supplement is given in a cup through athin tube along the nipple. The mother holdsa cup containing F75. The tip of a nasogastrictube (size No. 8) is placed in the cup and theother end of the tube is placed on the nippleof thebreast (Figure13).The infant shouldbepositionedtobreastfeed.Thecupisplaced5-10cmbelowthenippletofacilitatebreastfeeding.Whenthebabysucklesmorestrongly, thecupcanbeloweredto30cm.

FigUre 13: sUpplementAl sUckling techniQUe

F100-Diluted for infantsInfants below 6months of age should notreceiveF100fullstrengthastheconsistencyis unsuitable, F75 and F100 diluted havesimilar concentration to breast milk witharound 75 calories per 100ml. PreparedF100 should be further diluted by adding30%safewater

IfF100isnotreadilyavailable,infantscanbefedwiththesamequantitiesofcommercialinfant formula diluted according to theinstructionsonthetin.Ifthereisarangeofmilkformulastochoosefrom,useaformuladesignedforprematureinfants.

Notethatinfantformulaisnotdesignedtopromoterapidcatch-upgrowth.

Unmodified powdered whole milk should notbeused.

boX c


IftheinfantisNOTabletosuckleorissucklingweakly:

• Ifthemotheriswilling,encouragehertostartexpressingherbreastmilk.

• Showherhowtohandexpressallthatshecanatleast8-12timesaday.Thiswillstimulateherbreaststomakemoremilk.

• Measuretheexpressedbreastmilkand feed it to thebabybycupandsaucerornasogastrictube,inthesamewayasthesupplementarymilk.

• Givetheexpressedbreastmilkinadditiontothefullamountofsupplementarymilk.

• Whentheinfantstartstosuckle,givesomeorallofthesupplementaryfeedsbysupplementarysucklingtechniqueifpossible.

• Ifthemotherisreluctanttoexpresshermilkbutherbabyistooweaktosuckleeffectively,useSSTwiththecupheldashighasthebaby’smouth.Astheinfantgainsstrength,lowerthecup.

Feeding during Transition:

Whentheinfantbeginstogainweight(atleast20gperday)for2to3days:

• Graduallydecreasetheamountofmilksupplement(therapeuticfeed)byonethird,sothattheinfantgetsmorebreastmilkandmaintainthisamountfor2to3days

• Iftheinfantcontinuestogainweightsatisfactorily(20gperday),furtherreducetheamountofmilksupplement,inthesameproportions,untilnotgivinganymore.

• Ifweightgain isnotsatisfactorywithreducingthevolumeofmilksupplement, increasethevolumetothepreviouslevelfor2daysandtryagain.

Feeding during Rehabilitation:

Duringthisphase,theinfantshouldnotreceiveanymoremilksupplementandshouldbegainingweightwithexclusivelybreastfeeding.

Observe feeding in order to ensure that the infant is feedingwell, and as often and as long aspossible.

Preparethemothertoexclusivelybreastfeedtheinfantuntiltheageof6monthsbeforestartingtodiversifyfoodat6months.

Note: If the mother is HIV positive, refer her for specialized care on HIV and infant feeding.

Discharge criteria:

Any in-patient stay inanutritionwardorhospital shouldbeas short aspossible toavoid crossinfectionanddefaulting.

Infantswhoarelessthan6monthsofagecanbedischargedwhen;

Theyarebreastfeedingeffectivelyorfeedingwellwithreplacementfeeds

• Breastfedinfantscanbedischargedwhentheyhavegainedaminimumof20gramsperdayonbreastfeedingalonefor5days,regardlessofthetotalbodyweightorweight-for-length

• Haveweightforlength≥-2Z-score


Feeding infants less than six months with SAM with no prospect to breastfeed

Feeding during Stabilization

Incaseswherethemotherdiedorunderdifficultcircumstancesasalreadydescribedabove,theinfantshouldtobefedonappropriateandadequatereplacementfeedssuchascommercialinfantformula,orF75ordilutedF100:

• Dilutetheinfantformulaasdirectedonthepackage

• Calculatetheappropriatevolumeaccordingtotheweightoftheinfantonadmission(seeAnnex9foramountstogive).

• Give the volume for 24 hours inmeals organized every 2 hourswith a cup and a saucer ornasogastrictube

• Continuetogivethefullvolumeofmilkuntilthebabyshowsthefollowingsignsofrecovery:

o Lossofalloedema

o Improvedappetite

Feeding during Transition

Thisphaseshouldcontinuefor4-5days.

Whentheinfantshowsthesignsofrecoverymentionedabove:

• Increasethevolumeby30%(seeAnnex9fordetails)

• Monitortheinfant’sweight.Weigheverydayanduseappropriatescales.

Feeding during Rehabilitation

Duringrehabilitation,infantsshouldbefedusingacupandasaucer;themotherorcaregiverwillhavetobesensitizedtousethesamemethodtofeedtheinfantathomeafterdischarge.

• After4-5days,increasethevolumeofmilkrationsforanother30%(seeAnnex9)

• Iftheinfantisstillhungryafterfinishingthefeed,givehimmore.Increasethefeedsby5mlperfeed

Itisessentialtoshowtheinfant’scaregiverhowtodilutecommercialinfantformula(cleanwater,properdilution),howmuchtogive,howoftenandhowtocleantheutensilsduringtherehabilitationphase.

Supervisepreparationoffeedsandfeedingwhiletheinfantisonthenutritionunit/ward.

Discharge criteria:

Foraninfantwhoisnotbreastfed,theplanningandpreparationfordischargeisespeciallyimportantsincethefuturefeedingsecurityoftheinfantismoreuncertainthanifhewasbreastfed.

Dischargecanbedonewhen:

• Stafffindsthatthepersoncaringfortheinfantisconfidenttoprepareandgivethebreastmilksubstitutecorrectly

• Theinfanthasgainedatleast20gperdayfor5days


Micronutrient supplementation

Theinfantshouldreceivethefollowingmicronutrientssupplements:

vitamin A:

• Giveadoseof50,000IUtoeveryinfantatthetimeofdischargefromthenutritionunit/ward.

Iron:

• Ironsupplementshouldbegivenwhentheinfantstartstogainonweight.• Giveiron3mg/kg/dayintotwodivideddoses(crushthetabletanddiluteitinthemilk).

Folic acid• Give2.5mg(onetablet)asasingledoseonadmissionifachildisbeingfedonF75ordiluted

F100.

• Ifachildisbeingfedoninfantformulagive2.5mgoffolicacidonthefirstdayandasmallerdose(1mg)onsubsequentdays.

• Thechildshouldbesenthomewithatleastaweek’ssupplyoffolicacidondischarge

• Whenachildreturnsforfollowup,morecanbegiven.

7.3 MonitoringinfantswithSAMInfantslessthan6monthswithSAMarefragileandrequireclosemonitoring.Theseinfantsneedtobereviewedbyanurseordoctorornutritionistdaily:

ThefollowingparametersshouldbemonitoreddailyandrecordedontheCCP:

• Recordandreviewthetotalintakeofsupplementarymilkfeedsand/ornumberofbreastfeedsper24hours.

• Assessandrecordoedema(+/Grade1,++/Grade2,+++/Grade3)

• Monitorweight gain, urinary output, activity level and other signs that breastmilk is beingproduced.Minimumacceptableweightgainduringcatch-upgrowthinyounginfants(weighinglessthan4kgsonadmission)is20geveryday

Note: other important information such as: vomiting, refusal to be fed, placement of a nasogastric tube.

7.4 Infantfeedingcounsellingandsupport• Mothersshouldbecounselledandsupportedtocontinuebreastfeedingortore-lactateifthey

hadstopped.

• Infants should be supplementedwith therapeuticmilk administered through the SST. This isnecessaryasatemporarymeasureuntilbreastfeedingorre-lactationisfullyestablished.

• HIV-positivemothersofinfantswithSAM,shouldbesupportedtocontinuebreastfeedingasperthecurrentnationalHIVpolicyguidelinesonInfantandyoungchildfeeding.

• A mother choosing to re-lactate will need more support than a mother who is alreadybreastfeeding.

• Motherandbabyshouldsleeptogethertoencouragebreastfeedingespeciallyovernight.


Nutrition support for the breastfeeding mother

• Allmotherswhoarebreastfeeding/re-lactatingshouldbecounselledand supportedon theirownfeedingandnutrition.Wherepossible,theyshouldreceiveextrameals.

• AllbreastfeedingmothersshouldreceiveIronandfolicacidsupplements(60mgofironperdayand400mgoffolicacid)tocomplete6monthsupplementation.

Infants less than 6 months of age with SAM and who don’t require inpatient care, or whose caregivers declined admission for assessment and treatment.

• CounsellingandsupportforoptimalIYCFshouldbeprovided,basedongeneralrecommendationforfeedinginfantsandyoungchildren,includingforlowbirthweightinfants

• Weightgainoftheinfantshouldbemonitoredweeklytoobservechanges;ifinfantdoesn’tgainweight,orlossesweightwhilethemotherorthecaregiverisreceivingsupportforbreastfeeding,thenhe/sheshouldbereferredtoinpatientcare

• Assessmentofthephysicalandmentalhealthstatusofmothersorcaregiversshouldbepromotedandrelevanttreatmentorsupportprovided

Follow-up

Continuityofcareafterdischargeisimportantfortheseinfants,tosupervisethequalityofrecoveryandeducatethecaregivers.Itisalsoimportanttosupporttheintroductionofcomplementaryfoodsattheappropriateageof6months.

• Monitor infant’s progress closely, support safe replacement feeding and growth monitoringthroughclosehealthfacilityormaternalandchildhealthprogramme

• HIVexposed/positive infantsshouldbereferredandfollowedup inPaediatricHIVclinic/anti-retroviraltherapyclinic

• Supportbreastfeeding/replacementfeedingthroughclosehealthfacilityormaternalandchildhealthprogramme.

• It is also important to support appropriate introduction of complementary food at age of 6months

Discharge from all Care

Infantswhoare lessthan6monthsofageandhavebeenadmittedto ITCcanbetransferredtooutpatientcarewhen:

• Allclinicalconditionsormedicalcomplications,includingoedema,areresolved,

• Theinfanthasgoodappetite,isclinicallywellandalertandweightgainoneitherexclusivebreastfeedingorreplacementfeedingissatisfactorye.g.abovethemedianoftheWHOgrowthvelocitystandardsormorethan5gms/kg/dayforat-least3successivedays

• Theinfanthasbeencheckedforimmunizationsandotherroutineinterventions,andthemothersorcaregiversarelinkedwithneededcommunitybasedfollow-upandsupport.

• Infantswhoarelessthan6monthsofagecanbedischargedfromallcarewhentheyarebreastfeedingeffectivelyorfeedingwellwithreplacementfeeds,andhaveadequateweightgainandhaveaweightforlength≥-2Zscore


CHAPTER EIGHTemergency nutrition resPonse

8.0 IntroductionEmergenciesmaybeeitherman-madedisaster, suchas anexacerbationof anon-going conflictwithpopulationdisplacement,orduetoenvironmentalissuessuchasaseriousdroughtorsevereflooding/landslides.Thelocalinfrastructuremaynothavethecapacitytorespondduetolimitedresourcesparticularlyfinancial,human,logisticsand/orstructurallimitations.Geographicalisolationmay furtheraffectability to respond.When situations suchas thisoccurespecially if there is asubstantialproportionofthepopulationaffected,thisoftenresultsinfoodshortagesandimpairsthenutritionalstatusofaffectedcommunities,inparticularinfants,childrenandadolescents,butalsoadults,especiallypregnantandlactatingwomenandelderlypersons.Thereisaneedtorapidlyrespondtopreventincreasedand/orexcessivemorbidityandmortality.

Nutritional EmergencyNutritionalemergencyoccurswhenthereisanabnormallyhighrateofacutemalnutritionresultingfromacrisisevent.

• Globalacutemalnutritionrate>10%or

• Crudemortalityrate>1death/10,000personsperdayor

• Under-fivemortalityrates>2deaths/10,000underfivesperday(SPHERE,2004)

Emergency Nutrition Response: An intervention that primarily aims to prevent individualswithmildandmoderatemalnutritionfrombecomingseverelymalnourishedandtotreatall formsofacutemalnutritionduringnutritionalemergencies.

Therearethreemainnutritionreliefresponses:o Generalfooddistributionsforalltheaffectedhouseholds*

o SupplementaryFeedingProgramme(SFP)formoderatelymalnourished individualsandat-riskgroups(blanketortargeted)*

o Therapeuticfeedingprogramme(TFP)forseverelymalnourishedindividuals*

• FormoreinformationontheserefertorelevantsectionsofthisIMAMguideline.


Emergencynutritioninterventionsrequiresubstantialresourcestobeset-upandmonitored.Non-governmentalorganisations(NGOs)oftensupporttheMinistryofHealth(MoH)withcollaborativeimplementation.

8.1 StepsforEmergencyNutritionResponse

Step 1: Coordination and information sharing

Coordinationofalltheemergencyactivitiesatalllevelsandamongallimplementingpartnersiskeytoensureeffectiveness.Thispreventsduplicationofprogrammesandalsoidentifiesgapsthathavenotbeenmetineachsector.

Step 2: Conduct Rapid Nutrition Assessment

• Jointlyplanandconductaninitialassessmenttounderstandthesituationandidentifytheextentofthethreattopeople’slives,theircopingstrategiesandaccesstoservicessuchashealth,safedrinkingwater/sanitationandbasicdietusingnationalstandardisedtoolsorguidelines..

• Conductamulti-sectoralassessment,tounderstandthedifferentfactorsaffectingmalnutritioni.e. the immediate, underlying and basic causes. This will ensure a holistic approach to themanagementofacutemalnutrition.

• Review existing interventionswhere an existing humanitarian response is in place but thereisdeteriorationinthesituation,andidentifyneedsrequiredtoincreasecapacitytomeetthedemandsofadeterioratingsituation.

• Carryouton-goingnutritionsurveysperiodicallyduringtheprogrammetomonitoreffectivenessofresponse

Step 3. Selecting appropriate emergency nutrition responses

• Whentheemergencyassessmentreportsindicatethatthenutritionneedsareunmet,and/orthereareincreasing/highlevelsofacutemalnutrition,appropriateresponsesareidentified.Adecisionchart(Figure13)canbeusedforguidanceonthetypeofresponserequired.

• The under five age-group, pregnant and lactating women are usually the primary target inemergencynutritioninterventions.OtheridentifiedvulnerablegroupssuchastheelderlyandchronicallyillespeciallyPeopleLivingwithHIV/AIDS(PLWHA)andTBpatientsshouldbetargeted.

• Thenutritionstatusofunder5agegroupisusuallytakenastheproxyindicatorofthenutritionstatusofthecommunitytoinformnutritionplanninginemergencysituations.


FigUre 14: decision tree For the implementAtion oF selective Feeding progrAmmes

Step 4. Planning an emergency nutrition response

Theseresponsesshouldinclude:• Establishing an emergency response team (refer to section 8.2) with defined roles and

responsibilities.

• Selectingnutritionprogrammesites.Programmesitesareidentifieddependingonthepopulationsizeaffected,theplannedgeographicalcoverageandaccessibility.Thesizeoftheprogrammewilldependonthepopulationneedsandthecapacityoftheimplementingpartner.Theareacanbedefinedbyusingadministrativeboundaries.

• Integrating screening and referral for acutemalnutritionat all health facility and community

aggravating Factors

General food ratio below the mean energy requirements

Crude mortality rate > 1 per 10,000 per day

Epidemic of measles or whooping cough

High prevelance of respiratory or diarrhoeal diseases

Malnutrition rate

Proportion of child population (6 months to

5 years) who are

• below 80% weight for height or

• below -2 Z-score weight for height

MALNUTRITION RATE10-14%

OR

OR

MALNUTRITION RATE<5% in presence of

AGGRAVATING FACTORS

MALNUTRITION RATE>=15%

MALNUTRITION RATE10-14% in presence of AGGRAVATING FACTORS

MALNUTRITION RATE5-9% in presence of

AGGRAVATING FACTORS

MALNUTRITION RATE<10% WITH NO

AGGRAVATING FACTORS

SERIOUSBLANKET supplementary

feeding programme

THERAPEUTIC feeding Programme

ALERTTargeted supplementary

feeding programme

THERAPEUTIC feeding programme

ACCEPTABLENo need for population level

interventions(individual attention formalnourished trhough

regular community services)

ALWAYS IMPROVE GENERAL RATION

GENERALRATION<2,100

Kcals/person/day

OR


contactpoints.Ensuremedical-nutritional follow-upofpatientswithMAMandSAMwithoutmedical complications andmanagementof thosehaving SAMwithmedical complications asin-patients.

• Maximizingpositiveimpactandlimitingharm(beawareofcompetitionforscarceresources/increasedresources,misuseormisappropriationofsupplies).

• Providingequitablehumanitarianservices..

8.2 GeneralrequirementsforEmergencyNutritionReliefProgrammesPersonnel• When implementing emergency nutrition interventions the appropriate staff and staffing

levelsarevital.Thereisaneedformanagers/administration,logisticssupport, technicalstaff(clinicians,nutritionists,nurses,recordsperson,etc)andsupportstaff.

• Wherepossiblepriotizerecruitmentofqualifiedlocalstaffastheyunderstandthecontext,speakthelocallanguageandunderstandthecultureofthepopulation.

• Allthestaffmustbetrainedandorientatedpriortocommencingthereliefprogrammes.Theyshouldhaveclearjobdescriptionswithclearrolesandresponsibilities.

Thefollowingaresomestaffneededonsite:• Programmemanager

• Supervisors,

• Technicalstaffe.g.doctors,nutritionists,nurses,pharmacistsetc.

• Administratorssuchasregistryclerks

• Store-keepersandfooddistributionsupervisors

• Supportstaff(Securityguards,cleaners)etc

• Villagehealthteams(VHTs)orCommunityhealthextensionworkers(CHEWs).

Supply Provision Inanyemergencyresponse, it is importanttohaveagoodlogisticssystemtoensurethereisnobreakinthesystem.Theseprogrammesneedtoruncontinuouslyandnotbeaffectedbylackofcommodities.Bufferstocksshouldbeinplaceespeciallywhereinsecurityisanissue.

Programme Linkages for Prevention and Management of Acute Malnutrition in EmergenciesPreventing and addressing under nutrition requiresmulti-sectoral action and other programmelinkagesforpreventionandmanagementofacutemalnutritioninemergencies.Theseinterventionsincludeinfantandyoungchildfeedinginemergencies(IYCF-E),health,water,sanitationandhygieneandfoodsecurity.

i) Acute malnutrition

• ThemanagementofMAMshouldbelinkedwiththemanagementofSAMwhereverpossible.• Linkagesatthehealthfacilityandcommunitylevelsareessentialinemergenciestotakecareof

theincreasednumbersofacutelymalnourishedchildren.

• Referralmechanismsbetweenpreventionandmanagementofacutemalnutritionactivitiesarealsoveryimportantandshouldbeestablishedaspartofthenutritionresponse.


ii) Infant and young Child Feeding in emergencies (IyCF-E)

• It is importanttoaddressIYCF-Easpartofthepreventionofacutemalnutrition,particularlyto emphasizeexclusive and continuedbreastfeeding andoptimal complementary feeding inchildren6-23monthsofage.

• It isalso importantto includebasic informationon infantandyoungchild feeding inanHIVcontext.

iii) Health and Water/Sanitation

• Earlyandacceleratedmanagementofsanitation,hygiene,watersources,andhealthprogramsforcommonchildhoodillness(e.g.,diarrhoea,measles)shouldaugmentthemanagementofacutemalnutritionduringanemergency.

• Feedingcentresanddistributionsitesshouldincludeaccesstosafewaterfordrinkingandforhand-washing.

iv) Food Security and Livelihood Programmes

• Wherefoodinsecurityisaresultofanemergencyorexistspriortotheemergency,resourcesshouldbespentonnutritioninterventionsforpreventionofacutemalnutritionortreatmentofMAMonlywhenaGFDorequivalenttransferincashorvoucherisinplace.

8.3 ExitStrategyforEmergencyNutritionResponse(ENR)AnexitstrategyshouldbedevelopedrightatthebeginningoftheENRprogrammethroughstronginvolvementofthedistricthealthteamsand/orstaffoftherelevanthealthfacilities.

Anexitstrategyindicateswhenanemergencyinterventionshouldbephasedoutorcloseddown.Inemergencynutritioninterventionsthisoccurswhenthelevelsofacutemalnutritionhavereduced(<10%withnoaggravatingfactors9)orcrudemortalityrates<1/10,000/day.Itisalsoimportantthatfoodsecurityshouldhaveimprovedandthattherearenootheraggravatingfactorssuchassevere climaticconditionsandinadequateshelter.

Otherfactorstoconsidermayinclude;

• Net reduction in thenumberof childrenattending thecentres (through improvement in thenutritionalstatusorthedisplacementofthepopulationetc.)

• Depletionoffoodstockwithoutbeingrenewed

• Endoforlackoffinancialfunding

• Epidemiologicalcontrolofinfectiousdiseasesiseffective

• Improvedclimaticconditionswhereapplicable.

Programmeclosuremustbedonegraduallyoveraperiodof3-6months.Itisdesirabletostartwithareductionintherations,stoppingnewadmissions,establishinghand-oversolutions,andtrainingofidentifiedfocalperson(s)forthespecificprogrammes

Monitoring and Evaluation

Monitoringandevaluationofanemergencynutritionresponseiscoveredinchapter 10.


CHAPTER NINEnutrition information, education

and communication

9.0 IntroductionNutrition Information, Education and Communication (IEC) is key to management of acutemalnutrition.

Theactivitiesrelyonavarietyofwell-designedandeffectivematerialswhichmayincludetrainingmaterials thatareusedbyhealthworkers.Healthworkers,VHTsandothercommunityresourcepersonsshouldreceiveappropriatetrainingandfollow-uponuseoftheIECmaterials.

Nutrition education is any combination of education strategies designed to facilitate voluntaryadoption of food choices and other food and nutrition related behaviours to help individualsandcommunitiesmakethebestchoiceoffoodsforadequatenutritionandhealth.Itisdeliveredthroughmultiple channelsand involvesactivitiesat the individual, institutional, communityandpolicylevels.

qualities of effective nutrition education:

• Focusesonspecificbehaviours,actionsandpractices

• Usescommunicationandeducationstrategiestoenhanceawarenessandmotivation

• Employsasystematicbehaviourchangeprocess,includingsocialsupportandempowerment

• Includesenvironmentalinterventions,communityactivationandorganization.

Health Education is any combination of learning experiences designed to help individuals andcommunitiesimprovetheirhealth,byincreasingtheirknowledgeorinfluencingtheirattitudesandpositivebehaviourchange.


9.1 NutritionEducationProgrammeThe nutrition education programme comprises of goals, objectives, outputs and activities. Thegoalofthenutritioneducationprogrammeistore-enforcespecificnutritionrelatedpracticesorbehaviourstochangehabitsthatcontributetopoorhealth.Thisisdonebycreatingamotivationforchangeamongpeopletoestablishdesirablefoodandbehaviourforpromotionandprotectionofgoodhealth.Effectivenutritioneducationprogrammesmustbeplannedandexecutedinsuchawayastomotivatebeneficiariestodevelopskillsandconfidencefortheadoptionofpositiveandlastingpractices.

Nutritioneducationprogrammesshouldaimat:

1. Increasingthenutritionknowledgeandawarenessofthepublicandofpolicymakers

2. Promotingdesiredfoodbehavioursandnutritionpractices

3. Increasingthediversityandquantityoffamilyfoodsupplies.

Attheonsetoftheprogram,implementersandotherstakeholdersshouldhaveamonthly,quarterlyorannualplanofactivitiesthataretobeconducted.Further,anongoingmonitoringandevaluationplan should be developed. The plan should be specific to the programme and must be wellunderstoodby implementers.Figure15belowshowsaschemeforplanningnutritioneducationprogrammes.

FigUre 15: A scheme For plAnning nUtrition edUcAtion progrAmmes

phAse 1: prepArAtion

• Definingthenutritionalproblem

• Determiningthecausesoftheproblem

• Establishingtheeducationalframe

phAse 2: FormUlAtion

• Settingobjectives

• Designingmessages

• Choosingthemediaandmultimediacombination

phAse 3: implementAtion

• Producingthematerials

• Trainingthechangeagents

• Executingthecommunicationintervention

phAse 4: evAlUAtion

Source: FAO, 1994


9.2 CommunicatingNutritionInformationKeybenefitsofnutritioninformationandeducationinclude:• CreatesawarenessaboutservicesatHealthfacilitiesandinthecommunity

• Helpstodispelrumours/mythsandmisconceptions

• Helpstolearnaboutcommunityexpectations

• Improvedhealthcareseekingbehaviour

• StrengthenslinkagesbetweencommunityandHealthfacilities.

Principles of effective communication

Clarity:Useconcreteexpressions,simplewords,shortsentencesandavoidambiguity

Completeness- use the 5Ws and H i.e.Who,When,Where,What,Why and How. Answer thequestionsindesigningandrespondingtoanycommunicationmessage

Consideration: Ensuresufficientregard,empathyandrespectfortherecipientanduseappropriatelanguage,mediaandstyle,maintainpleasantandpositiveapproachesandintegrity

Conciseness:Bebrief,exactandtothepointasmuchaspossible

Courtesy: Beandkeeppolite,welcoming,modest,approachable,friendly,attentiveandresponsive

Correctness: Use the correctwords and facts from correct source, through a correctmedia, tocorrectaudienceundercorrectcircumstances

Channelsandmethodsusedtoprovidenutritioneducation

• Individualdiscussions

• Counsellingsessions

• Groupdiscussions

• Communitymeetingsandevents(dramas,healthgameevents)

• Peereducation

• Employeeeducationalseminars

• ElectronicMedia(Television/Radio:Visualandaudiodramas)

• PrintMedia(Brochures,booklets,Posters,Banners,BillBoards,flyers,flipcharts)

• OtherPromotionalmaterials(T.Shirts,calendars,cartyrecovers,pens).

9.3 Proceduresforplanningandfacilitatinganutritioneducationsession• Identifyarelevanttopicfordiscussion

• Identifyaknowledgeablepersontoconductthenutritioneducationsession

• Determinethetargetaudienceandtheapproachyouwillusetohelpthemlearnandparticipateinthesessionforexamplepregnantandlactatingmothers)

• Makeobjectivesforthesession(theyshouldbeSMART:S-Specific,M-Measurable,A-Attainable,R-Realistic,T-Timebound)

• Reviewinformationonthetopicandensureitisuptodate


• Preparethematerialsyouwillneedtoconductthesession(e.g.handouts,flyers,counsellingcards,flipcharts,posters);preparebriefpromptingnotes

• Communicatethedate,time,venueandtopicofdiscussion

• Documentthenutritionandhealtheducationsession.

9.4 Conductinganutritioneducationsession• Introduction

o Welcomeparticipantsandintroduceyourself

o Reviewtheagenda

o Explorethegroundrules

o Introducethetopicfordiscussion

• Outlinesessionobjectives

• Statewhattheclientwillgainfromthesession

• Reviewanddiscussthetopic

• Reviewthekeypoints

• Conductanevaluationofthetopicdiscussed

Prepare for a Food Demonstration Session• Gatherfooditems,equipmentandmaterials

o Food-ensurethereisvariety-Go,GrowandGlow

o Utensils (plates, cups, chopping boards, sauce pans, knives) and othermaterials - ensuregoodhygiene

o Fuelforcooking-,

o Handwashingfacilities.

Conduct a Food Demonstration:

• Demonstrate tomothers/caregivers how toprepare a simple andnutritiousmeal (for youngchildren,pregnantandlactatingwomen,andothervulnerablegroups)usinglocalingredients.

• Emphasizethefollowing:

o FATVAH(Frequency,Adequacy,Thickness,Variety,Active(responsive)feedingandHygiene

o Feedingasickchild

o Continuedbreastfeedingupto2yearsandbeyond

o Involvingfathersandothercaregiversorfamilymembers.

Mothers/Caregivers Conduct a Return Food Demonstration• Lookatthestepsusedtoperformthereturnfooddemonstration

• Observeareasofomissionthatrequirecorrection

• Thankthemotherorcaregiversforconductingthefooddemonstration.

• Gothroughtheareasthatneedimprovement

• Summarizethekeypoints


Afterthecookingdemonstration,servethepreparedfoodforthechildrenandmother/caregivers

Summarize the Food Demonstration Session• Checkunderstanding(questionandanswer)

• Re-emphasizekeymessages.

• Thankthemothers/caregiversforcomingandparticipating.

9.5 KeyNutritionRecommendationsThefollowingrecommendations(Table19)willguidethedevelopmentofkeynutritionmessagesthatcanbeemphasizedwhileconductingnutritioneducation.

tAble 19: key nUtrition recommendAtions

topic recommendAtion

OptimalBreastfeeding

• Earlyinitiationofbreastfeedingwithinonehourofbirthforthebabytobenefitfromcolostrum(firstyellowishmilk)

• Exclusivebreastfeedingforthefirst6completedmonths• Breastfeedondemand(aslongastheinfantwants,atleast8–12

timesduringdayandnight)• Appropriatepositioningandattachment• Continuedbreastfeedingupto2yearsorbeyondOR• Continuedbreastfeedingupto12monthsoflifeifthemotherisHIV

positiveandtheinfantisHIVnegative,themotherisonHAARTandtheinfantreceiveARVprophylaxis.

• Continuedbreastfeedingduringillnessandexpressbreastmilkifthebabyisnotabletobreastfeed

OptimalComplementaryfeeding

• At6completedmonthsstartappropriatecomplementaryfoodswhilecontinuingtobreastfeed

• Giveavarietyoffoodstoincludeenergygivingfoods(GO),bodybuildingfoods(Grow)andprotectivefoods(Glow)

• Ensure:

o Properhygieneduringfoodstorage,preparationandservingo Growthmonitoringandpromotionmonthlyo VitaminAsupplementationevery6monthso Immunisation

Feedingofthesickchild(oranadultwhereapplicable)

• Increasefrequencyofbreastfeedingandofferadditionalfood(smallfrequentmeals)

• Asickchildshouldbegivenadiethighinenergy,proteinandmicronutrientespeciallyiron,zincandvitaminsinaformthatiseasytoeatanddigest

Maternal Nutrition

• Increasefoodintakebyeatingoneextramealduringpregnancy,twoextramealsduringlactationinadditiontoeatingtheregularmeals

• Ensureironandfolicacidsupplementation,intermittentpresumptivetreatmentandpreventionofmalaria

• Eatplentyoffruitsandvegetableswitheverymeal



• Drinkenoughliquidseveryday(8glassesor3NICEcups)• Emphasizetheuseofiodizedsaltandotherfortifiedfoods.• Pregnantmothersshouldbediscouragedfromalcoholconsumption,

smokingandotherun-prescribedmedicationthatmayharmthebaby.• Taketheweight,heightandMUACofallpregnantwomenandrecord

itinthemother/childpassport/ANCregisterandotherrelevantdatacollectingtools.

Control of VitaminAdeficiency(VAD)

Children• VitaminAissafeforchildrenandbooststheirimmunity• PromoteconsumptionofvitaminArichfoodse.g.mangoes,green

leafyvegetables,wildredandorangefruitsandfoodssuchaseggyolk,liver,milkandotherfortifiedfoodssuchasvegetableoil

Vitamin A supplementation• Children6-59monthsshouldbegivenvitaminAevery6monthsasit

protectsthemfromdiseasessuchasnightblindness,diarrhoea,acuterespiratoryinfectionsandreducesdeaths.

• AllnonbreastfedinfantslessthansixmonthsshouldbegivenvitaminA• Childrensickwithmeasles,certaineyeproblems,severemalnutrition.

TheymayneedadditionalvitaminAaccordingtothetreatmentschedule(refertoITC).

Mothers• Encouragepregnantwomenandlactatingmotherstoconsumea

balanceddietandfoodsrichinvitaminAsuchasliver,eggs,orangefleshsweetpotatoes,pumpkindarkgreenleafyvegetables

• LactatingmothersshouldnotbegivenvitaminAroutinely

Control of anaemia

• Emphasizeconsumptionofironrichfoodssuchasliver,redmeat,eggs,fish,wholegrainbread,legumesandironfortifiedfoods.

• PromoteconsumptionofvitaminC-richfoodssuchasoranges,greenvegetablesastheyenhancetheabsorptionofiron.

• Provideadviceonfooditemsandmedicinesthatshouldnotbetakentogetherwithironsupplementssincetheymayinhibitabsorptionsuchasmilk,antacids,teaandcoffee.

• Malaria control

• Dewormingroutinely

Malnourished children with nutritional anemia (commonly due to iron or folic acid deficiency)• Giveonedoseat6mg/kgofirondailyfor14daysforchildrennotinITC

andreceivingRUTF• ChildrenwithSAMandsevereanaemiashouldbemanagedfollowing

ITCprotocols• Avoidironinchildrenknowntosufferfromsicklecellanaemia.• Avoidfolateuntil2weeksafterachildhascompletedthedoseof

sulphurbaseddrugs(Fansidar,Septrinandothers)



Mothers• Giveallpregnantwomenadoseof200mgofironand5mgoffolate

onceaday(combinedferroussulphateBp200mgandfolicacid0.4mg)• Treatanaemiafor3months• Referseverecasesofanaemiatothenearesthigherlevelofcare• PromoteuseofantimalarialinterventionssuchasLongLasting

InsecticideTreatedmosquitonetstopreventmalariawhichmaycauseanaemia.

Hygieneandsanitation

Personal hygiene, domestic and environmental hygiene• Promotegoodhygienicpracticesinthepreparationandhandlingof

food• Handwashingwithsoapandcleanrunningwater• Protectfoodsfromcontaminationwithinsects,pestsandotheranimals• Keepallfoodpreparationpremises,utensils,andequipmentsclean• Cookfoodthoroughlyorre-heatitthorough• Keepfoodatsafetemperatures

Deworming • Usesafewaterandrawmaterials• Give250mgofmebendazoleor200mgofAlbendaoleforchildren

1-2yearsand500mgsmebendazoleor400mgmsAlbendazoleif>2yearsasasingledose

Note: DO NOT administer if child is less than I year

Growthmonitoringandpromotion(GMP)

• Childrenaged0-2yeasshouldbeweighedeverymonth,theirweightsplottedonthegrowthchartintheChildHealthCardorMotherChildPassport.Explaintothemotherthechild’sprogress

• LengthsforthesechildrenshouldbemeasuredatspecifiedintervalsasperGMPguidelines.Assessandexplaintothemotherthechild’sprogress(basedonlengthforage).

• Children2to5yearsshouldhaveweightsandheightsmeasuredevery6monthstodetermineiftheyaregrowingadequately

• WhenchildrencomeforGMP,checkfortheirimmunization,andvitaminAsupplementationstatus

• Childrenwhosegrowthisfalteringareathighriskandshouldbemonitoredcloselybyhealthfacilitystaff

Immunization

• Encourageallchildren0–5years,adolescentsandpregnantmotherstoreceivetherecommendedvaccinationsasperthenationalimmunizationschedule

• Explaintothemother

o Theimportanceofimmunizationandthenationalscheduleo Barrierstoimmunizationandhowtoovercomethemo Accesstoimmunizationservices

• Makeimmunizationsafe(i.e.checkexpirydate,usesteriledisposableneedles,observecoldchain,usetrainedpersonnel).


CHAPTER 10monitoring, suPervision,

rePorting and evaLuation, QuaLity imProvement and suPPLy chain

management for imam

10.0 IntroductionTo ensure that the Integrated Management of Acute Malnutrition (IMAM) interventions areachieving their objectives of early case identification and treating acutemalnutrition, activities,inputs,outputsandoutcomesmustbemonitored,supervisedandreportedon.Awelldesignedmonitoringandreportingsystemcanidentifygapsin implementationofrespectivecomponents,provide information for on-going needs assessment, advocacy, planning, and redesigning andaccountability. Monitoring, reporting and overall quality improvement should be an integralcomponentoftheIMAMprogramme.


10.1KeydefinitionsMonitoringisthesystematicandcontinuouscheckonallaspectsoftheprogrammewhileitisbeingimplemented.Thisisinordertoestablishifinputs,processesandoutputsareproceedingaccordingtoplansothattimelyactioncanbetakentocorrectdeficienciesdetected.ItisimportanttomonitorIMAM activities to ensure quality service delivery, effective use of resources and strengthenaccountability.MonitoringIMAMwillalsopromotecontinuouslearningandimprovement.

Supervision is aprocessofworkingwithand throughothersbyoverseeing theperformanceoroperations in order to achieve organization objectives. There should be regular supervision ofIMAMactivitiesbytrainedandskilledpersonnel.Supervisionaimsatempoweringtheindividualwithtechnicalandadministrativeskillsfordecisionmaking,leadership,communicationandteambuilding.Thiscanbeacquiredthroughonjobcoachingandmentoringamongothers.

Reporting refersto givinganaccountoftheprogramme’sperformanceandinformpolicy..ReportingonIMAMservicesisinlinewiththeHMIS.

Evaluation meansdeterminingthevalue,significance,orworthoftheprogrammethroughcarefulappraisal and study. It looks at programme’s results, changes and impact over time. Evaluationinvolvescarefullyexaminingdataaboutaprojectorprogramme’sresultsdeterminingwhetherandhowwellthesetobjectivesaremetoverasetperiod.

Coverageisameasureoftheextenttowhichtheservicesrenderedcoverthepotentialneedforthoseservicesinthecommunity.CoveragethereforereferstotheextenttowhichIMAMservicesareavailablefortheacutelymalnourishedindividualsincommunity.

Appropriatenessreferstoasuitableintervention,targetedtotherightaudienceandisrightlyandculturallyacceptable.

quality improvementistheuseofquantitativeandqualitativemethodstoimprovetheeffectiveness,efficiency,safetyofservicedeliveryprocessesandsystems,aswellastheperformanceofhumanresourcesindeliveringIMAMservices

Supply Chain Managementisasystemoforganisingpeople,activities,informationandresourcesinvolvedinmovingtheproductsfromthesuppliertothebeneficiary.

10.2MonitoringofIMAMservicesMonitoringcomprisesofthreemajorcomponents:

• Monitoringofindividualtreatmenttoassessclient/patientprogress

• monitoring to assess effectiveness of treatment interventions (i.e. proportion of acutelymalnourishedpatientstreatedeffectively)andcommunity-levelactivitiesformobilisationandcase-finding

• Assessmentofservicecoverage(i.e.proportionofthetargetgroupbeingreachedwithtreatment)andappropriatenessoftheprogrammeforcommunities.


10.2.1 IMAM data collection tools

Theseincludetoolsusedforindividualandprogrammelevelmonitoring(Table20)

tAble 20: tools Used in monitoring, sUpervision And reporting For imAm service

tools pUrpose

VHT/ICCMregister • TorecorddetailedinformationofclientsscreenedforacutemalnutritionusingMUAC

• Torecorddetailedinformationofclientsreferredtohealthfacilitiesfornutritionandotherhealthservicesaswellasthosefollowedup

Communityreferralforms • UsedbyVHTsandothercommunityhealthandnutritionproviderstoreferpatientswithinIMAMservicesandviceversa

QuarterlyreportformsforVHTs • UsedbyVHTsforquarterlyreportingoncases:assessed,identified;referredandfollowups;healthandnutritioneducationactivitiesandotherhealthrelatedactivitiescarriedoutinthecommunity

Integratednutritionrationcards • ForrecordingtherapeuticorsupplementaryfoodinOTCorSFP

• Totrackapatient’sprogressthroughmonitoringweight,heightandMUAConeveryvisittoOTC/SFP.

Integratednutritionregister • TorecorddetailedinformationofpatientsadmittedtoITC,OTCandSFP

• TotracktheindividualpatientsenrolledintotheIMAMservicesusingIntegratedNutritionregistrationnumber(INRNo.)

• Totrackapatient’sprogressthroughmonitoringweight,heightandMUAConeveryvisittoOTC/SFP

• Torecordpatients’outcomeonexitingthefeedingprogramme

Referralforms • UsedbyhealthcareproviderstoreferpatientswithinIMAMservicesandviceversa

CriticalCarePathwayChart • Torecordthepatient’spresentingsigns,symptomsandinitialmanagementaswellasmonitorprogress(weight,vitalsigns,medicalcomplications,feeding,antibiotics,fluidmanagementetc)

24hourFeedIntakeChart • Isarecordofthepatient’sfeedingplanina24hrperiod(type,frequency,amountandtotalfeeds)

• Monitorsthepatient’sfeedintakeovera24hrperiod


tools pUrpose

WeightGainTallySheetforWard • TorecordandmonitorrateofweightgainforchildrenreceivingF100(calculatedmonthlyorquarterly)

Tallysheets • Tosummarizeweekly,monthlydatafromINRandcompilereports

HMISmonthlyandquarterlyreports • Toreportoncasespresentedwith/treatedforacutemalnutritioninhealthfacilities

• TracksperformanceofIMAMservicesthroughmonitoringpatientoutcomesvis-a-vissetstandards

*CommunitySupervisionchecklists • Usedatcommunityleveltoassess/monitorqualityofIMAMservices

*HealthfacilityIntegratedsupportsupervisionchecklists

• Usedathealthfacilityleveltoassess/monitorqualityofIMAMservices

NutritionServiceDeliveryAssessment(NSDA)tools

• Toassessqualityofnutritionservicedeliveryatbothhighandlowlevelhealthfacilities

*ChecklistformonitoringENR • MonitorsavailabilityofrequirementsforsettingupandimplementingENRprogramme

*ToolsforconductingFGDsandKIIs • ToassessIMAMcoverageandaccessthroughconductingFGDsandinterviewsistouncoverpotentialbarrierstocomponentsofIMAMinordertoimproveitsdelivery

*Toolsforconducting:1-FGDs(includinginterviewguidesfor:VHTsandothercommunityresourcepersons;beneficiarycaregiversandothercommunitymembers;

2-KIIs(includingindividualinterviewguidesfor:healthandnutritionprogrammemanagersand;forhealthfacilityworkers

• TocaptureinformationfromthosedirectlyandindirectlyinvolvedinIMAM.Thisinformationshouldbecollectedatcommunity,districtandnationallevel

10.2.2 IMAM service performance indicators

ThefollowingaretheindicatorsusedinmonitoringtheeffectivenessofIMAMservices:

indicAtor deFinition

A: otc, sFp

1 Cure rate Numberofpatientssuccessfullycuredasapercentageoftotaldischargesduring thereportingquarter.Dischargesincludecured,defaulters,deathsandnonrespondents)

(Total discharged as cured/Total discharges x100)


indicAtor deFinition

2 Defaultrate Numberofpatientswhodefaultedasapercentageofalldischarges during the reporting quarter (Default/Total discharges x 100)

3 Non-respondentsrate Number of patients who are non-respondents as apercentageoftotaldischargesduringthereportingquarter(Total non-respondents/Total discharges x 100)

4 Coverage Number of eligible cases who are enrolled in IMAMprogrammedividedby total numberof eligible clients x100

5 Deathrate Thenumberofpatientswhodiedasapercentageoftotaldischargesduringthereportingquarter(Total Died/Total discharges x 100)

b: inpAtient therApeUtic cAre

1 Casefatalitya Numberofpatientswhodiedasapercentageofallnewadmissions for the reportingmonth (s) (Total Died/Total new admissions x 100)

2 Defaulterrate Number of patients who defaulted (ran away) as apercentageofallnewadmissionsforthereportingmonth(s)(Total defaulted/Total new admissions x 100)

3 Failuretorespondb Numberofpatientswhofailedtorespondasapercentageof all newadmissions for the reportingmonth (s) (Total failure to respond/Total new admissions x 100)

4 TransferratestoOTC NumberofpatientstransferredtoOTCasapercentageofnewadmissionsforthereportingmonth(s)(Total transfers to OTC /Total new admissions x 100)

5 Cure rate (if F100 is used for rehabilitation)

Number of patients cured as a percentage of newadmissions for the reporting month (Total cured /Total new admissions x 100)

6 Average rate of weightgainc (only for childrenfeedingfreelyonF100)

Averageweightgain(g)forpatientsonF-100fortheentireweek(7days)dividedbytheiraverageweight(kg)x100.

Good weight gain is >10 g/kg/day-; moderate weight gain 5 up to 10 g/kg/day and poor weight gain is <5 g/kg/day

aCase-fatalityrateof>20%isunacceptable;11-20%poor;5-10%moderateand<5%isacceptable

bseebelowfordetailsonhowtorecognizefailuretorespond

cIftheaveragerateofweightgainispoorfor≥10%ofthechildrenonF-100orthereisadecreaseinaveragerateofweightgainincomparisontopreviousthreemonths,thereisaproblemthatmustbeinvestigated.


How to recognize failure to respond:

condition ApproXimAte time AFter Admission

Failuretoregainappetite

Failuretostarttoloseoedema

Oedemastillpresent

Failuretogainatleast5g/kg/dayfor3successivedaysafterfeedingfreelyonF-100

Day4

Day4

Day10

AfterfeedingfreelyonF-100

Note: HIV/AIDS patients may not respond as those who are HIV negative

Theindicatorsgivenareprimarilyapplicabletochildren6-59monthsagegroupalthoughothersmaybepartoftheprogram.Morethan90%ofthetargetpopulationiswithinlessthan1daysreturnwalk(includingtimefortreatment).Coverageisgreaterthan50%inruralareas,greaterthan70%inurbanareasand90%incampSituation.

tAble 21 typicAl tArget levels For cUre, mortAlity And deFAUlting rAtes

indicAtors AcceptAble AlArming

sFp otc itc sFp otc

Cure rate >75% >75% >75% <50%

Deathrate <3% <5% <10% >10%

Defaulterrate <15% <15% <15% >30%

Nonrespondentrate <10% <10% <10% >10%

Coverage >70% -

Averagelengthofstayforcuredpatients <90days <60days 7–8days*

Distributionofcentres >90%targetpopulationliveswithin1dayreturnwalkfromcentre

Source:Spherestandards,2011.

• If cure rates are low and death rates are high, it means the programme is not performingeffectively.Thisneedstobeinvestigatedandaddressed.

• If cure rates are low and defaulter rates are high, it means that service is not performingeffectively.Anydefaultercouldrepresentadeath.

*ITClinkedtoOTC

10.2.3 Nutrition Information, Education and Communication

Monitoringanutritioneducationprogrammeisessentialtodetermineitsprogresstowardsachievingthesetobjectives.Qualitativedatacanbecollectedcontinuouslytodeterminetheprogram’s:

o Appropriatenesseffectiveness

o Coverage


MonitoringindicatorsforNutritionEducationProgrammeinclude:

• Proportionoftopicsconducted;

• ProportionofTrainingsconducted;

• Proportionof“Trainersoftrainers”(TOTs)trained;

• Proportionofprogramsupervisorsandmanagerstrained;

• ProportionofCommunitygroups/individualstrained;

• ProportionofIECmaterialsdeveloped/providedvsthoseplannedfor.

• Proportionofactivecommunitygroupsvsthosetrained.

10.2.4 Emergency Nutrition Response (ENR)

Monitoring helps to ensure that the emergency nutrition response is effective at preventingincreasedand/orexcessivemorbidityandmortalityrelatedtoacutemalnutrition.

The following requirements for setting up and implementation of ENR programme should bemonitored:

• Personnel

o Appropriatestaffandstaffinglevels(managers,logisticssupport,administrationandtechnicalstaff(clinicians,nutritionists,nurses)andsupportstaff.

o Staffspeak/understandthelocallanguageandcultureofthepopulation.

o Stafftrained/orientatedprioronconductingthereliefprogrammes.

o Staffhaveclearjobdescriptionswithclearrolesandresponsibilities.

• Supplies and logistics

o Availabilityofgoodlogisticssystemtoensurethereisnobreakinthepipeline.

o Bufferstocksshouldbeinplaceespeciallywhereinsecurityisanissue.

• Service Linkages for Prevention and Management of Acute Malnutrition o Interventionsto:

- Manageacutemalnutrition

- StrengthenIYCF-E,

- Addresshealth,water,sanitationandhygieneandfoodinsecurity.

• Aggravating factors

o GAMrates(>10%)

o Crudemortalityrates(>1/10,000/day)

o Availabilityoffunding

o Effectiveepidemiologicalcontrolofinfectiousdiseases

o Climaticconditions(severeornot)

o Shelter(whetheradequateornot).


10.2.5 Monitoring Coverage of IMAM services

Coverage is a critical indicator that should be monitored at programme level. If programmeperformanceisgood(highcure,lowmortalityanddefaultrates)butcoverageispoor,thenthereislowprogrammeimpactatpopulationlevel.Wherecureratesarelower,highercoverageratesareneededtoeffectagivenGAMreductionatpopulationlevel.

Table22showsthecoverageneededinordertoachieveareductioninglobalacutemalnutrition(GAM)atpopulationlevel,at75%curerate.

tAble 22: coverAge needed to eFFect A given redUction in gAm

gAm redUction Aim minimUm coverAge needed

100% Notpossiblewithacurerateof75%

75% 100%

50% 66.7%

25% 33.3%

Note: 75% cure rate is constant

AssessingcoverageidentifiestheproportionofclientsenrolledintheIMAMservicesoutofthetotalnumberofpeoplewhoneedtheinterventioninagivenarea.Coverageisnormallyexpressedasapercentage(i.e.if100peopleareacutelymalnourishedinthecommunityand50areadmittedintheIMAMprogramme,thenthecoverageis50%).

CoverageisoneofthemostimportantindicatorsofhowwelltheIMAMserviceismeetinganeed.A“metneed”istheproductofcoveragerateandcurerate.Aprogrammewithahighcoveragebutlowercurerates(75%coverageX70%curerate=53%ofneedmet)maybebetteratmeetingtheneedthanonewithhighcureratewithalowcoverage(80%cureX25%coverage=20%ofneedmet).

The IMAM coverage is estimated using a population based coverage survey which requiresspecializedassistance(seeValidCommunity-basedTherapeuticCare:AfieldManual-chapter9forinformationonconductingcoveragesurveys.Thereareseveralmethodologiesthatcanbeusedforassessingcoveragee.g.SLEACandSQUEAC.

Monitoring Appropriateness of IMAM programme:

Thefollowingcanbeused:

• Focusgroupdiscussions(FGDs)and

• Interviewswithkeymembersofthecommunity.

ThepurposeofthesediscussionsandinterviewsistouncoverpotentialbarrierstocomponentsofIMAMinordertoimproveitsdelivery.


10.3 IMAMservicesupervisionAsupervisorshould:

• Givedirectiontotheteam,makedecisions,solveproblems,monitorprogress,providefeedbackandkeeprecords;

• Beendowedwithknowledgeandskillsand;

• Receivesupportandguidancefromtheworkplacetoenablehim/herbeeffectiveasasupervisor

SupervisorsshoulduseintegratedsupportsupervisionchecklisttoassistinmonitoringthequalityoftheIMAMprogramme.

Indicators for Supervision

• Percentageofsupportsupervisionsconductedvsplannedforannuallyatdistrictandnationallevel

• Proportionofsupervisorstrainedonintegratedsupportsupervisionatdistrictandnationallevel

10.4 ReportingFigUre 16: the reporting system oF the imAm progrAmme

At FAcility level:

Health Care Service Providers:• FillinIntegratedNutritionRegistersHMIS Focal Persons:• Compilemonthlyandquarterlyreportsandsubmit

tothefacilityin-chargesFacility In-charges:• Cross-checkthereports• Convenemeetingtoreviewthereports• Submitreportsandrequisitionsfornutrition

supplies/orequipmenttodistrictthroughthehealthsubdistrict(whereapplicable)

ministry oF heAlth

• Summarises,analysesandinterprets,utilizesdatafromdistricts

Providesfeedbacktothedistricts

• Sharesthesummaryreportswithpartners• Consolidatesrequisitionsforsupplies

andequipmentandsubmitstorelevantpartners

• Followsuprequisitionsfornutritionsuppliestoensuretimelydeliverytothedistrict

AT HEALTH SUB-DISTRICT LEVEL:

HMIS Focal Persons:• Crosscheckthereports• Sendreportsandrequisitionsfornutrition

supplies/orequipmenttothedistrict

At district level:

HMIS Focal Persons (Biostaticians):

• Compilethedatafromeachindividualsiteintoasummaryreport

• Analyse,interpret,utilizedataandgivefeedbacktohealthfacilities

• Summariserequisitionsfornutritionsupplies/orequipmentfromeachindividualsite

• SubmitssummaryreportsandrequisitionstoMOHandpartners


Reporting on stock

a) Amountofstockconsumedinthereportingmonthorquarter(F75,F100,ReSoMal,RUTFandsupplementaryfoods)

b) Stockbalance(athand)isgivenbyamountavailableatbeginningofmonth+stockreceivedduringthemonthminusstockutilized+wastage/leakagesforeachsupply

c) Wastage/leakagesinareportingmonth(s)maybeduetodamagebyrodents,expiryorlossesduringfeedpreparation,etc

d) Supplyprojectionsforthenextquarter–seesectiononsupplychainmanagementfordetails

10.5 EvaluationAnevaluationwilloftenaddresstwomainquestions:

• Aretheresultsthosethatwereintended?

• Andaretheyofvalue?

Evaluationcanbeperformedusing:

• Theexistingdatabasescollectedovertime

• Specificevaluationstudiesconductedatbaseline,midtermandattheendoftheprogramme(seetable22fortools).

10.6Qualityimprovementinintegratedmanagementofacutemalnutritionquality refers to:

• Theabilitytosatisfystatedorimpliedneedsofaperson/population

• Performanceaccordingtostandardsorexpectations

quality improvement in IMAM programming refers to:

• SystematicallyimprovingqualityofIMAMservicesbybridgingthegapsbetweenservicesactuallyprovidedanddesiredstandards.

Attributes of quality:

• Accesstoservices

• Effectivenessofcare

• Interpersonalrelations

• Efficiencyofservicedelivery

• Continuityofservices

• Safety

• Physicalinfrastructureandcomfort(amenities)


Principles of quality improvement

Qualityimprovementisbasedonfourkeyprinciples:

• Client focus: IMAMservicesshouldbedesignedtomeettheneedsandtheexpectationsoftheclientsorcommunityinordertoimproveserviceuptakeandutilization.

• Focus on systems and processes:

o Byanalysinggapsandidentifyingcausesofpoorperformance

• Testing changes and emphasizing the use of data:

o Changesaretestedtofindoutwhethertheyyieldtherequiredimprovement.

o Dataareusedtoanalyseprocesses,identifyproblemsanddeterminewhetherthechangeshaveresultedinimprovement.

• Team work: Improvement is achieved through the team approach to problem solving andqualityimprovement.

the moh Qi FrAmework And coordinAtion strUctUre:

IMAMQIshouldbefullyembeddedwithintheexistingQIframeworkatalllevels(national,regional,district,sub-districtandhealthfacilitylevels)usingthe5-SmodelandtheiterativePDSA(refertoHSQIFrameworkandHSSP2010/11– 2014/15 for details).

5-S Model

5-Sissequenceofactivitieswhichinclude:sort-set-shine-standardize-sustain.The5-Smodelistheinitialstep/foundationforallqualityimprovementinitiativesbyMoH.

Objectives of 5-S

• Toimprovedhealthcarequalityandproductivity

• Toimprovedinfrastructuremaintenance

• Toimprovedhealthandsafety

Steps in implementing 5-S

a. Sort refers toremovingunnecessaryitemsfromyourworkplace.

b. setreferstoorganizingeverythingneededinproperorderforeasyoperation.

c. Shine refersto maintainingahighstandardofcleanlinessincludingtools,instrumentsandmachinesanddevelopingalongtermmaintenanceplan.

PROCESS OF CAREHow it is done• Quality improvement approaches• Cycle of learning and Improvement

CONTENT OF CAREWhat is done• Norms• Standards• Protocols• Guidelines

OUTPUT/OUTCOMEImproved quality of care and health (e.g standards developed and applied)


d. Standardize-referstoestablishingtheabovethreeSsasthenormineveryworkplaceandensuringregularmaintenance,cleanlinessandimprovedqualityofcare.

e. Sustain referstocontinuoustrainingandmaintainingthedisciplineofthepersonnel-ensureteamwork, workimprovementteam(WIT)and5-Straining

FIgURE 17: WORk PLACE IMPROVEMENT THROUgH 5-S

The PDSA cycle

• Isawaytotryoutideastoimprovebeforedecidingtoimplement

• Allowsteamstoknowquicklywhetherthechangewillwork

• Gathersdatatoconvincecolleaguesthatthechangeswork

TheQIteamshouldusethePDSAcycletoidentifythegaps,testchangestobridgethegaps,studythetestedchangesandadaptchangesthathavecausedimprovementinIMAMservicedeliveryasbestpractices.

• UsetheappropriateQItools(documentationjournals)todesignQIprojectsonIMAM,monitorperformanceanddocumentbestpractices

• StrengthenexistingQIteamstoaddressIMAMQIactivities

Work EnvironmentImprovement

QI PerformanceImprovement

Higher work efficiency

Better quality assurance• Preparedness• Standardization• Timeliness• Completeness• Communication• Safety

5-S ACTIVITIESSORTSET

SHINESTANDARDISE

SUSTAIN


FigUre 18: the pdsA cycle

Flow chart is a quality improvement tool that explains the process of doing something frombeginningtoendsuchasanOTCpatientflowchart(asillustratedinFigure19below).

Do: Test the changeFor example start taking and recording weight of all patients attending OTC

Make sure that the change is being implemented according to plan

Collect data about the process being changed

Document any changes which were not in the original plan

Plan: Develop a plan of the changes to addressWhat changes will occur and why? (For example start taking and recording weight of all patients attending OTC to track their progress

Who is responsible for making the changes?

When and how will the changes occur?

• Collect baseline data to measure the effects of change

• Educate and communicate: Inform people about the changes you are testing and include those involved in the changes

act: Summarize and communicate what was learnt from previous stepsIf the change does not give the desired results, then either modify or abandon the plan and repeat the PDSA cycle

If the change was successful, then implement the change as standard procedure or consider implementing the change throughout the system

Study: Verify that the change tested was according to planSee if data is complete and accurate and compare the data with baseline information to see if an improvement has occurred


FigUre 19: process Flow oF pAtients in otc

CLINICaL aSSESSmENT:• Medical and dietary

history taken• Physical examination• Drugs prescribed

Refer to Inpatient Therapeutic Care (ITC)

RoutIne CounselIng and testIng

foR HIV

appETITE TEST:Appetite test for RUTF conducted

REGISTRaTION IN OTC:• Prescribing RUTF • Recording in

Integrated nutrition register and ration card

• Counselling on use of RUTF

• Given Return dates for follow up

DISpENSING:• Receives prescribed

drugs and RUTF from pharmacy/dispensary

aNTHROpOmETRy aREa:• MUAC, Weight, Height

taken• Classification of nutrition

status

PatIent exIts

PatIent aRRIVal

WaITING aREa:Triage, Nutrition and Health Education

MedICal CoMPlICatIons Passes

aPPetIte test

YES

YES

NO

NO


Surge Approach

TheIMAMSurgeapproachisaprocessthatinvolvesasetofpracticaltoolstohelphealthsystemstobettermanageservicesforacutemalnutritionovertime.Specifically,theapproachfocusesonimprovingplanningandmanagementoftreatmentservicesduringseasonalspikesorsurgesincaseloadsof acutemalnutrition. It is used toaddressboth severeandmoderateacutemalnutritionwhereappropriate

Components of the Surge Approach include:

• Risk analysis and capacity assessment

Healthfacilitiesshouldanalysethemostlikelycausesofacute malnutritionintheircatchmentareatoestablishwhata‘normal’caseloadlookslikeandwhenandtowhatdegreesurgesoccurthroughouttheyear.

• Thresthshold setting

In this context, thresholdsare thenumberof casesof severeacutemalnutrition seen in thefacility permonth, abovewhich the health facilitywould need tomodify their normal clinicprocedures (usually the ‘alert’ threshold) and/or receive external support from the DistrictHealthOffice(usuallythe‘serious’or‘emergency’threshold).

Basedon thecapacityassessmentandpreviousexperience,a setof caseload thresholdsareagreedonforeachhealthfacility.

• Monitoring against set threstholds

Thresholdsaremonitoredperiodically,byplottingcaseloadsagainsttime.

• Provision of surge support

ThroughtheDHTandotherstakeholders,acomprehensivesurgeappropriateactionandsupportpackagearedeliveredtothehealthunits

• Scaling down surge support

As caseloads reduce, any surge support package is gradually scaled down in line with thethresholds.Ultimately,caseloadsandexternalsupportareexpectedtoreturnto‘normal’pre-surgelevels.

Note: At the end of the ‘surge season’, the health facility and District health staff should review how the scale up of support worked and how the actual caseload trends differed from the trends predicted. This review should also occur whenever major changes in capacity occur at Health Facilities.


TABLE 23: SAMPLE ACTION PLAN FOR IMPLEMENTATION OF qI IN IMAM SERVICES (ALTERNATIVELy ONE CAN USE THE DOCUMENTATION JOURNAL AS IN ANNEx 20)

HealthFacility____________________________

DatePrepared____________________________

Step current status (What we do now)

Changes to be introduced (New things we must do)

Who will organize the changes

New resources needed

Source Who will organize the resources

Who? When? Who? When?

10.7 SupplychainmanagementforimamThis topicoutlines thegoals, typeof supplies, their sourcesand stockmanagementatdifferentlevelsofthehealthsystem.

GoalsofSCMforIMAMsupplies:

i) Topreventstockouts,

ii) Toreducetimeloss,and

iii) Tobuildconfidenceinservicemanagement

tAble 24: types oF imAm sUpplies

type eXAmples when to order

Therapeuticfeeds F75,F100,RUTF,CMVandResomal Quarterly

Supplementaryfoods CornSoyaBlend(CSB),lipidbasednutrientsupplement,Fortifiedblendedfoods(SuperCerealandSuperCerealPlus),BP100,BP5,RUSF,

Quarterly

Anthropometricequipment

MUACtapes,weighingscales,heightboards,

basedonneed

Datacollectiontools HMIS-Integratednutritionregister,integratednutritionrationcard,monthlyandquarterlyreports,registersatdifferentcarepoints

basedonneed

Routinemedicinesandsupplements

RefertochaptersonspecificIMAMcomponents

AsperNMScycle


Managingstocks involvesthefollowing:

a. quantification of supplies

Projectionsfornutritionsuppliesaredoneregularlyinordertoensureeffectiveprogrammingandminimize on stock outs. Calculations are either based on case loads and target populations orpreviousconsumptionlevelsandshouldinclude10%ofsupplies(bufferstock)estimates.

Consumptionestimatesofthenutritionsuppliesarederivedfromtotalnumberofnewadmittedcasesmultipliedby the recommendedquantitiesof the therapeuticsuppliesused for treatingachild.Forexampleachildin:

ITC (LINkED TO AN OTC) otc sFp

Requiresanestimateof;

o 12sachetsofF75,

o 0.2sachetsofReSoMal.

o MinimalRUTF

o 4sachetsofF100

requiresanestimateof:-

o 136sachetsofRUTF.

Buffer stock

Bufferstockisdefinedasreservesuppliestosafeguardagainstunforeseenshortagesordemands.Itisstockusedoverandabovetheactualstockrequiredorneededtoruntheprogramme.

Itisobtainedbycalculating10%ofthestockneededfortheprogramme.

Transportation,distribution,storageanddispensingofnutritionsuppliesshouldbeintegratedwithothersuppliesatalllevels.Similarly,managementofstockoutsshouldfollowtheexistingprotocols.


references

WHO, 2004; Guidelines for the Inpatient Treatment of Severely Malnourished Children, WorldHealthOrganisation,Geneva.

iAsc, 2008; Transitioning to the WHO Growth Standards: Implications for Emergency Nutrition Programmes,ameetingReportofIASCNutritionClusterInformalConsultation,Geneva,25-27June

Collins, S., Arabella D. and Myatt, M. 2000;Adults:AssessmentofNutritionalStatusinEmergency-AffectedPopulations,July.

Community based therapeutic care (CTC), 2006). CTS research and development programme incollaborationwithValidInternationalandConcernWorldwide.

Valid International, 2006: Community-based Therapeutic Care (CTC), A Field Manual, ValidInternational,FirstEdition.

etAt, 2011,EmergencyTriageandTreatment(ETAT)handbook,Kampala,UgandaUganda2011

FAo, 1994; CorporateResourceDocumentRepository:Agriculture, foodandnutrition forAfricaresource book for teachers, Corporate Resource Document Repository, Food and AgricultureOrganization,1994

golden, M. and grellety, y. , 2006;GuidelinesfortheManagementoftheSeverelyMalnourished,September,2006.

Howard, g. and Snetro, 2004;Howtomobilizecommunitiesforsocialchange

MoH , 2006.ImprovingtheQualityofLifethroughNutrition,AguidelineforfeedingpeoplewithHIV/AIDS,2ndEdition,UgandaMinistryofHealth,KampalaUganda2ndEditionMay2006

MoH , August 2007; Outpatient Care of Children with Acute Malnutrition Training Manual,MinistryofHealthRepublicofUganda,KampalaMinistryofHealth,August2007.

MoH , September 2008; DraftPolicyGuidelinesonInfantandYoungChildFeeding:TheRepublicofUganda,MinistryofHealth,Kampala

MoH , September 25, 2008;Minutes of the IMAM Technical Working Group meeting,MinistryofHealth,RepublicofUgandaKampala.

MoH 2008;DecisionstakenduringameetingtoDiscussKeyTechnicalIssuesonIMAMImplementationin Uganda, presentation of the IMAM TechnicalWorkingGroup,Ministry of Health Republic ofUganda,Kampala.August29.

MoH September 2008; Draft, Integrated Management of Acute Malnutrition,RepublicofKenyaMinistryofHealth,RepublicofKenya.Draft,September.

MoH, 2010, Health Sector quality Improvement Framework and Strategic Plan 2010/11– 2014/15. The Republic of Uganda,MinistryofHealth,Kampala


MoH, February 2002;NationalAnaemiaPolicy,Uganda,MinistryofHealth,RepublicofUgandaKampala,February.

MoH, 2004,GuidelinesonInpatientManagementofSevereAcuteMalnutrition,MinistryofHealth,Kampala,Uganda.

MoH, February, 2007;DraftInterimGuidelinesfortheManagementofAcuteMalnutritionThroughCommunity-basedTherapeuticCare,GovernmentofMalawi,MinistryofHealth,February.

MoH 2007; Protocol for the Management of Severe Acute Malnutrition,EthiopiaFederalMinistryofHealth,February.

MoH, 2006; Interim Guidelines for the Management of Acute Malnutrition in Adolescents and Adults,MinistryofHealthGovernmentofMalawi,MinistryofHealth,March.

MoH, UNICEF and VALID International, 2006; Draft 2 Integrated Management of Acute Malnutrition Guidelines for Uganda,Valid International,MinistryofHealth,UgandaandUNICEF,Draft2,NovemberKampalaUganda.

MoH, UNICEF and WHO, 2002;Managementofthechildwithsevereillnessorseveremalnutrition:Guidelines for referral facilityqualityof care improvement.Handbook forManagers andHealthworkers,Uganda,MinistryofHealth,Uganda UNICEFandWorldHealthOrganisation,Kampala,Uganda2002

msF, 1995.Nutritionguidelines

Onis, M., et al, September, 2007, 2007;Development of a WHO growth reference for school-age children and adolescents,BulletinoftheWorldHealthOrganisation,September2007.

sphere, 2011;HumanitarianCharterandMinimumStandards inDisasterResponse,TheSphereProject,Secondedition.

UDHS,2011.UgandaDemographicSurvey

UNHCR/WFP (year??) Guidelines on Selective feeding programme, United Nations HighCommissionerforRefuges

UniceF, 2008; Steven-Muyeti,Rianne, CommunityBasedManagementofAcuteMalnutrition inUganda:AProcessReview,UNICEFUganda.

who 1999 Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers, Geneva,WorldHealthOrganisation,1999.

who 2006;Guidelines for the management of common illnesses with limited resources, PocketbookofHospitalcareforchildren,reprintedversion,WorldHealthOrganization,Geneva

who, 2000;ManagementoftheChildwithaSeriousInfectionorSevereMalnutrition:Guidelinesfor care at the first-referral level in developing countries, Department of Child and AdolescentHealthandDevelopment,WorldHealthOrganization,Geneva

WHO, 2003; Guidelines for the Inpatient Treatment of Severely Malnourished Children, World HealthOrganisationGeneva.


who, 2004; Severe Malnutrition: Report of a Consultation to review current literature,NutritionforHealthandDevelopment,WorldHealthOrganization,September6-7.

who, 2007;GuidelinesforanIntegratedApproachtotheNutritionalCareofHIV-infectedChildren(6months-14years)atTreatmentSites/ReferralFacilities,draftHandbook,WorldHealthOrganizationGeneva.

who, 2008;GuidelinesforanIntegratedApproachtotheNutritionalCareofHIV-infectedChildren(6months-14years): Guide forLocalAdaptation,Preliminaryversion forCountry Introduction,WorldHealthOrganization,Geneva.

who, 2008; Transitioning to the WHO Growth Standards: Implications for Emergency Nutrition Programmes,ameetingReportofIASCNutritionClusterInformalConsultation,Geneva,25-27June

who, 2013; Guidelines: Updates onManagement of Severe AcuteMalnutrition in Infants andChildrenWorldHealthOrganization,Geneva.

Woodruff, B. A. and Arabella D; Adolescents: Assessment of Nutritional Status in Emergency-Affected Populations,SecretariatoftheUNACC/Sub-CommitteeonNutrition,July,WorldHealthOrganization,Geneva.


ANNEXES


Ward Equipment/Supplies• Glucostix/sticksforrandom

bloodsugar

• Runningwater

• Thermometers

• MUACtapes(childrenandadults)

• Weighingscales(mustbefunctioningcorrectly)

o Itemsofknownweightforcheckingscales

• Boardformeasuringlength

o Poleofknownlengthforcheckingaccuracy

• Stadiometer(tomeasurestandingheight)

• Haemoglobinometer

Supplies for IV:• Scalpvein(butterfly)

needles,gaugeforchildren(22,24)foradults(18,20)

• PolesormeansofhangingbottlesofIVfluid

• Givingsets

• IVfluids

• Nasogastrictubes(pediatricsandadults)

• Adhesiveplaster

• Syringes(20and50mlforfeeds)

• Syringes(2mlfordrugs,5mlfordrawingblood,10ml)

• Sterileneedles

• Eyepads

• Bandages

• Gauze

Supplies for blood transfusion:• Unitsofblood

• Syringesandneedles

• Bloodtransfusionsets

• Blanketsorwrapsforwarmingchildren

• Incandescentlamporheater

• Washbasinforbathingpatients

• Safe,homemadetoys

• Clock

• Calculator

For hygiene of mothers and staff• Toiletandhandwashing

facilities

• Cleanwaterandsoapforhandwashing

• Placeforwashingbeddingandclothes

• Facilityforwastedisposal

For reference and record keeping• Relevanttablessuchas:

o Weight-for-Length/HeightReferenceCard

o BMIReferenceCardo F-75ReferenceCardo F-100ReferenceCardo RUTFappetitetest

ReferenceCardo RUTFdosingReference

Cardo AntibioticsReference

Card

o Suitableformsforrecordkeeping,suchastheCCP(CriticalCarePathway)orotherformsrequestingsimilarinformation(weightcharts,monitoringrecords)

o 24-HourFeedIntakeCharts

kitchen Equipment/Supplies• Dietaryscalesabletoweigh

to5g

• Electricblenderormanualwhisks

• Largecontainersandspoonsformixing/cookingfeedfortheward

• Facilitiesforcooking

• Feedingcups,saucers,spoons

• Measuringcylinders(orsuitableutensilsformeasuringingredientsandleftovers)

• Jugs(1-litreand2-litres)

• Refrigeration

• FormakingF-75andF-100:o Driedskimmedmilk,

wholedriedmilk,freshwholemilk,orlong-lifemilk

o Sugaro Cerealflouro Vegetableoilo Safewatersupply

Locallyavailablefoods(forteaching/useintransitiontohomefoods)

ANNEX 1EQUIPMENTANDSUPPLIESNEEDEDFORANUTRITIONWARD/UNIT


Pharmacy Equipment/Supplies• Pharmaceuticalscales

• WHOORSforuseinmakingReSoMal(orcommercialReSoMal)

• CombinedMineralVitaminMix(CMV)

IfCMVnotavailable:

*Mineralmix(maybepreparedinthepharmacy)or

Electrolytesandminerals:

o Potassiumchloride

o Tripotassiumcitrate

o Magnesiumchloride

o Zincacetate

o Coppersulphate

*Multivitaminwithoutiron

• Ironsyrup(e.g.,ferrousfumarate)

• Folicacid

• VitaminA(highpotencysyrupor50,000/100000/200000IUcapsules)

• Glucose(orsucrose)

• IVfluids–oneofthefollowing:

o Half-strengthDarrow’ssolutionwith5%glucose(dextrose)

o Ringer’slactatesolutionwith5%glucose*

o 0.45%(half-normal)salinewith5%glucose*

*Ifeitheroftheseisused,sterilepotassiumchloride

(20moll/l)shouldbeaddedifpossible.

• Sterilewaterfordiluting

• Waterforinjection(ampoules2,5and10ml)

• Vaccines(BCG,OPV,Pentavalent,RotaVirus,PCVandMeasles)

Drugs(SeeformulationslistedonAntibioticsReferenceCard)

• Amoxicillin

• Ampicillin

• Benzylpenicillin

• Cotrimoxazole

• Gentamicin

• Metronidazole

• Cloxacilllin

• Ceftriaxone

• Mebendazole,albendazoleand/orotherdrugsfortreatmentofworms(asonnoteofdrugkitformanagementofsevereacutemalnutritionwithmedicalcomplications(Seesupportmaterials))

• Gentamycinorchloramphenicoleyedrops

• Atropine1%eyedrops

• Artemether+Lumefantrinetablets

• Artesunate suppository

Forskin

• Gentianviolet

• Zincoxideointment

• Petroleumjellyointment

• Nystatinointmentorcream(forCandidiasis)

• Vaselinegauze(tullegras)

• Silversulphurdiazine

Laboratory resources accessible where applicable• TBtests(x-ray,cultureof

sputum,Mantoux)

• Urinalysis

• Stoolanalysisandculture

• Bloodculture

• Cerebrospinalfluidanalysisandculture

• Genexpert

• HIVtest

o HIVrapidTestingkits

• Bloodsample

o Filterpapers

o RDT


ANNEX 2TRIAGEOFSICKCHILDREN

• Tiny-Sickinfantaged<2months• Temperatureveryhigh>390• Trauma-majortrauma• Pain-Childinseverepain• Poison-motherreportspoisoning• Pallor-severepalmerpallor• Restless/Irritable/Floppy• Respiratorydistress• Referral-hasanurgentreferralletter• Malnutrition:o visibleseverewastingo Bilateralpittingoedema

• Burns-severeburnsFrontoftheQueue-Clinicalreviewassoonaspossible:• Weigh• Baselineobservations

• Hypoglycaemia(BloodSugar<3mml/dl)• HypothermiaTemp≤35.50C,axillar• Severeinfections• DiarrheaandSeveredehydration• Shock• Verysevereanemia(Hb≤4g/dl)• Cardiacfailure• Severedermatosis• CornealUlceration

priority signs

medicAl complicAtions iF severe AcUte mAlnUtrition

emergency signs:

NON URgENT- CHILDRENWITHNONEOFTHEABOVESIGNS/MEDICALCOMPLICATIONS

Diarrhoeawithsunkeneyes→assessment/treatmentforseveredehydration

Comma/convulsing/confusion:AVPU=‘PorU’orConvulsions

Airway&breathing

Circulation

• Obstructedbreathing• CentralCyanosis• SevereRespiratorydistress• Weak/absentbreathing

Coldhandswithanyof:• Capillaryrefill>3seconds• Weak+fastpulse• Slow(<60bpm)orabsent

pulse

Immediatetransfertoemergencyarea:• Startlifesupport

procedures• Giveoxygen• Weighifpossible


ANNEX 3 3A:WEIGHT-FOR-LENGTHREFERENCECARDa

(WHO growth Standards)

BOyS' WEIgHT (kg) gIRLS' WEIgHT (kg

-3 sd -2 sd -1 sd median LENgTH (CM) median -1 sd -2 sd -3 sd

1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9

2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0

2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2

2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3

2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4

2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6

2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8

2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9

3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1

3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3

3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5

3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7

4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9

4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1

4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3

4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5

4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7

5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9

5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1

5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3

5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5

5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6

6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8

6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0

6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1

6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3

6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5

7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6

7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8

7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9



-3 sd -2 sd -1 sd median LENgTH (CM) median -1 sd -2 sd -3 sd

7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1

7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2

7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4

7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5

8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7

8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8

8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0

8.5 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1

8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3

8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5

9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7

9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9

9.5 10.2 11.1 12.0 87 11.7 10.7 9.9 9.1

9.7 10.5 11.3 12.2 88 12.0 11.0 10.1 9.3

9.9 10.7 11.5 12.5 89 12.2 11.2 10.3 9.5

10.1 10.9 11.8 12.7 90 12.5 11.4 10.5 9.7

10.3 11.1 12.0 13.0 91 12.7 11.7 10.7 9.9

10.5 11.3 12.2 13.2 92 13.0 11.9 10.9 10.1

10.7 11.5 12.4 13.4 93 13.2 12.1 11.1 10.2

10.8 11.7 12.6 13.7 94 13.5 12.3 11.3 10.4

11.0 11.9 12.8 13.9 95 13.7 12.6 11.5 10.6

11.2 12.1 13.1 14.1 96 14.0 12.8 11.7 10.8

11.4 12.3 13.3 14.4 97 14.2 13.0 12.0 11.0

11.6 12.5 13.5 14.6 98 14.5 13.3 12.2 11.2

11.8 12.7 13.7 14.9 99 14.8 13.5 12.4 11.4

12.0 12.9 14.0 15.2 100 15.0 13.7 12.6 11.6

a Amoredetailed tableisavailable onhttp://www.who.int/childgrowth/standards/weight_for_length/en/index.htmlbLengthismeasuredforchildrenbelow2yearsor,ifageisnotknown,below87cm.Forchildren2yearsandabove(or,ifageisnotknown,87cmormore),heightismeasured(seefollowingtable).Recumbentlengthisonaverage0.7cmgreaterthanstandingheight;althoughthedifferenceisofnoimportancetoindividualchildren,acorrectionmaybemadebyadding0.7cmtotheheightifthechildislessthan2years(orbelow87cmifagenotknown)whenrecumbentlengthcannotbemeasured.

http://www.who.int/childgrowth/standards/weight_for_length/en/index.html

http://www.who.int/childgrowth/standards/weight_for_length/en/index.html


3B:WEIGHT-FOR-HEIGHTREFERENCECARDa

(WHO growth Standards)


-3 sd -2 sd -1 sd median heightb (CM) median -1 sd -2 sd -3 sd

5.9 6.3 6.9 7.4 65 7.2 6.6 6.1 5.6

6.1 6.5 7.1 7.7 66 7.5 6.8 6.3 5.8

6.2 6.7 7.3 7.9 67 7.7 7.0 6.4 5.9

6.4 6.9 7.5 8.1 68 7.9 7.2 6.6 6.1

6.6 7.1 7.7 8.4 69 8.1 7.4 6.8 6.3

6.8 7.3 7.9 8.6 70 8.3 7.6 7.0 6.4

6.9 7.5 8.1 8.8 71 8.5 7.8 7.1 6.6

7.1 7.7 8.3 9.0 72 8.7 8.0 7.3 6.7

7.3 7.9 8.5 9.2 73 8.9 8.1 7.5 6.9

7.4 8.0 8.7 9.4 74 9.1 8.3 7.6 7.0

7.6 8.2 8.9 9.6 75 9.3 8.5 7.8 7.2

7.7 8.4 9.1 9.8 76 9.5 8.7 8.0 7.3

7.9 8.5 9.2 10.0 77 9.6 8.8 8.1 7.5

8.0 8.7 9.4 10.2 78 9.8 9.0 8.3 7.6

8.2 8.8 9.6 10.4 79 10.0 9.2 8.4 7.8

8.3 9.0 9.7 10.6 80 10.2 9.4 8.6 7.9

8.5 9.2 9.9 10.8 81 10.4 9.6 8.8 8.1

8.7 9.3 10.1 11.0 82 10.7 9.8 9.0 8.3

8.8 9.5 10.3 11.2 83 10.9 10.0 9.2 8.5

9.0 9.7 10.5 11.4 84 11.1 10.2 9.4 8.6

9.2 10.0 10.8 11.7 85 11.4 10.4 9.6 8.8

9.4 10.2 11.0 11.9 86 11.6 10.7 9.8 9.0

9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2

9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4

10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6

10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8

10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0

10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2

10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4

11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6

11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8



-3 sd -2 sd -1 sd median heightb (CM) median -1 sd -2 sd -3 sd

11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9

11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1

11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3

11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5

12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7

12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0

12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2

12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4

13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6

13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9

13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1

13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4

13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7

14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9

14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2

14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5

14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8

15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1

15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4

15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7

16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0

16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3

16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6

16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9

17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3

a A more detailed table is available on http://www.who.int/childgrowth/standards/weight_for_height/en/index.html.

b For children 2 years and above (or, if age not known, 87 cm or more), height is measured.Recumbentlength isonaverage0.7cmgreater than standingheight;althoughthedifference isofnoimportancetoindividualchildren,acorrectionmaybemadebysubtracting0.7cmfromthelengthsifthechildis2yearsormoreorabove86.9cmwhenstandingheightcannotbemeasured.

http://www.who.int/childgrowth/standards/weight_for_height/en/index.html

http://www.who.int/childgrowth/standards/weight_for_height/en/index.html


3C:BMI-FOR-AGEREFERENCECARDFORCHILDREN5TO19YEARS

Boy’sBMI(kg/m2) Age Girl’sBMI(kg/m2)

-3SD -2SD -1SD Median Year:Months Months Median -1SD -2SD -3SD

12.1 13.0 14.1 15.3 5:1 61 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:2 62 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:3 63 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:4 64 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:5 65 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:6 66 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:7 67 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:8 68 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:9 69 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:10 70 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:11 71 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 6:0 72 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 6:1 73 15.3 13.9 12.7 11.712.2 13.1 14.1 15.3 6:2 74 15.3 13.9 12.7 11.712.2 13.1 14.1 15.3 6:3 75 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:4 76 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:5 77 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:6 78 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:7 79 15.3 13.9 12.7 11.712.2 13.1 14.2 15.4 6:8 80 15.3 13.9 12.7 11.712.2 13.1 14.2 15.4 6:9 81 15.4 13.9 12.7 11.712.2 13.1 14.2 15.4 6:10 82 15.4 13.9 12.7 11.712.2 13.1 14.2 15.5 6:11 83 15.4 13.9 12.7 11.712.3 13.1 14.2 15.5 7:0 84 15.4 13.9 12.7 11.812.3 13.2 14.2 15.5 7:1 85 15.4 13.9 12.7 11.812.3 13.2 14.2 15.5 7:2 86 15.4 14.0 12.8 11.812.3 13.2 14.3 15.5 7:3 87 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:4 88 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:5 89 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:6 90 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:7 91 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:8 92 15.6 14.0 12.8 11.812.4 13.2 14.3 15.7 7:9 93 15.6 14.1 12.8 11.812.4 13.3 14.4 15.7 7:10 94 15.6 14.1 12.9 11.912.4 13.3 14.4 15.7 7:11 95 15.7 14.1 12.9 11.912.4 13.3 14.4 15.7 8:0 96 15.7 14.1 12.9 11.912.4 13.3 14.4 15.8 8:1 97 15.7 14.1 12.9 11.912.4 13.3 14.4 15.8 8:2 98 15.7 14.2 12.9 11.912.4 13.3 14.4 15.8 8:3 99 15.8 14.2 12.9 11.912.4 13.4 14.5 15.8 8:4 100 15.8 14.2 13.0 11.912.5 13.4 14.5 15.9 8:5 101 15.8 14.2 13.0 12.0




12.5 13.4 14.5 15.9 8:6 102 15.9 14.3 13.0 12.012.5 13.4 14.5 15.9 8:7 103 15.9 14.3 13.0 12.012.5 13.4 14.5 15.9 8:8 104 15.9 14.3 13.0 12.012.5 13.4 14.6 16.0 8:9 105 16.0 14.3 13.1 12.012.5 13.5 14.6 16.0 8:10 106 16.0 14.4 13.1 12.112.5 13.5 14.6 16.0 8:11 107 16.1 14.4 13.1 12.112.6 13.5 14.6 16.0 9:0 108 16.1 14.4 13.1 12.112.6 13.5 14.6 16.1 9:1 109 16.1 14.5 13.2 12.112.6 13.5 14.7 16.1 9:2 110 16.2 14.5 13.2 12.112.6 13.5 14.7 16.1 9:3 111 16.2 14.5 13.2 12.212.6 13.6 14.7 16.2 9:4 112 16.3 14.6 13.2 12.212.6 13.6 14.7 16.2 9:5 113 16.3 14.6 13.3 12.212.7 13.6 14.8 16.2 9:6 114 16.3 14.6 13.3 12.212.7 13.6 14.8 16.3 9:7 115 16.4 14.7 13.3 12.312.7 13.6 14.8 16.3 9:8 116 16.4 14.7 13.4 12.312.7 13.7 14.8 16.3 9:9 117 16.5 14.7 13.4 12.312.7 13.7 14.9 16.4 9:10 118 16.5 14.8 13.4 12.312.8 13.7 14.9 16.4 9:11 119 16.6 14.8 13.4 12.412.8 13.7 14.9 16.4 10:0 120 16.6 14.8 13.5 12.412.8 13.8 15.0 16.5 10:1 121 16.7 14.9 13.5 12.412.8 13.8 15.0 16.5 10:2 122 16.7 14.9 13.5 12.412.8 13.8 15.0 16.6 10:3 123 16.8 15.0 13.6 12.512.9 13.8 15.0 16.6 10:4 124 16.8 15.0 13.6 12.512.9 13.9 15.1 16.6 10:5 125 16.9 15.0 13.6 12.512.9 13.9 15.1 16.7 10:6 126 16.9 15.1 13.7 12.512.9 13.9 15.1 16.7 10:7 127 17.0 15.1 13.7 12.613.0 13.9 15.2 16.8 10:8 128 17.0 15.2 13.7 12.613.0 14.0 15.2 16.8 10:9 129 17.1 15.2 13.8 12.613.0 14.0 15.2 16.9 10:10 130 17.1 15.3 13.8 12.713.0 14.0 15.3 16.9 10:11 131 17.2 15.3 13.8 12.713.1 14.1 15.3 16.9 11:0 132 17.2 15.3 13.9 12.713.1 14.1 15.3 17.0 11:1 133 17.3 15.4 13.9 12.813.1 14.1 15.4 17.0 11:2 134 17.4 15.4 14.0 12.813.1 14.1 15.4 17.1 11:3 135 17.4 15.5 14.0 12.813.2 14.2 15.5 17.1 11:4 136 17.5 15.5 14.0 12.913.2 14.2 15.5 17.2 11:5 137 17.5 15.6 14.1 12.913.2 14.2 15.5 17.2 11:6 138 17.6 15.6 14.1 12.913.2 14.3 15.6 17.3 11:7 139 17.7 15.7 14.2 13.013.3 14.3 15.6 17.3 11:8 140 17.7 15.7 14.2 13.013.3 14.3 15.7 17.4 11:9 141 17.8 15.8 14.3 13.013.3 14.4 15.7 17.4 11:10 142 17.9 15.8 14.3 13.113.4 14.4 15.7 17.5 11:11 143 17.9 15.9 14.3 13.113.4 14.5 15.8 17.5 12:0 144 18.0 16.0 14.4 13.2




13.4 14.5 15.8 17.6 12:1 145 18.1 16.0 14.4 13.213.5 14.5 15.9 17.6 12:2 146 18.1 16.1 14.5 13.213.5 14.6 15.9 17.7 12:3 147 18.2 16.1 14.5 13.313.5 14.6 16.0 17.8 12:4 148 18.3 16.2 14.6 13.313.6 14.6 16.0 17.8 12:5 149 18.3 16.2 14.6 13.313.6 14.7 16.1 17.9 12:6 150 18.4 16.3 14.7 13.413.6 14.7 16.1 17.9 12:7 151 18.5 16.3 14.7 13.413.7 14.8 16.2 18.0 12:8 152 18.5 16.4 14.8 13.513.7 14.8 16.2 18.0 12:9 153 18.6 16.4 14.8 13.513.7 14.8 16.3 18.1 12:10 154 18.7 16.5 14.8 13.513.8 14.9 16.3 18.2 12:11 155 18.7 16.6 14.9 13.613.8 14.9 16.4 18.2 13:0 156 18.8 16.6 14.9 13.613.8 15.0 16.4 18.3 13:1 157 18.9 16.7 15.0 13.613.9 15.0 16.5 18.4 13:2 158 18.9 16.7 15.0 13.713.9 15.1 16.5 18.4 13:3 159 19.0 16.8 15.1 13.714.0 15.1 16.6 18.5 13:4 160 19.1 16.8 15.1 13.814.0 15.2 16.6 18.6 13:5 161 19.1 16.9 15.2 13.814.0 15.2 16.7 18.6 13:6 162 19.2 16.9 15.2 13.814.1 15.2 16.7 18.7 13:7 163 19.3 17.0 15.2 13.914.1 15.3 16.8 18.7 13:8 164 19.3 17.0 15.3 13.914.1 15.3 16.8 18.8 13:9 165 19.4 17.1 15.3 13.914.2 15.4 16.9 18.9 13:10 166 19.4 17.1 15.4 14.014.2 15.4 17.0 18.9 13:11 167 19.5 17.2 15.4 14.014.3 15.5 17.0 19.0 14:0 168 19.6 17.2 15.4 14.014.3 15.5 17.1 19.1 14:1 169 19.6 17.3 15.5 14.114.3 15.6 17.1 19.1 14:2 170 19.7 17.3 15.5 14.114.4 15.6 17.2 19.2 14:3 171 19.7 17.4 15.6 14.114.4 15.7 17.2 19.3 14:4 172 19.8 17.4 15.6 14.114.5 15.7 17.3 19.3 14:5 173 19.9 17.5 15.6 14.214.5 15.7 17.3 19.4 14:6 174 19.9 17.5 15.7 14.214.5 15.8 17.4 19.5 14:7 175 20.0 17.6 15.7 14.214.6 15.8 17.4 19.5 14:8 176 20.0 17.6 15.7 14.314.6 15.9 17.5 19.6 14:9 177 20.1 17.6 15.8 14.314.6 15.9 17.5 19.6 14:10 178 20.1 17.7 15.8 14.314.7 16.0 17.6 19.7 14:11 179 20.2 17.7 15.8 14.314.7 16.0 17.6 19.8 15:0 180 20.2 17.8 15.9 14.414.7 16.1 17.7 19.8 15:1 181 20.3 17.8 15.9 14.414.8 16.1 17.8 19.9 15:2 182 20.3 17.8 15.9 14.414.8 16.1 17.8 20.0 15:3 183 20.4 17.9 16.0 14.414.8 16.2 17.9 20.0 15:4 184 20.4 17.9 16.0 14.514.9 16.2 17.9 20.1 15:5 185 20.4 17.9 16.0 14.514.9 16.3 18.0 20.1 15:6 186 20.5 18.0 16.0 14.515.0 16.3 18.0 20.2 15:7 187 20.5 18.0 16.1 14.5




15.0 16.3 18.1 20.3 15:8 188 20.6 18.0 16.1 14.515.0 16.4 18.1 20.3 15:9 189 20.6 18.1 16.1 14.515.0 16.4 18.2 20.4 15:10 190 20.6 18.1 16.1 14.615.1 16.5 18.2 20.4 15:11 191 20.7 18.1 16.2 14.615.1 16.5 18.2 20.5 16:0 192 20.7 18.2 16.2 14.615.1 16.5 18.3 20.6 16:1 193 20.7 18.2 16.2 14.615.2 16.6 18.3 20.6 16:2 194 20.8 18.2 16.2 14.615.2 16.6 18.4 20.7 16:3 195 20.8 18.2 16.2 14.615.2 16.7 18.4 20.7 16:4 196 20.8 18.3 16.2 14.615.3 16.7 18.5 20.8 16:5 197 20.9 18.3 16.3 14.615.3 16.7 18.5 20.8 16:6 198 20.9 18.3 16.3 14.715.3 16.8 18.6 20.9 16:7 199 20.9 18.3 16.3 14.715.3 16.8 18.6 20.9 16:8 200 20.9 18.3 16.3 14.715.4 16.8 18.7 21.0 16:9 201 21.0 18.4 16.3 14.715.4 16.9 18.7 21.0 16:10 202 21.0 18.4 16.3 14.715.4 16.9 18.7 21.1 16:11 203 21.0 18.4 16.3 14.715.4 16.9 18.8 21.1 17:0 204 21.0 18.4 16.4 14.715.5 17.0 18.8 21.2 17:1 205 21.1 18.4 16.4 14.715.5 17.0 18.9 21.2 17:2 206 21.1 18.4 16.4 14.715.5 17.0 18.9 21.3 17:3 207 21.1 18.5 16.4 14.715.5 17.1 18.9 21.3 17:4 208 21.1 18.5 16.4 14.715.6 17.1 19.0 21.4 17:5 209 21.1 18.5 16.4 14.715.6 17.1 19.0 21.4 17:6 210 21.2 18.5 16.4 14.715.6 17.1 19.1 21.5 17:7 211 21.2 18.5 16.4 14.715.6 17.2 19.1 21.5 17:8 212 21.2 18.5 16.4 14.715.6 17.2 19.1 21.6 17:9 213 21.2 18.5 16.4 14.715.7 17.2 19.2 21.6 17:10 214 21.2 18.5 16.4 14.715.7 17.3 19.2 21.7 17:11 215 21.2 18.6 16.4 14.715.7 17.3 19.2 21.7 18:0 216 21.3 18.6 16.4 14.715.7 17.3 19.3 21.8 18:1 217 21.3 18.6 16.5 14.715.7 17.3 19.3 21.8 18:2 218 21.3 18.6 16.5 14.715.7 17.4 19.3 21.8 18:3 219 21.3 18.6 16.5 14.715.8 17.4 19.4 21.9 18:4 220 21.3 18.6 16.5 14.715.8 17.4 19.4 21.9 18:5 221 21.3 18.6 16.5 14.715.8 17.4 19.4 22.0 18:6 222 21.3 18.6 16.5 14.715.8 17.5 19.5 22.0 18:7 223 21.4 18.6 16.5 14.715.8 17.5 19.5 22.0 18:8 224 21.4 18.6 16.5 14.715.8 17.5 19.5 22.1 18:9 225 21.4 18.7 16.5 14.715.8 17.5 19.6 22.1 18:10 226 21.4 18.7 16.5 14.715.8 17.5 19.6 22.2 18:11 227 21.4 18.7 16.5 14.715.9 17.6 19.6 22.2 19:0 228 21.4 18.7 16.5 14.7

ThistablehasbeenconstructedusingtheWHOreferencetablesforBMI-for-agez-scoresfor5to19years.


3D:BODYMASSINDEXREFERENCECARD

Height(cm)

BodyMassIndex

18.5 18 17.5 17 16.5 16

140 36.3 35.3 34.3 33.3 32.3 31.4

141 36.8 35.8 34.8 33.8 32.8 31.8

142 37.3 36.3 35.3 34.3 33.3 32.3

143 37.8 36.8 35.8 34.8 33.7 32.7

144 38.4 37.3 36.3 35.3 34.2 33.2

145 38.9 37.8 36.8 35.7 34.7 33.6

146 39.4 38.4 37.3 36.2 35.2 34.1

147 40.0 38.9 37.8 36.7 35.7 34.6

148 40.5 39.4 38.3 37.2 36.1 35.0

149 41.1 40.0 38.9 37.7 36.6 35.5

150 41.6 40.5 39.4 38.3 37.1 36.0

151 42.2 41.0 39.9 38.8 37.6 36.5

152 42.7 41.6 40.4 39.3 38.1 37.0

153 43.3 42.1 41.0 39.8 38.6 37.5

154 43.9 42.7 41.5 40.3 39.1 37.9

155 44.4 43.2 42.0 40.8 39.6 38.4

156 45.0 43.8 42.6 41.4 40.2 38.9

157 45.6 44.4 43.1 41.9 40.7 39.4

158 46.2 44.9 43.7 42.4 41.2 39.9

159 46.8 45.5 44.2 43.0 41.7 40.4

160 47.4 46.1 44.8 43.5 42.2 41.0

161 48.0 46.7 45.4 44.1 42.8 41.5

162 48.6 47.2 45.9 44.6 43.3 42.0

163 49.2 47.8 46.5 45.2 43.8 42.5

164 49.8 48.4 47.1 45.7 44.4 43.0

Height(cm)

BodyMassIndex

18.5 18 17.5 17 16.5 16

165 50.4 49.0 47.6 46.3 44.9 43.6

166 51.0 49.6 48.2 46.8 45.5 44.1

167 51.6 50.2 48.8 47.4 46.0 44.6

168 52.2 50.8 49.4 48.0 46.6 45.2

169 52.8 51.4 50.0 48.6 47.1 45.7

170 53.5 52.0 50.6 49.1 47.7 46.2

171 54.1 52.6 51.2 49.7 48.2 46.8

172 54.7 53.3 51.8 50.3 48.8 47.3

173 55.4 53.9 52.4 50.9 49.4 47.9

174 55.0 54.5 53.0 51.5 50.0 48.4

175 56.7 55.1 53.6 52.1 50.5 49.0

176 57.3 55.8 54.2 52.7 51.1 49.6

177 58.0 56.4 54.8 53.3 51.7 50.7

178 58.6 57.0 55.4 53.9 52.3 50.7

179 59.3 57.7 56.1 54.5 52.9 51.3

180 59.9 58.3 56.7 55.1 53.5 51.8

181 60.6 59.0 57.3 55.7 54.1 52.4

182 61.3 59.6 58.0 56.3 54.7 53.0

183 62.0 60.3 58.6 56.9 55.3 53.6

184 62.6 60.9 59.2 57.6 55.9 54.2

185 63.3 61.6 59.9 58.2 56.5 54.8

186 64.0 62.3 60.5 58.8 57.1 55.4

187 64.7 62.9 61.2 59.4 57.7 56.0

188 65.4 63.6 61.9 60.1 58.3 56.6

189 66.1 64.3 62.5 60.7 58.9 57.2

190 66.8 65.0 63.2 61.4 59.6 57.8

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Act

ion

1.Treatorp

revent

Hypo

glycem

ia(Low

bloo

dsugar)

Hypo

glycem

iais

abloo

dglucose

<3mmol/L

Fora

llchild

ren:-

1.Fee

dstraightaw

ayand

then

every

2-3ho

urs,dayand

night.

2.Encou

ragem

othe

rsto

watchfo

rany

deterio

ratio

n,helpfeed

and

kee

pchild

1.Low

tempe

rature

(hyp

othe

rmia)n

oted

onrouti

ne

check.

2.Letha

rgy,lim

pnessa

ndlo

ssof

consciou

sness.

3.Childcan

becom

esdrowsy.

PerformDextrostix

testonad

miss

ion,beforegiving

glucoseor

feed

ing.If

hyp

ogly

cem

ia is

susp

ecte

d an

dno

dextrostix

are

availableorifitisnotpossib

leto

geteno

ughbloo

dfortest,

assumethatth

echild

hashyp

oglycemiaand

givetreatm

ent

immed

iatelywith

outlab

oratoryconfi

rmati

on.

Ifconsciou

s:

1.Giveabo

luso

f10%

glucose(5

0ml)orsu

garsoluti

on(1

roun

dedteaspo

onsu

garin3tablespo

onso

fwater).Bo

luso

f10

%glucoseisbest,bu

tgivesugarsoluti

onorF

75fo

rmula

ratherth

anwaitforglucose.

2.Startfe

edingstraightaw

ay:Fee

d2-ho

urly(1

2feed

sin24

ho

urs).U

sefe

edcha

rtto

find

amou

ntto

givean

dfeed

every

2-3ho

ursd

ayand

night.

If un

cons

ciou

s, giveglucoseIV(5

ml/k

gofsterile10%

glucose),

follo

wed

by50

mlo

f10%

glucoseorsucrosebyNGtube

.

2.Treatorp

revent

Hypo

thermia(Low

tempe

rature)

Hypo

thermiaisa

rectalte

mpe

rature

<35.50

C(95.90

F)ora

nun

derarm

tempe

rature

<350

C(950

F).

Fora

llchild

ren:-

1Feed

straightaw

ayand

then

every

2-3ho

urs,dayand

night.

2.Kee

pwarm.

3.Useth

ekang

aroo

techniqu

e,cover

with

ablanket.Letm

othe

rsleep

with

child

tokee

pchild

warm.

Lowte

mpe

rature

NOTE:H

ypothe

rmiain

malno

urish

edchildren

often

indicatesc

oexisting

hypo

glycem

iaand

serio

us

infecti

on.

Takere

ctalte

mpe

ratureonad

miss

ion.(E

nsurethermom

eter

iswellsha

kendo

wn).

Iftherectalte

mpe

ratureisbelow

35.50

C:

1.Fee

dstraightaw

ay(o

rstartre

hydrati

onifnee

ded).

2.Re-warm.P

utth

echild

onthemothe

r’sbarechest(skinto

skincon

tact)a

ndcoverth

em,O

Rclothe

thechild

includ

ing

thehe

ad,coverwith

awarmed

blanketand

placeaheatero

rlampne

arby.

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

155

JAN

UA

RY

201

6

3.Kee

proom

warm,n

odrau

ghts.

4.Kee

pbe

dding/clothe

sdry.D

ry

carefullyafte

rbathing

(dono

tbathe

if

veryill).

5.Avoidexposuredu

ring

exam

inati

ons,bathing

.

6.Useaheatero

rincan

descen

tlam

pwith

cau

tion,d

o no

t use

hotbott

le

waterorfl

uorescen

tlam

p.

3.Fee

d2-ho

urly(1

2feed

sin24

hou

rs).

Mon

itord

uringre-w

arming

•Takere

ctalte

mpe

ratureeverytw

oho

urs:stop

re-

warmingwhe

nitrisesabo

ve36.50

C

•Takeevery30minutesifheaterisu

sedbe

causethechild

maybecom

eoverhe

ated

.

3.Treatorp

revent

dehydrati

on

(Too

littlefluidinth

ebo

dy)

Whe

nachild

haswaterydiarrhoe

a,

giveReSoM

albetwee

nfeed

safte

rea

chlo

osestoo

l.Asaguide

,give50

-10

0mlafte

reachwaterystoo

lifchild

isaged

<2years,or1

00-200

mlifa

ged

2yearso

rolder.

Profusewaterydiarrhoe

a,

thirst,hypo

thermia,sun

ken

eyes,w

eakorabsen

trad

ial

pulse

,coldha

ndsa

ndfe

et,

redu

cedurineou

tput.

DONOTGIVE

IVFLU

IDSEX

CEPT

INSHO

CK(see

sepa

rate

protocolfo

rtreati

ngsh

ock)

Ifde

hydrated

:

1.GiveRe

SoMal5ml/k

gevery30

minutesfo

r2hou

rs(o

rally

orbyna

sogastric

tube

)

2.The

ngive5-10m

l/kginalte

rnateho

ursforupto10ho

urs

(i.e.giveRe

SoMaland

F75

form

ulainalte

rnateho

urs).U

se

InitialM

anagem

entC

hart.

3.StopRe

SoMalwhe

nthereare3orm

orehydrati

onsign

s,or

signsofo

ver-h

ydratio

n.

Mon

itord

uringrehydrati

onfo

rsignsofo

ver-h

ydratio

n:

•increa

singpu

lseand

respira

toryra

te

•increa

singoe

demaan

dpu

ffyeyelid

s

Checkforsignsatlea

sthou

rly.Stopifpu

lsein

crea

sesb

y25

be

ats/minutean

drespira

toryra

teby5

breaths/minute.

4.Correctelectrolyte

imba

lance(Too

litt

lepotassiu

mand

magne

sium,and

too

muchsodium

)

1.UseReSoM

aland

F75

form

ulaas

thesearelowin

sodium

.

2.Dono

tadd

salttofo

odintrod

uced

du

ringthereha

bilitati

onpha

se.

Oed

emade

velopsorw

orsens.

Follo

wfe

edingrecommen

datio

n,asw

ellasrecom

men

datio

norpreventi

onortreatmen

tofd

ehydratio

n:

extrapo

tassium(4

mmol/kgbo

dyweigh

t)and

magne

sium

(0.6mmol/kg)areim

portan

t.

For p

otas

sium

,add

CMVorelectrolyte/m

ineralso

lutio

nor

10%potassiu

mchloridesolutio

ntofe

edsa

ndto

prepa

re

ReSo

Mal.Ifthe

seareuna

vailable,givecrushe

dSlow

K½

tablet/kgbo

dyweigh

tdaily.

For m

agne

sium

,add

CMVorelectrolyte/m

ineralso

lutio

nto

feed

sand

toReSoM

al.

NOTE:P

otassiu

mand

magne

siumarealre

adyad

dedinre

ady

todilu

teF75

and

F10

0pa

ckets.

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

157

JAN

UA

RY

201

6

1.Kee

pmalnu

trition

wardina

sepa

ratero

om

2.Red

uceovercrow

ding

ifpossib

le.

3.W

ashha

ndsb

eforeprep

aringfeed

san

dbe

foreand

afte

rdea

lingwith

any

child

.

4.Givem

easle

svaccine

to

unim

mun

izedchild

renover6m

onths

ofage.

5.Goo

dnu

rsingcare

NOTE:T

heusualsign

sof

infecti

on,suchasfe

ver,are

often

absen

tso

assu

me

all

severelym

alno

urish

edchildren

haveinfecti

onand

treatw

ith

antib

iotic

s.

Hypo

thermiaand

hypo

glycae

miaaresign

sof

severeinfecti

on.

NOTE:e

nsurealld

osesare

given.

Giveth

emontim

e.

Startin

gon

thefirstday,givebroa

d-spectrum

anti

bioti

cs*to

allchildren.

1.Ifth

echild

hasnocomplicati

ons,give:-

Cotrim

oxazole5mlp

aediatric

suspen

sionorallytw

iceada

yfor5

days

OR

2. If

the

child

is se

vere

ly il

l (ap

athe

tic,letha

rgic)o

rhas

complicati

ons(hypo

glycem

ia,h

ypothe

rmia,raw

skin/

fissures,re

spira

torytracto

rurin

arytractinfectio

n)giveIV/IM

ampicillinAN

Dgentam

icin.

Am

picillin:50m

g/kgIM

/IV6-ho

urlyfo

r2days,th

enoral

amoxycillin15m

g/kg8-hou

rlyfo

r5dayso

rifa

moxycillinis

nota

vailableconti

nuewith

ampicillinbu

tgiveorally,50m

g/kg

6-ho

urly

Ge

ntam

icin:7

.5mg/kgIM

/IVon

cedailyfo

r7days.

Inadd

ition

,giveMetronida

zoleaccording

tonati

onalpolicy.

If a

child

fails

to im

prov

e aft

er 4

8 ho

urs A

DDchloram

phen

icol

25mg/kg8hou

rlyIM

/IVfor5

day.

*Sh

ouldbeinline

with

nati

onalpolicy.

For p

aras

itic

wor

ms (

helm

inth

iasi

s, w

hipw

orm

):treatm

ent

shou

ldbede

layedun

tilth

ereha

bilitati

onpha

se.

Forc

hildrenover2yea

rs:G

iveAlbe

ndazole(400

mg,sing

le

dose)a

ndM

eben

dazole100

mgorallytw

iceada

yforthree

da

ys.

Forc

hildrenun

der2

yea

rs:G

ivepyrantel(1

0mg/kg,single

dose)o

rascariasis

with

pyran

telo

rpiperazine.

step

mA

nA

gem

ent

6. C

orre

ct

micronu

trient

deficiencies

1. g

ive

Vita

min

A o

n da

y 1.Ifund

er6m

onthsg

ive50

,000

units;if6

-12mon

thsg

ive10

0,00

0un

its;and

if>12

mon

thsg

ive20

0,00

0un

its.If

thechild

hasanysign

sofv

itaminAdefi

cien

cy,rep

eatthisd

oseon

day2and

day14.

Giveth

efollo

wingda

ily:

2.Folicacid:5

mgon

day1;the

n1mgda

ilyifm

icronu

trientsn

otin

clud

edin

thefeed

s.

3.M

ultiv

itaminsy

rup5mlo

nlyifmicronu

trientsn

otin

clud

edin

thefeed

s.

4.Zinc(2mg/kgbod

yweigh

t)and

cop

per(0.3m

g/kgbod

yweigh

t)ifm

icronu

trientsn

otin

clud

edin

thefeed

s

5.Startiron

(3mg/kg/day)a

fter2

dayso

nF100

catch-upform

ula.(D

ono

tgiveiro

ninth

estab

ilisatio

nph

asean

ddo

notgiveiro

nifchild

receivingRU

TF)

NOTE:V

itaminA,folicacid,m

ultiv

itamins,zincand

cop

pera

realre

adyad

dedinF75

and

F10

0pa

ckets.The

yarealsoin

CMV.

7.Begincau

tious

feed

ingstab

ilizatio

nph

asean

dtran

sition

ph

ase

Stab

ilisatio

nph

ase:

1.GiveF75form

ula(see

feed

cha

rtfo

ramou

nts).The

seprovide

130

ml/k

g/da

y.

2.Give8-12

feed

sover2

4ho

urs

3.Ifth

echild

hasoed

ema++

+,re

duceth

evolumeto100

ml/k

g/da

y(see

feed

cha

rtfo

ramou

nts)

4.Ifth

echild

haspoo

rapp

etite,encou

rageth

emothe

rtocoaxand

supp

ortthe

childfinishingthefeed

.Ife

ating

80%

orlesso

fthe

amou

nt

offered

for2

con

secutiv

efeed

s,useanasog

astrictu

be.Ifindo

ubt,seefeed

cha

rtfo

rintakesbelow

whichtu

befe

edingisne

eded

.

5.Kee

pa24

-hou

rintakechart.Mea

surefe

edsc

arefully.Recordlefto

vers.

6.Ifth

echild

isbreastfe

d,encou

ragecon

tinue

dbrea

stfee

ding

butalso

giveF75.

7.TransfertoF100

form

ulaasso

onasa

ppeti

tehasre

turned

(usuallywith

inone

wee

k)and

oed

emaha

sbee

nlostorisred

uced

8.W

eigh

dailyand

plotw

eigh

t.

Tran

sition

pha

se:

1.Cha

ngetoF10

0:

•for2

days,re

placeF75with

thesameam

ountofF

100on

thene

xtdayin

crea

seeachfeed

by10

mlu

ntilsom

efeed

remainsune

aten

.

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

159

JAN

UA

RY

201

6

8.In

crea

sefe

edingto

recoverw

eigh

tloss:

“Catch-upgrow

th”

reha

bilitati

onpha

se

1.Give6feed

sover2

4ho

urs.The

secan

be3feed

sofF

100an

d3speciallym

odified

familym

eals,highinene

rgyan

dprotein.Rea

dy-to

-use

therap

eutic

food

isanalternati

veto

F10

0,re

commen

dedtobegivenifthechild

isbeing

referred

tooutpa

tientcare.

2.Encou

rageth

echild

toeatasm

uchaspossib

le,sothechild

can

gainweigh

trap

idly.Ifth

echild

isfinishingeverything

,offe

rmorean

dincrea

sesu

bseq

uentfe

eds.M

akesureth

atth

echild

isacti

velyfe

d.

3.W

eigh

dailyand

plotw

eigh

t.

9.Stim

ulateem

otion

al

andsensorial

developm

ent:

Loving

care,playan

dstimulati

on

1.Provide

tend

erlo

ving

care

2.Helpan

den

couragemothe

rsto

com

fort,fee

d,and

playwith

theirc

hildren

3.Givestructured

playwhe

nthechild

iswelleno

ugh.

10.P

repa

refo

rdischa

rge

andfollo

w-up.

1.Obtaininform

ation

onfamilybackgroun

dan

dsocio-econ

omicstatus.

2.In

structm

othe

rshow

tom

odify

familyfo

ods,how

ofte

ntofe

edand

how

muchtogive.

3.Estab

lishalin

kwith

com

mun

ityhea

lthworkersfo

rhom

efollo

w-up.

4.W

ritefullclinicalsu

mmaryinpati

ent-h

eldcard.

5.Sen

dareferrallette

rtotheclinic.

6.Ifoutpa

tientm

anagem

ento

fseveremalnu

trition

exists,inform

themothe

rofthe

closestoutpa

tientcarereferralpointto

herhom

ean

dgiveth

emothe

rawee

klyratio

nofRUTFfo

rhom

eba

sedreha

bilitati

on.

ANNE

X 5

TargetW

eigh

tforReh

ydratio

n

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

2.0

2.04

2.10

2.1

2.14

2.21

2.2

2.24

2.31

2.3

2.35

2.42

2.4

2.45

2.52

2.5

2.55

2.63

2.6

2.65

2.73

2.7

2.75

2.84

2.8

2.86

2.94

2.9

2.96

3.05

3.0

3.06

3.15

3.1

3.16

3.26

3.2

3.26

3.36

3.3

3.37

3.47

3.4

3.47

3.57

3.5

3.57

3.68

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

3.6

3.67

3.78

3.7

3.77

3.89

3.8

3.88

3.99

3.9

3.98

4.10

4.0

4.08

4.20

4.1

4.18

4.31

4.2

4.28

4.41

4.3

4.39

4.52

4.4

4.49

4.62

4.5

4.59

4.73

4.6

4.69

4.83

4.7

4.79

4.94

4.8

4.90

5.04

4.9

5.00

5.15

5.0

5.10

5.25

5.1

5.20

5.36

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

5.2

5.30

5.46

5.3

5.41

5.57

5.4

5.51

5.67

5.5

5.61

5.78

5.6

5.71

5.88

5.7

5.81

5.99

5.8

5.92

6.09

5.9

6.02

6.20

6.0

6.12

6.30

6.1

6.22

6.41

6.2

6.32

6.51

6.3

6.43

6.62

6.4

6.53

6.72

6.5

6.63

6.83

6.6

6.73

6.93

6.7

6.83

7.04

TARg

ET W

EIg

HT

FOR

REH

yDRA

TIO

N (

DO

NO

T Ex

CEED

)

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

161

JAN

UA

RY

201

6

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

6.8

6.94

7.14

6.9

7.04

7.25

7.0

7.14

7.35

7.1

7.24

7.46

7.2

7.34

7.56

7.3

7.45

7.67

7.4

7.55

7.77

7.5

7.65

7.88

7.6

7.75

7.98

7.7

7.85

8.09

7.8

7.96

8.19

7.9

8.06

8.30

8.0

8.16

8.40

8.1

8.26

8.51

8.2

8.36

8.61

8.3

8.47

8.72

8.4

8.57

8.82

8.5

8.67

8.93

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

8.6

8.77

9.03

8.7

8.87

9.14

8.8

8.98

9.24

8.9

9.08

9.35

9.0

9.18

9.45

9.1

9.28

9.56

9.2

9.38

9.66

9.3

9.49

9.77

9.4

9.59

9.87

9.5

9.69

9.98

9.6

9.79

10.0

8

9.7

9.89

10.1

9

9.8

10.0

010

.29

9.9

10.1

010

.40

10.0

10.2

010

.5

10.1

10.3

010

.61

10.2

10.4

010

.71

10.3

10.5

110

.82

Weigh

tbe

fore

rehydrati

on

Targetweigh

t

Lowest

High

est

10.4

10.6

110

.92

10.5

10.7

111

.025

10.6

10.8

111

.13

10.7

10.9

111

.24

10.8

11.0

211

.34

10.9

11.1

211

.45

11.0

11.2

211

.55

11.1

11.3

211

.66

11.2

11.4

211

.76

11.3

11.5

311

.87

11.4

11.6

311

.97

11.5

11.7

312

.08

11.6

11.8

312

.18

11.7

11.9

312

.29

11.8

12.0

412

.39

11.9

12.1

412

.50

12.0

12.2

412

.60

TARg

ET W

EIg

HT

FOR

REH

yDRA

TIO

N (

DO

NO

T Ex

CEED

)

ANNE

X 6

ANTIBIOTICS

REF

EREN

CECAR

D

Sum

mar

y: A

ntibi

otics

for S

ever

ely

Mal

nour

ishe

d Ch

ildre

niF

:g

ive:

NOCOMPLICAT

IONS

Amox

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gen

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ANNEX 7RECIPESFORF-75ANDF-100AlternAtives ingredient AMOUNT FOR F-75Use one of the following recipes for F-75 (Note that cooking facilities are needed):Ifyouhavedriedwholemilk

Driedwholemilk 35g

Sugar 70gCerealflour 35g

Vegetableoil 20g

ComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**

Ifyouhavefreshcow’smilk,orfull-cream(whole)longlifemilk

Milk 300mlSugar 70gCerealflour 35gVegetableoil 20gComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**

Use one of the following recipes for F-100:Ifyouhavefreshcow’smilk,orfull-cream(whole)longlifemilk

Freshcow’smilk,orfull-cream(whole)longlifemilk 880ml

Sugar 75g

Vegetableoil 20g

ComplexMineralandVitaminmix* ½leveledscoop

Watertomake1000ml 1000ml**

Ifyouhavedriedwholemilk

Driedwholemilk 110gSugar 50gVegetableoil 30gComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**

*WhereCMVisnotavailable,amineralmixshouldbeused(20mlforoneliterofpreparation).Contentsofmineralmixaregiveninannex3ModuleIntroduction*

**Important note about adding water:Addjusttheamountofwaterneededtomake1000mlofformula.(Thisamountwillvaryfromrecipetorecipe,dependingontheotheringredients.)Donotsimplyadd1000mlofwater,asthiswillmaketheformulatoodilute.Amarkfor1000mlshouldbemadeonthemixingcontainerfortheformula,sothatwatercanbeaddedtotheotheringredientsuptothismark.

Directions for making cooked F-75 with cereal flour (top recipes)Youwillneeda1-litreelectricblenderorahandwhisk (rotarywhiskorballoonwhisk),a1-litremeasuringjug,acookingpot,andastoveorhotplate.Amountsof ingredientsarelistedonthepreviouspage.Cerealflourmaybemaizemeal,riceflour,orwhateveristhestaplecerealinthearea.

Itisimportanttousecooled,boiledwaterevenforrecipesthatinvolvecooking.Thecookingisonly4minutesofgentleboiling,andthismaynotbeenoughtokillallpathogensinthewater.Thewatershouldbecooledbecauseaddingboilingwatertothepowderedingredientsmaycreatelumps.


If using an electric blender:1. Putabout200mloftheboiled,cooledwaterintotheblender.(Ifusingliquidmilkinsteadofmilk

powder,omitthisstep.)

2. Addtheflour,milkormilkpowder,sugar,oilandblend.

3. Addboiled,cooledwatertothe1000mlmarkandblendatahighspeed.

4. Transferthemixturetoacookingpotandboilgentlyfor4minuteswhilestirringcontinuously.

5. Somewaterwill evaporatewhile cooking, so transfer themixture back to the blender aftercookingandaddenoughboiled,cooledwatertomake1000ml.AddtheCMVandblendagain.

If using a hand whisk:1. Mixtheflour,milkormilkpowder,sugarandoilina1-litremeasuringjug.(Ifusingmilkpowder,

thiswillbeapaste.)

2. Slowlyaddboiled,cooledwaterupto1000mlmark.

3. Transfertocookingpotandwhiskthemixturevigorously.

4. Boilgentlyfor4minuteswhilestirringcontinuously.

5. Somewaterwillevaporatewhilecooking,sotransferthemixturebacktothemeasuringjugaftercookingandaddenoughboiledcooledwatertomake1000ml.AddtheCMVandwhiskagain

Directions for making non-cooked F-100 recipes If using an electric blender:1. Putabout200mloftheboiled,cooledwaterintotheblender.(Ifusingliquidmilkinsteadofmilk

powder,omitthisstep.)

2. Addtherequiredamountsofmilkormilkpowder,sugar,oil,andCMV.

3. Addboiledcooledwatertothe1000mlmarkandthenblendathighspeed.*

If using a hand whisk:1. Mixtherequiredamountsofmilkpowderandsugarina1-litremeasuringjug;thenaddtheoil

andstirwelltomakeapaste(Ifyouuseliquidmilk,mixthesugarandoil,andthenaddthemilk.)

2. AddCMV,andslowlyaddboiled,cooledwaterupto1000mlmark,whilestirringallthetime1.*

3. Whiskvigorously.

IfCMVisnotavailable,useMineralmix

MineralmixisincludedineachrecipeforF-75andF-100.ItisalsousedinmakingReSoMal.Thecontentsofthemineralmixare listed inAnnexD.Themixcontainspotassium,magnesium,andotheressentialminerals.Itmust beincludedinF-75andF-100tocorrectelectrolyteimbalance.Themineralmixmaybemadeinthepharmacyofthehospital

VitaminsVitaminsarealsoneeded inorwith the feed.Thevitaminmixdescribed inAnnexD cannotbemade in thehospital pharmacybecause amounts are so small. Thus, children areusually givenmultivitamindropsaswell.RecommendedvitaminstobeincludedinthemultivitaminpreparationarelistedinAnnexD.Themultivitaminpreparationshouldnot includeiron.

IfCMV isused,separatemultivitamindropsarenotneeded.

1 Whetherusingablenderorawhisk,itisimportanttomeasureuptothe1000mlmarkbeforeblending/whisking.Otherwise,themixturebecomestoofrothytojudgewheretheliquidlineis.


ANNEX 8 F-75,F100ANDRUTFREFERENCECARDSF-75 Reference Card Volume of F-75 to give for children of different weightsSee reverse for adjusted amounts for children with severe (+++) oedema.

Weight with +++ oedema (kg)

Every 2 hoursb (12 feeds)

Every 3 hoursc

(8 feeds)Every 4 hours

(6 feeds)Daily total

(130 ml/kg)80% of daily total

(minimum)

2.0 20 30 45 260 2102.2 25 35 50 286 2302.4 25 40 55 312 2502.6 30 45 55 338 2652.8 30 45 60 364 2903.0 35 50 65 390 3103.2 35 55 70 416 3353.4 35 55 75 442 3553.6 40 60 80 468 3753.8 40 60 85 494 3954.0 45 65 90 520 4154.2 45 70 90 546 4354.4 50 70 95 572 4604.6 50 75 100 598 4804.8 55 80 105 624 5005.0 55 80 110 650 5205.2 55 85 115 676 5405.4 60 90 120 702 5605.6 60 90 125 728 5805.8 65 95 130 754 6056.0 65 100 130 780 6256.2 70 100 135 806 6456.4 70 105 140 832 6656.6 75 110 145 858 6856.8 75 110 150 884 7057.0 75 115 155 910 7307.2 80 120 160 936 7507.4 80 120 160 962 7707.6 85 125 165 988 7907.8 85 130 170 1014 8108.0 90 130 175 1040 8308.2 90 135 180 1066 8558.4 90 140 185 1092 8758.6 95 140 190 1118 8958.8 95 145 195 1144 9159.0 100 145 200 1170 9359.2 100 150 200 1196 9609.4 105 155 205 1222 9809.6 105 155 210 1248 10009.8 110 160 215 1274 1020

10.0 110 160 220 1300 1040

aVolumesinthesecolumnsareroundedtothenearest5ml.bFeed2-hourlyforat least thefirstday. Then,when littleornovomiting,modestdiarrhoea(<5waterystoolsperday),andfinishingmostfeeds,changeto3-hourlyfeeds.cAfteradayon3-hourlyfeeds:Ifnovomiting,lessdiarrhoea,andfinishingmostfeeds,changeto4-hourlyfeeds.


Volume of F-75 for Children with Severe (+++) Oedema

Weightwith+++oedema(kg)

VolumeofF-75perfeed(ml)a Dailytotal(100ml/kg)

80%ofdailytotala (minimum)

Every2hoursb (12feeds)

Every3hoursc (8feeds)

Every4hours(6feeds)

3.0 25 40 50 300 2403.2 25 40 55 320 2553.4 30 45 60 340 2703.6 30 45 60 360 2903.8 30 50 65 380 3054.0 35 50 65 400 3204.2 35 55 70 420 3354.4 35 55 75 440 3504.6 40 60 75 460 3704.8 40 60 80 480 3855.0 40 65 85 500 4005.2 45 65 85 520 4155.4 45 70 90 540 4305.6 45 70 95 560 4505.8 50 75 95 580 4656.0 50 75 100 600 4806.2 50 80 105 620 4956.4 55 80 105 640 5106.6 55 85 110 660 5306.8 55 85 115 680 5457.0 60 90 115 700 5607.2 60 90 120 720 5757.4 60 95 125 740 5907.6 65 95 125 760 6107.8 65 100 130 780 6258.0 65 100 135 800 6408.2 70 105 135 820 6558.4 70 105 140 840 6708.6 70 110 145 860 6908.8 75 110 145 880 7059.0 75 115 150 900 7209.2 75 115 155 920 7359.4 80 120 155 940 7509.6 80 120 160 960 7709.8 80 125 165 980 785

10.0 85 125 165 1000 80010.2 85 130 170 1020 81510.4 85 130 175 1040 83010.6 90 135 175 1060 85010.8 90 135 180 1080 86511.0 90 140 185 1100 88011.2 95 140 185 1120 89511.4 95 145 190 1140 91011.6 95 145 195 1160 93011.8 100 150 195 1180 94512.0 100 150 200 1200 960

aVolumesinthesecolumnsareroundedtothenearest5ml.bFeed2-hourlyforat least thefirstday. Then,when littleornovomiting,modestdiarrhoea(<5


waterystoolsperday),andfinishingmostfeeds,changeto3-hourlyfeeds.cAfteradayon3-hourlyfeeds:Ifnovomiting,lessdiarrhoea,andfinishingmostfeeds,changeto4-hourlyfeeds.

RUTF reference card. quantities of RUTF in Transition.

Child’sweight

DailyweightofRUTF(g)

NumberofRUTFsachetsperday(ifonesachet=92g).

3 83 1

3.2 88 1

3.4 94 1

3.6 99 1.2

3.8 105 1.2

4.0 110 1.5

4.2 116 1.5

4.4 121 1.5

4.6 127 1.5

4.8 132 1.5

5 138 1.5

5.2 144 1.5

5.4 149 1.75

5.6 155 1.75

5.8 160 1.75

6 166 1.75

6.2 171 2

6.4 177 2

Child’sweight

DailyweightofRUTF(g)

NumberofRUTFsachetsperday(ifonesachet=92g).

6.6 182 2

6.8 188 2

7 193 2.2

7.2 199 2.2

7.4 204 2.2

7.6 210 2.5

7.8 215 2.5

8 221 2.5

8.2 226 2.5

8.4 232 2.5

8.6 237 2.75

8.8 243 2.75

9 248 2.75

9.2 254 2.75

9.4 259 3

9.6 265 3

9.8 270 3

10 276 3

quantities of RUTF in Rehabilitation (OTC)

WEIgHT OF PATIENT (kg) SACHETS/DAy SACHETS/WEEk3.0-3.4 1.25 9

3.5-3.9 1.5 11

4.0-5.4 2 14

5.5-6.92 2.5 18

7.0-8.4 3 218.5-9.4 3.5 25

9.5-10.4 4 28

10.5-11.9 4.5 32> 12.0 5 35

Adolescents10-14yrs 5 35Adolescents>14yrsandadults 6 42


F-100 Reference Card - Range of Volumes for Free-Feeding with F-100

WeightofChild(kg)

Rangeofvolumesper4-hourlyfeedofF-100(6feedsdaily) RangeofdailyvolumesofF-100Minimum(ml) Maximum(ml)a Minimum

(150ml/kg/day)Maximum

(220ml/kg/day)2.0 50 75 300 4402.2 55 80 330 4842.4 60 90 360 5282.6 65 95 390 5722.8 70 105 420 6163.0 75 110 450 6603.2 80 115 480 7043.4 85 125 510 7483.6 90 130 540 7923.8 95 140 570 8364.0 100 145 600 8804.2 105 155 630 9244.4 110 160 660 9684.6 115 170 690 10124.8 120 175 720 10565.0 125 185 750 11005.2 130 190 780 11445.4 135 200 810 11885.6 140 205 840 12325.8 145 215 870 12766.0 150 220 900 13206.2 155 230 930 13646.4 160 235 960 14086.6 165 240 990 14526.8 170 250 1020 14967.0 175 255 1050 15407.2 180 265 1080 15887.4 185 270 1110 16287.6 190 280 1140 16727.8 195 285 1170 17168.0 200 295 1200 17608.2 205 300 1230 18048.4 210 310 1260 18488.6 215 315 1290 18928.8 220 325 1320 19369.0 225 330 1350 19809.2 230 335 1380 20249.4 235 345 1410 20689.6 240 350 1440 21129.8 245 360 1470 2156

10.0 250 365 1500 2200

ªVolumesperfeedareroundedtothenearest5ml.


Danger Signs Related to Pulse, Respirations, and Temperature

Alert a physician if these occur.

Danger sign: Suggests:

PulseandRespirations Confirmedincreaseinpulserateof25ormorebeatsperminute,alongwithConfirmedincreaseinrespiratoryrateof5ormorebreathsperminute

InfectionorHeartfailure(possiblyfromoverhydrationduetofeedingorrehydratingtoofast)

Respirationsonly Fastbreathing:• 50breaths/minuteormoreinchild2

monthsupto12monthsold*• 40breaths/minuteormoreinchild12

monthsupto5years

Pneumonia

Temperature AnysuddenincreaseordecreaseRectaltemperaturebelow35.5oC(95.9oF)

• Infection• Hypothermia(possiblydueto

infection,amissedfeed,orchildbeinguncovered)

Inadditiontowatchingforincreasingpulseorrespirationsandchangesintemperature,watchforotherdangersignssuchas:• anorexia(lossofappetite)

• changeinmentalstate(e.g.,becomeslethargic)

• jaundice(yellowishskinoreyes)

• cyanosis(tongue/lipsturningbluefromlackofoxygen)

• difficultbreathing

• difficultyfeedingorwaking(drowsy)

• abdominaldistention

• newoedema

• largeweightchanges

• increasedvomiting

• petechiae(bruising)Normal ranges of pulse and respiratory rates:

AgeNORMAL RANgES (PER MINUTE)

pUlse respirAtions

2monthsupto12months 80upto160 20upto60*

12monthsupto60months(5years) 80upto140 20upto40

*Some children age 2 months up to 12 months will normally breathe fast (i.e. 50 – 60 breaths per minute) without having pneumonia. However, unless the child’s normal respiratory rate is known to be high, he should be assumed to have either overhydration or pneumonia. Careful evaluation, taking into account prior fluid administration, will help differentiate the two conditions and plan appropriate treatment.


ANNEX 9: THERAPEUTIC MIlk REFERENCE CARdS FOR INFANTS lESS THAN 6 MONTHS WITH SAM9A:THERAPEUTICMILKREFERENCECARDSFORINFANTSLESSTHAN6MONTHSWITHSAM(STABILIZATIONPHASE)Checktheweightofthechildandseethevolumeofmilkneededfor24hoursandfrequencyoffeedsexpected.

•Donotmakeadjustmentsforoedema

•Tryatallcoststofeedverysmallbabiesatleast8timesaday.

Togiveallthenecessaryvolumein24hours,whentheidealfrequencyisimpossibletofollow,itisbettertoreducethenumberoffeedwithoutreducingthetotaldailyamountthantoskipmeals.

Weight of infant (kg)

Total feed volume in 24

hours (ml)

Volume of feed according to feed frequency (per 24 hours)12 feeds

(ml)10 feeds

(ml)8 feeds

(ml)7 feeds

(ml)6 feeds

(ml)5 feeds

(ml)1.2 240 20 20 25 30 35 451.3 240 20 25 30 30 35 451.4 240 20 25 30 35 40 451.5 240 20 25 30 35 40 451.6 300 25 30 35 40 45 551.7 300 25 30 35 40 45 551.8 300 25 30 40 40 45 601.9 300 25 30 40 45 50 602.0 300 25 35 40 45 50 652.1 300 25 35 40 45 50 652.2 360 30 35 45 50 60 702.3 360 30 35 45 50 60 702.4 360 30 35 45 50 60 702.5 420 35 40 50 55 65 752.6 420 35 40 50 55 65 752.7 420 35 40 50 55 65 752.8 420 35 40 55 60 70 802.9 420 35 40 55 60 70 803.0 480 40 45 60 65 75 853.1 480 40 45 60 65 75 853.2 480 40 45 60 65 75 853.3 480 40 45 60 65 75 853.4 480 40 45 60 65 75 853.5 480 40 50 65 70 80 953.6 480 40 50 65 70 80 953.7 480 40 50 65 70 80 95


Weight of infant (kg)


hours (ml)

Volume of feed according to feed frequency (per 24 hours)12 feeds

(ml)10 feeds

(ml)8 feeds

(ml)7 feeds

(ml)6 feeds

(ml)5 feeds

(ml)3.8 480 40 50 65 70 80 953.9 480 40 50 65 70 80 954.0 540 45 55 70 75 85 1104.4 540 45 55 70 75 85 1104.5 600 50 60 80 90 95 1204.9 600 50 60 80 90 95 1205.0 720 60 70 90 100 110 1304.4 720 60 70 90 100 110 1304.5 720 60 80 100 110 120 1504.9 720 60 80 100 110 120 1506.0 840 70 85 110 120 140 175

How total feed volumes are calculated for initial feeding

Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaguide,theaveragevolumeoffeed/kg,accordingtoweightinthestabilizationphaseis:

weight Feed ML/kg/ 24 hoUrs*

1.2-1.5kg 180 ml/kg

1.6-1.9kg 170 ml/kg

2.0-3.0kg 155 ml/kg

3.1-3.5kg 145 ml/kg

3.6 -6.0 kg 130 ml/kg

*averageroundedto nearest5mltherefore absolutevolumesper kgbodyweight mayvaryalittle,these are guidancevolumes.

9B:THERAPEUTICMILKREFERENCECARDFORINFANTSLESSTHAN6MONTHSWITHSAMWHOARENOTBREASTFED(TRANSITIONPHASE).

Weight of infant

kg


hours (ml)

Volume of feed according to feed frequency (per 24 hours)

12 feeds(ml)

10 feeds(ml)

8 feeds(ml)

7 feeds(ml)

6 feeds(ml)

5 feeds(ml)

1.2 300 25 25 35 40 45 601.3 300 25 30 40 40 45 601.4 300 25 30 40 45 50 601.5 300 25 30 40 45 50 601.6 360 30 40 45 50 60 701.7 360 30 40 45 50 60 701.8 360 30 40 50 50 60 801.9 360 30 40 50 60 65 802.0 360 30 45 50 60 65 852.1 360 30 45 50 60 65


Weight of infant

kg


hours (ml)

Volume of feed according to feed frequency (per 24 hours)

12 feeds(ml)

10 feeds(ml)

8 feeds(ml)

7 feeds(ml)

6 feeds(ml)

5 feeds(ml)

2.2 480 40 45 60 65 80 902.3 480 40 45 60 65 80 902.4 480 40 45 60 65 80 902.5 540 45 50 65 70 85 1002.6 540 45 50 65 70 85 1002.7 540 45 50 65 70 85 1002.8 540 45 50 70 80 90 1052.9 540 45 50 70 80 90 1053.0 600 50 60 80 85 100 1103.1 600 50 60 80 85 100 1103.2 600 50 60 80 85 100 1103.3 600 50 60 80 85 100 1103.4 600 50 60 80 85 100 1103.5 600 50 65 85 90 105 1253.6 600 50 65 85 90 105 1253.7 600 50 65 85 90 105 1253.8 600 50 65 85 90 105 1253.9 600 50 65 85 90 105 1254.0 720 60 70 90 100 110 1454.4 720 60 70 90 100 110 1454.5 780 65 80 105 125 125 1554.9 780 65 80 105 125 125 1555.0 960 80 90 115 130 145 1704.4 960 80 90 115 130 145 1704.5 960 80 105 130 145 155 1954.9 960 80 105 130 145 155 195

6.0 1080 90 110 145 155 180 225

How total feed volumes are calculated for the transition phase (non-breastfed infants)

Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaroughguide,theaveragevolumeoffeed/kg,accordingtoweightinthetransitionphaseis:


1.2 -1.5 kg 225 ml/kg

1.6 -1.9 kg 205 ml/kg

2.0 -3.0 kg 200 ml/kg

3.1 -3.5 kg 180 ml/kg

3.6-6.0kg 170 ml/kg

*averageroundedtonearest5mlRefer to the large table to manage individual infants


9C: THERAPEUTICMILK FEEDS IN THE RECOVERY PHASE FOR INFANTSLESSTHAN6MONTHSWHOARENOTBEINGBREASTFED.

Weightof infant

Totalfeedvolumein24hours

Volumeoffeedaccordingtofeedfrequency(per24hours)

12feeds 10feeds 8feeds 7feeds 6feeds 5feeds

1.2 360 30 30 40 50 55 70

1.3 360 30 40 50 50 55 70

1.4 360 30 40 50 55 65 70

1.5 420 35 40 50 60 70 80

1.6 480 40 50 55 65 70 90

1.7 480 40 50 55 65 70 90

1.8 480 40 50 65 65 70 95

1.9 480 40 50 65 70 80 95

2.0 480 40 55 65 70 80 105

2.1 480 40 55 65 70 80 105

2.2 600 50 55 70 80 95 110

2.3 600 50 55 70 80 95 110

2.4 600 50 55 70 80 95 110

2.5 660 55 65 80 90 105 120

2.6 660 55 65 80 90 105 120

2.7 660 55 65 80 90 105 120

2.8 660 55 65 90 95 110 130

2.9 660 55 65 90 95 110 130

3.0 780 65 70 95 105 120 135

3.1 780 65 70 95 105 120 135

3.2 780 65 70 95 105 120 135

3.4 780 65 70 95 105 120 135

3.5 780 65 80 105 110 130 150

3.6 780 65 80 105 110 130 150

3.7 780 65 80 105 110 130 150

3.8 780 65 80 105 110 130 150

3.9 780 65 80 105 110 130 150

4.0 840 70 90 110 120 135 175

4.4 840 70 90 110 120 135 175

4.5 960 80 95 130 145 150 190

4.9 960 80 95 130 145 150 190

5.0 1140 95 110 145 160 175 210

5.4 1140 95 110 145 160 175 210

5.5 1140 95 130 160 175 190 240

5.9 1140 95 130 160 175 190 240

6.0 1320 110 135 175 190 225 280


How total feed volumes are calculated for catch-up/rehabilitation (non-breastfed infants)

Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaroughguide,theaveragevolumeoffeed/kg,accordingtoweightinthecatchupphaseis:


1.2 -1.9 kg 270 ml/kg

2.0 - 3.0 kg 270 ml/kg

3.1 -3.5 kg 240 ml/kg

3.6 -6.0 kg 230 ml/kg

*average roundedtonearest5ml

Refer to the large table to manage individual infants


ANNEX 1024-HOURFEEDINTAKECHART

Completeonechartforevery24-hourperiod.

Name:____________________________________________________

HospitalIDnumber______Admissionweight(kg)_____Today’sweight(kg)_____

DATE: TYPEOFFEED: GIVE: feedsof ml

Time a.Amountoffered(ml)

b.Amountleftincup(ml)

c.Amounttakenorally(a–b)(ml)

d.AmounttakenbyNG,ifneeded(ml)

e. Estimatedamountvomited(ml)

f.Waterydiarrhoea(ifpresent,yes)

Columntotals c. d. e. Totalyes:

Total volume taken over 24 hours =amounttakenorally(c)+amounttakenbyNG(d) –totalamountvomited(e) =___ml


ANNEX 11DAILYWARDFEEDCHART

DATE:

WARD:

NameofChild

F-75 F100/F-100Diluted(SDTM)*

Numberfeeds

Amount/feed(ml)

Total(ml) Numberfeeds

Amount/feed(ml)

Total(ml)

F-75(totalml)neededfor24hours F-100/F100Diluted(totalml)neededfor24hrs

Amountneededfor hours* Amountneededfor hours**

Amounttoprepare(rounduptowholelitre)

Amounttoprepare(roundupto wholelitre)

*F100Diluted(SDTM)isforinfantslessthansixmonths

**Dividedailyamountbythenumberoftimesfeedsarepreparedeachday. Forexample,iffeedsarepreparedevery12hours,dividedailyamountby2.


ANNEX 12WEIGHTGAINTALLYSHEETFORWARD

week oF:dd/mm/yr

good weight gAin:10 g/kg/day

moderAte weight gAin: 5 up to 10 g/

kg/day

poor weight gAin: < 5 g/kg/

day

NumberofchildrenonF-100forentire

week:.............

Totals

%ofchildrenonF-100inward


ANNEX 13 MONITORINGCHECKLISTS

checklist For monitoring Feed prepArAtion

observe: yes no comments

Areingredientsfortherecipesavailable?

Areingredients’expirydateswithinacceptableranges?

Isthecorrectrecipeusedfortheingredientsthatareavailable?

Areingredientsstoredappropriatelyanddiscardedatappropriatetimes?

Arecontainersandutensilskeptclean?

Dokitchenstaff(orthosepreparingfeeds)washhandswithsoapbeforepreparingfood?

AretherecipesforF-75andF-100followedexactly? (Ifchangesaremadeduetolackofingredients,arethesechangesappropriate?)

Aremeasurementsmadeexactlywithpropermeasuringutensils(e.g.,correctscoops)?

Areingredientsthoroughlymixed(andcooked,ifnecessary)?

Istheappropriateamountofoilmixedin(i.e.,notleftstuckinthemeasuringcontainer)?

IsmineralmixorCMVaddedcorrectly?

Iscorrectamountofwateraddedtomakeupalitreofformula?(Staffshouldnotaddalitreofwater,butjustenoughtomakealitreofformula.)

Arefeedsservedatappropriatetemperatures?

Arethefeedsconsistentlymixedwhenserved(i.e.oilismixedin,notseparated)?

Arecorrectamountsputinthecupforeachchild?

Isleftoverpreparedfooddiscardedpromptly?

Other:


checklist For monitoring wArd procedUres

observe: yes no commentsFeedingArecorrectfeedsservedincorrectamounts?Arefeedsgivenattheprescribedtimes,evenonnightsandweekends?Arechildrenheldandencouragedtoeat(neverleftalonetofeed)?Arechildrenfedwithacup(neverabottle)?Isfoodintake(andanyvomiting/diarrhoea)recordedcorrectlyaftereachfeed?Areleftoversrecordedaccurately?AreamountsofF-75keptthesamethroughouttheinitialphase,evenifweightislost?Aftertransition,areamountsofF-100givenfreelyandincreasedasthechildgainsweight?wArmingIstheroomkeptbetween25oC-30oC(totheextentpossible)?Areblanketsprovidedandchildrenkeptcoveredatnight?Aresafemeasuresusedforre-warmingchildren?Aretemperaturesofpatientstakenandrecordedcorrectly?weighingArescalesfunctioningcorrectly?Arescalesstandardizedmonthly?Arechildrenweighedataboutthesametimeeachday?Aretheyweighedaboutonehourbeforeafeed(totheextentpossible)?Dostaffadjustthescaletozerobeforeweighing?Arechildrenconsistentlyweighedwithoutclothes?Dostaffcorrectlyreadweighttothenearestdivisionofthescale?Dostaffimmediatelyrecordweightsonthechild’sCCP?AreweightscorrectlyplottedontheWeightChart?giving Antibiotics, medicAtions, sUpplementsAreantibioticsgivenasprescribed(correctdoseatcorrecttime)?Whenantibioticsaregiven,dostaffimmediatelyrecordontheCCP?IsfolicacidgivendailyandrecordedontheCCP?IsvitaminAgivenaccordingtoschedule?IsamultivitamingivendailyandrecordedontheCCP?AfterchildrenareonF-100for2days,isthecorrectdoseofirongiventwicedailyandrecordedontheCCP?wArd environmentAresurroundingswelcomingandcheerful?Aremothersofferedaplacetositandsleep?Aremotherstaught/encouragedtobeinvolvedincare?Arestaffconsistentlycourteous?Aschildrenrecover,aretheystimulatedandencouragedtomoveandplay?


checklist For monitoring hygiene

observe: yes no commentshAnd wAshingAretherefunctionalhandwashingfacilitiesintheward?Dostaffconsistentlywashhandsthoroughlywithsoap?Aretheirnailsclean?Dotheywashhandsbeforehandlingfood?Dotheywashhandsbetweeneachpatient?MOTHERS’ CLEANLINESSDomothershaveaplacetobathe,anddotheyuseit?Domotherswashhandswithsoapafterusingthetoiletorchangingdiapers?Domotherswashhandsbeforefeedingchildren?bedding And lAUndryIsbeddingchangedeverydayorwhensoiled/wet?Arediapers,soiledtowelsandrags,etc.storedinbag,thenwashedordisposedofproperly?Isthereaplaceformotherstodolaundry?Islaundrydoneinhotwater?generAl mAintenAnceArefloorsmopped?Istrashdisposedofproperly?Isthewardkeptasfreeaspossibleofinsectsandrodents?

Aresurfacesandwallsdusted?Food storAgeAreingredientsandfoodkeptcoveredandstoredatthepropertemperature?Areleftoversdiscarded?Feeding Utensils wAshingArefeedingUtensilswashedaftereachfeed?Aretheywashedinhotwaterwithsoap?toysAretoyswashable?Aretoyswashedregularly,andaftereachchildusesthem?

ANNE

X 14

SA

MPL

EDISCH

ARGECA

RDTh

issampledischa

rgecardisin

tend

edto

befolded

.Thistype

ofc

ardwou

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ttached

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For C

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over

ing

from

Sev

ere

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nutr

ition

Hosp

ital N

ame

Child

’s na

me:

___

____

____

____

___

M

F

Dat

e of

birt

h: _

____

__

date

Wei

ght (

kg)

Ht_/

Leng

th (c

m)

% w

eigh

t-for

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ght

Adm

issi

onDi

scha

rge

Inst

ructi

ons f

or fe

edin

g at

Hom

e

Wha

ttofeed

?(In

clud

erecipe

ifnee

ded)___

____

____

____

____

____

____

____

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

____

____

____

____

____

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Howm

uchan

dho

wofte

n?___

____

____

____

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____

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___

Med

icati

ons a

nd S

uppl

emen

ts

Give__

____

____

__drops

____

____

____

(mul

tivita

min

pre

para

tion)

with

food

onc

e da

ily.

Give1ta

bletfo

licacidon

cedailyfo

r___

____

____

_days.

Give__

____

____

____

____

____

Iron

twiceda

ilyfo

r1m

onth.

Other:_

____

____

____

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Dang

er S

igns

– B

ring

Child

for I

mm

edia

te C

are

i

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r Sch

edul

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Imm

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Stop

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1day

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ginfe

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hand

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ifficultbreathing

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Fever(feelsh

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OPV

0

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OPV

3

Mea

sles

ANNE

X 15

SPEC

IALIZE

DNUTR

ITIO

USFO

ODSSH

EET

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

185

JAN

UA

RY

201

6

Abbreviatio

ns:B

=Belgium

,Ban

=Ban

galade

sh,C

h=Sw

itzerland

,D=German

y,DR

=Dom

inianRe

public,Fr=

France,I=India,IL=Italy,Mad

=

Mad

agacar,M

al=M

alaw

i,N=Norway,SA=So

uthAfric

a,US=UnitedStatesofA

merica

Note:Referto

thede

cisio

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guida

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usin

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etand

follo

wingthede

cisio

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*Qua

ntityisre

ferringtookcalsinmostcases

GNCMAM

TaskforcePRO

DUCT

SHE

ET,V

ERSIONApril20

14

ANNE

X 16

CR

ITICAL

CAR

EPA

THWAY

CHAR

T(-5

PAG

ES)

sig

ns

oF

sho

ckN

oneLetha

rgic/uncon

sciousCo

ldperiphe

riesSlow

cap

illaryrefill(>3

second

s)

Wea

k/fastpulse

If le

thar

gic

or u

ncon

scio

us, p

lus e

ither

slow

capi

llary

refil

l or w

eak/

fast

pul

se, g

ive

oxyg

en.

Give

IV g

luco

se a

s des

crib

ed u

nder

Blo

od G

luco

se (l

eft).

Then

giv

e IV

flui

ds:

Amou

nt IV

flui

ds p

er h

our:

15m

lx__

___k

g (c

hild

’s w

t)=_

____

____

ml

Start:

Mon

itore

very10minutes

*2nd

hr.

Mon

itore

very10minutes

Time

*

Resp.rate

*

Pulse

rate

*

*If r

espi

rato

ry &

pul

se a

re sl

ower

afte

r 1ho

ur, r

epea

t sam

e am

ount

IV fl

uids

for 2

nd h

our:

then

alte

rnat

e Re

SoM

al a

nd F

-75

for u

p to

10

hour

s as i

n rig

ht p

art o

f cha

rt b

elow

. If n

o im

prov

emen

t on

IV fl

uids

, tra

nsfu

se

who

le fr

esh

bloo

d. (S

ee le

ft. H

aem

oglo

bin.

)

sig

ns

oF

seve

re m

Aln

Utr

itio

nSeverewastin

g?YesNo

Oed

ema?0+++++

+De

rmatosis?

0+++++

+(ra

wsk

in,fi

ssures)

Weigh

t(kg):Heigh

t/leng

th(cm):

SDsc

ore:orM

UAC:

tem

perA

tUre

____

___0 C

rectalaxillary

If re

ctal

<35.

50C

(95.

90F)

, or a

xilla

ry <

350C

(950

F),

activ

ely

war

m p

atien

t . C

heck

tem

pera

ture

eve

ry 3

0 m

inut

es

blo

od

glU

cose(m

mol/l):

If <3

mm

oVI a

nd a

lert

. Giv

e 50

ml b

olus

of 1

0% g

luco

se

or su

cros

e (o

ral o

r NG)

If <

3mm

oVI a

nd le

thar

gic,

un

cons

ciou

s, o

r con

vulsi

on, g

ive

ster

ile 1

0% g

luco

se IV

: 5m

lx__

kg(child’swt)=_

__ml,then

give50

mlb

olus

NG.

Tim

eglucosegiven:OralNGIV

hAem

og

lobi

n(H

b)(g/I):o

rPackedcellvol(PC

V):

Bloo

dtype

:

diAr

rho

eAWatery

diarrhoe

a?Yes

No

Ifdiarrhoe

a,circ

leSkinpinchgo

esbackslo

wly

Blood

instoo

l?Yes

No

signspresent:R

estle

ss/irritab

leLethargic

Thirsty

Vomiting

?Yes

No

Sunken

eyes

Drymou

th/ton

gueNotears

CRIT

ICAL

CAR

E PA

THW

Ay (C

CP) -

-- N

UTR

ITIO

N W

ARD/

UN

ITN

AME _

____

____

____

____

____

M F

DAT

E O

F BI

RTH

OR

AgE_

____

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TE O

F AD

MIS

SIO

N__

____

__ T

IME_

____

___H

OSP

.ID N

o....

......

..

Com

men

ts o

n pr

e-re

ferr

al a

nd/o

r em

erge

ncy

trea

tmen

t alre

ady

give

n:

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

init

iAl

mAn

Agem

ent

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

187

JAN

UA

RY

201

6

Time

Start:

Resp.R

ate

Pulse

rate

Weigh

t

Passed

urin

e?YN

Num

berstools

Num

berv

omits

Hydrati

onsign

s

Amou

ntta

ken(m

l)F-75

F-75

F-75

F-75

*Sto

p Re

SoM

al if

: Inc

reas

e in

pul

se r

esp.

rate

s

Jugu

lar v

eins

eng

orge

d

Inc

reas

ing

oede

ma

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y ey

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s Weigh

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ve5%ofw

eigh

tbeforerehydrati

on

If di

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and/

or v

omiti

ng, g

ive

ReSo

Mal

. Ev

ery

30 m

inut

es fo

r firs

t 2 h

ours

, mon

itor a

nd

give

:*

5mlx___

__kg(child’swt)=__

__mlR

eSoM

al

For u

p to

10

hour

s, g

ive

ReSo

Mal

and

F-7

5 in

alte

rnat

e ho

urs.

Mon

itor e

very

hou

r. Am

ount

of R

eSoM

al to

offe

r:*

5to10mlx___

_kg(child’swt)=__

__to__

__mlR

eSoM

al

AN

TIB

IOT

ICS

(All

rece

ive)

D

rug/

Rou

teD

ose/

Freq

uenc

y/D

urat

ion

Tim

e of

1st d

ose

If Hb

<4g/

dI o

r PCV

<12%

tran

sfus

e 10

mVk

g w

hole

fres

h bl

ood

(or 5

-7)m

l/kg

pack

ed c

ells

slow

ly o

ver 3

hou

rs

Amou

nt:Tim

estarted:

eye

sig

nsNon

eLeftRight

meA

slesYesN

oBitot’ssp

otsPus/in

flammati

onCorne

al-cloud

ing

Cornea

lulcerati

onIf

ulce

ratio

n, g

ive

vita

min

A &

atr

opin

e im

med

iate

ly.

Reco

rd o

n Da

ily C

are

page

.Orald

osesvita

minA:

<6m

onths

50000

IU

6-12

mon

ths

10000

0IU

≥12

mon

ths

20000

0IU

Feed

ing

Beginfe

edingwith

F-75asso

onasp

ossib

le.

(Ifchildisre

hydrated

,rew

eigh

beforede

term

ining

amou

ntto

feed

.New

weigh

t:___

___kg)

Amou

nt fo

r 2-h

ourly

feed

ings

:___

__mlF-75*

Timefirstfe

d:__

____

____

____

_*I

f hyp

ogly

caem

ic, f

eed

1/4

of th

is am

ount

eve

ry h

alf

hour

for fi

rst 2

hou

rs: c

ontin

ue u

ntil b

lood

glu

cose

re

ache

s 3m

mol

/l.Re

cord

all

feed

s on

24-h

ours

Fee

d in

take

cha

rt

dAily

cAr

e

W

eek1

W

eek2

Wee

k3

dAys

in h

osp

itAl

12

34

56

78

910

1112

1314

1516

1718

1920

21

Date

Dailyweigh

t(kg)

Weigh

tgain(g/kg)

Calculateda

ilyafte

ron

F-100

Oed

ema0+++

+++

Diarrhoe

a/vomit0

DV

FEED

PLA

N:Typ

efeed

Nofeed

sdaily

Totalvolum

etaken

(ml)

ANTIBIOTICS

Listprescrib

edanti

bioti

csin

leftcolumn.Allo

wone

rowfo

reachda

ilydose.Drawaboxaroun

dtheda

ys/ti

mesth

ateachdrug

shou

ldbegiven.Recordinitialsw

hengiven

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

189

JAN

UA

RY

201

6

FOLICAC

ID5m

g1m

g

VITA

MINA*

*GiveDa

y1routi

nelyifnotin

feed

sunlesse

vide

nceofdoseinpastm

onthorn

oeyesig

n.GiveDa

y2&Day15if

patie

ntadm

itted

with

eyess

ignsorrecen

tmea

sles

Multiv

itamin(ifn

otin

feed

)

Drug

forw

orms(Note

type

ofw

orm)

Beginiro

naft

er2dayso

nF-10

0Iro

n2xda

ily

FOREYEPR

OBLEM

S:Ch

loramph

enicolor

gentam

ycin

1drop

4xdaily

After10da

ys,w

heneyedrop

sarenolong

ernee

ded,sh

ade

boxesforeyedrops

Atropine

1drop

3xda

ily

Derm

atosis0+++

++

+

Bathing,1%

perm

angana

te

OTH

ER

mo

nit

ori

ng

rec

ord

Mon

itorrespiratoryra

te,p

ulsera

te,a

ndte

mpe

rature4-hou

rlyunti

lafte

rtransition

toF-100

and

pati

entisstab

le.T

henmon

itorin

gmaybelessfreq

uent

(e.g.twiceda

ily

Respira

toryra

te

BREA

THS/

MIN

UTE

Pulsera

te

BEAT

S/ M

INU

TE

Tempe

rature

39.0

38.5

38.0

37.5

GU

IDE

LIN

ES

FO

R N

TEGR

ATED

MAN

AGEM

ENT

OF A

CUTE

MAL

NUTR

ITIO

N IN

UG

AN

DA

191

JAN

UA

RY

201

6

37.0

36.5

36.0

35.5

35.0

34.5

Date/T

ime:

Dang

ersign

s:W

atchfo

rincreasingpu

lseand

respira

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ANNEX 17: REFERRAl FORMS17A:COMMUNITYREFERRALFORM

ministry oF heAlthcommUnity reFerrAl Form

ClientRef.No:________________ Date:________________________

ClientName:_________________ Sex: Male Female

SubCounty:__________________ Parish:________________________

Village:__________________________________________________________

Healthyfacilityclientisreferredto:____________________________________

MUAC:(Tick correct colour of MUAC) Green Yellow Red

Oedema(Swellingofbothfeet: Yes No

(Tick“Yes”ifclienthasswellingofbothfeetand“No”ifthereisnoswellingofbothfeet

Volunteer’sName:_________________________________

Feedback from Health Worker to Community Volunteer(Fill and give to the client)

Date:_____________________

Clientadmittedto:(Tick as appropriate)

OutpatientTherapeuticCare(OTC)(followuponRUTFadherence)

InpatientTherapeuticCare(ITC)

SupplementaryFeedingProgramme

Doesnotqualifyforadmission(counseloneatingwellandhygiene)

HealthWorker’sNameandSignature:_________________________________


17B:HMIS032:REFERRALNOTE

DateofReferal________________

TO______________________________

FROM

HealthUnit_________________________________ Referralnumber________________

REFERENCE

PatientName:_________________________________________________________________

Age:________________Sex: Male Female

Pleaseattendtheabovepersonwhowearereferringtoyourhealthunitforfurtheraction.

HistoryandSymtoms:

Investigationsdone:

Diagnosis:

Treatmentgiven:

Reasonforreferral:

Please complete thiss note on discharge and send it back to our unit.

Nameofclinician:________________________________ Signature:__________________

To be completed at the referral site

Dateofarrival:__________________Dateofdischarge:___________________

Furtherinvestigationsdone:_________________________________________________________

Diagnosis:

Treatmentgiven:__________________________________________________________________

Treamentorsurveillancetobecontinues:______________________________________________

Remarks:________________________________________________________________________

Nameofclinician:________________________________ Signature:__________________


ANNEX 18 INTEGRATEDNUTRITIONRATIONCARD

#of visits Comment/treatment received

Adm

1

2

3

4

5

6

7

8

9

10

11

#of visits

date Weight (kg)

MUAC (colour code)

grade of oedema

Adm

1

2

3

4

5

6

7

8

9

10

11

#of units per day

#of units given

Date of next visit

Ministry of HealthIntegrated Nutrition Ration Centre

Nutritionprogram:SFP[]OTC[]

Otherspecify...................................................

Site:________________________________

District:_____________________________

Client’sName:_________________________

AgeofClient:_________________________

Sex:______________

Client’sNo.:_________________________

Caregiver/Nextofkin:___________________

Village:_________________________


ANNEX 19 HEALTHANDNUTRITIONEDUCATIONRECORDFORM

date Topic venue Conducted by Participants Areas Needing Emphasis

Remarks Sign

Males Females


ANNEX 20 DOCUMENTATIONJOURNALFORQIACTIVITIESDocumentation journal for qI activities

Thedocumentationjournal isastandardtoolusedfortrackingandreflectingonqualityof IMAMservices in the health facility and community continuously. The journal helps teams to suggestchanges and continuouslymonitor performance, share lessons learnt that contribute to change(improvement/decline).Thisfacilitatesfollow-upandroutinesupportsupervisionofIMAMservices.Thejournalhasthree(3)parts:

part 1: DocumentswhattheIMAMteam/facilityistryingtoaccomplishandwhy.

part 2:AworksheetwhereeachofthechangesimplementedattheIMAMfacility/communityarelisted,includingnotationoftheireffectivenessandthedateswhentheywerestartedorended(if applicable).

part3: A provision for graphing the IMAM dataor results,and annotating run charts with yourchangestoascertaintheimpactofthechangessuggestedandtried.

Dependingon thechanges suggested, levelof serviceprovisionand indicators tobeaddressed,teamscandecideonthefrequencyofdataaggregationandreporting/feedback.Refer to examples below:

Sample documentation journal for qI activities

Nameofthefacility:____________________District:______________Region:______________

Teamleader:__________________________Teammembers:_____________________________

Startdateforimprovementproject:_____________________Enddate:_____________________

Part 1: Descriptionof situation

Improvement objective(Improve nutrition assessment at OPD)

Indicator for the objectivePercentage of clients/patients assessed for nutrition status at OPD

Descriptionof problem

BrieflydescribetheIMAMproblembeingaddressedandgapsbetweenthecurrentsituationandyourimprovementobjectives.StatethedifferencesbetweentheMOHstandardofcareandthecurrentpractices.Alsodescribesomeofthechallengeswiththecurrentsituation.(E.g.,Only 10% of OPD clients are assessed for nutrition status)


Part 2: Changes Worksheet - qI Team Activities

Pleaselistbelowthechangesthattheteamhastriedinordertoachievetheimprovementobjective.Writeallchanges,whethereffectiveornot.Alsonotewheneachchangewasstartedandwhenitended(whereapplicable)toenableyoutoannotatetheresults.

Planned and tested changes

Inthespacebelow,listallofthechangesthatyouareimplementingtoaddresstheimprovementobjective.Writeonetotwosentencestobrieflydescribethetestedchange.

start dateDD/MM/yy

end date(if applicable)DD/MM/yy

Was any Improvement registered? (yes/No)

CommentsNoteanypotentialreasonswhythechangedidordidnotyieldimprovement;alsonoteanychangeinindicatorvalueobservedrelatedtothischange.

E.g., On-job training for all OPD staff

5th /Jan/2016 7th /June/2016 No Few staff at OPD

E.g., Allocate more staff to OPD

8th/June/2016 13th/Dec/2016 Yes Monthlyaggregateddataindicatedimprovement

3.

4.

5.

6.

7.

Part 3: graph Template – Annotated Results

Use the graph below to document your progress. Indicate the value of the numerator anddenominator.

TITLEIndicatorValue


Time 0 1 2 3 4 5 6 7 8 9 10 11 12

Numerator

Denominator

%

Notes on the indicators. Writedownanyadditionalcommentsyoumayhaveontheperformanceofindicators.Writeanythingderivedfromthechangesworksheetandthegraphtemplatethatmightexplaintheperformancetrendsoftheimprovementobjective.

_________________________________________________________________________

_________________________________________________________________________

Notes on other observed effects(lessons learnt). Pleasewritehereanyeffects(positiveornegative)youarecurrentlyobservingasaresultofthequalityimprovementeffort,suchascommentsfrompatients,changes inyourperformanceormotivation,improvedefficiency,orthesurvivalstoryofasickpatient.Youmayuseyournotestotellthecompletestoryatthenextlearningsession(s).

(Footnotes)

1 ReportoftheWHOInformalConsultationontheuseofPraziquantelduringPregnancy/LactationandAlbendazole/MobendazoleinChildrenunder24months

2 ManagementofsevereMalnutrition:Amanualforphysiciansandotherhealthworkers,WHO1998