protocols for management · 2017. 5. 16. · age acute gastro – enteritis aom acute otitis media...

Protocols for CM of Nutritional Support in SAM February 2015 1

Protocols for Management Of NUTRITION AL SUPPORT

In Children With Severe Acute Malnutrition

INTERNAL GUIDELINE – PILOT VERSION

MSF OCG & OCBA – FEBRUARY 2015

Protocols for Management of Malnutrition August 2015 2


This guideline is the only reference to manage malnutrition in OCG and OCBA programs. Recommendations that are defined in other MSF documents are not applicable without preliminary discussions with the OCG and OCBA Medical Departments. The MSF 2014 Nutrition guide is an excellent complement regarding: food security, assessment and surveillance, strategies and decisional process, outbreak management, blanket and targeted supplementary programs, program monitoring and nutritional products that means the global guide with exception of the chapter 7, and more precisely the sub-chapter 7.5. Case management (CM) of severe acute malnutrition needs a double nutritional and pediatrics approach. Actually, childhood illnesses not only further the onset of malnutrition and its evolution towards the severe form but also they are the causes of death associated with malnutrition. This protocol can apply in all nutrition programs of MSF OCG and OCBA, according to the skills of the health staff. It is the daily reference for our practice regarding case management of severe acute malnutrition (part I) and of its medical complications (parts II and III). The clinical and diagnostic part of complications in their severe form should be helpful for both early diagnosis and emergency treatment of children that need to be referred to the ITFC and early diagnosis and treatment of children already admitted in the ITFC. A good case management of acute malnutrition and its medical complications needs a good understanding of the physiopathology that explains the addition of the part IV. This protocol is integrative part of the BibOp and will be regularly updated according to the capitalization of collected field experiences (your feedback), the scientific evolution (literature) and the WHO recommendations. Be vigilant and use uniquely the most recent version. Some adaptations might be discussed according to the countries in order to follow a specific national protocol or in order to better cope with specific conditions. Nevertheless any change or adaptation should be communicated to the cell and validated by the medical department before use. We would like to warmly express gratitude to the different medical advisors and MOSU who, in Geneva and Barcelona, have participated to the writing of this protocol as well as training/coaching teams, RMP and colleagues from operations and fields, specifically Medcos, for their support regarding dissemination and implementation of this protocol in our fields. We hope this tool will really help you. We are looking forward to hear from you, remarks, comments, suggestions and questions. They will be welcomed and source of progress.


OCG NUT-PAEDIATRICS TEAM

Marie-Claude Bottineau, International MSF Pediatrics WG and OCG Women and Children Health Pool

Leader, [email protected] Nathalie Avril, Nutrition Advisor, [email protected]

Nicolas Peyraud, Pediatrics & Vaccination Advisor, [email protected] Roberta Petrucci, Pediatrics Support to the Operations, MOSU, [email protected]

Alejandra Garcia Naranjo, Elisabeth Canisius & Anne Pittet, Pediatrics Coaching & Training, [email protected], [email protected], [email protected]

OCBA NUT-PAEDIATRICS TEAM

Candella Lanusse, Référente Nutrition, [email protected], Nuria Salse, Référente Nutrition, [email protected]

Daniel Martinez, Paediatrics Advisor, [email protected], Laurent Hiffler, Paediatrics Advisor, [email protected],

Nadia Lafferty, Mobile Paediatrics Implementer, [email protected],


NUTRITIONAL SUPPORT AND SYSTEMATIC MEDICAL TREATMEN TS Chapter number

Chapter titles 1st page of chapters

Introduction 3 Content table 5 Logos & Acronyms 7 & 8 Reminder – NEW 11 1 ANTHROPOMETRIC AND CLINICAL CRITERIA FOR

ADMISSION 13

2 ADMISSION CATEGORIES DEFINITION 14 3 MOVEMENTS BETWEEN I-TFC AND A-TFC 15 4 CRITERIA FOR DISCHARGE FROM I-TFC, A-TFC AND TSFC

– Complement on non-respondent 16

5 YOUNG INFANT PROGRAM: INFANTS FROM 1 TO 6 MONTHS

– Complement on PTME 18

6 INPATIENT THERAPEUTIC FEEDING CENTRE: I-TFC

– Changes on nutrition and medical systematic treatment 37

7 AMBULATORY THERAPEUTIC FEEDING CENTRE FOR

SEVERE ACUTE MALNUTRITION: A-TFC – Changes on medical systematic treatment

53

8 TARGETTED SUPPLEMENTARY FEEDING CENTRE: TSFC

– Changes on medical systematic treatment 62

9 MONITORING / SURVEILLANCE / EVALUATION

– Complement and changes 70

10 PHSYCHOSOCIAL WELLBEING AND MENTAL HEALTH

– Complement 74

11 HEALTH EDUCATION 81 Conclusion 84 Annexes 86 1 Criteria for admission and discharge for all age group – NEW 87 2 Quality indicators for nutritional program 88


3 Surveillance form (A3) 90 4 Using the dosette – With the catalogue code 94 5 Anthropometry & Edema measurements; W/H & BMI tables – NEW 96 6 Health promotion, messages for caregivers – NEW 114 7 Supervision in ITFC 117 8 Insert a naso-gastric tube & Feeding by gravidity – NEW 123 BIBOP 129


NURSING CARE Care that are explained in the guide of nursing care

ATTENTION Important information to be memorized

PRACTICAL ADVICES Practical and helpful Endorsement for case management

FOR MEMORY Key informations


AGE Acute Gastro – Enteritis

AOM Acute Otitis Media

ASA Acetylic Salicylic Acid

A-TFC Ambulatory Therapeutic Feeding Centre

BLB Benzyl Benzoate

BP Blood Pressure

BS Blood Slide

CM Case Management

CRT Capillary Refill Time

CSF Cerebral Spinal Fluid

D5%, 10%, 20%, 50% Dextrose 5%, 10%, 20%, 50%

ENT Ear Nose Throat

EPI Enlarged Program Immunization

EPTB Extra-Pulmonary Tuberculosis

ETAT Emergency Triage Assessment Treatment

EZP Eezeepaste®

FUO Fever of Un Explicated Origin

Hb Hemoglobin

HBP High Blood Pressure

HIV / AIDS Human Immunodeficiency Virus / Acquired Immune Deficiency

Syndrome

HR / RR Heart Rate / Respiratory Rate

ICHBP Intra Cranial High Blood Pressure

ICU Intensive Care Unit

Ig Immunoglobulins

IM / IV / SIV Intra-Muscular / Intra-Venous / Slow Intra-Venous

IPR Intra-Peritoneal Rehydration

IOI Intra-Osseous Infusion

I-TFC Inpatient Therapeutic Feeding Centre

IUGR Intrauterine Growth Retardation

LIC Low Income Countries


LP Lumbar Puncture

LRTI Low Respiratory Tract Infection

M+PTB Sputum Positive Pulmonary Tuberculosis

M-PTB Sputum Negative Pulmonary Tuberculosis

MSF Médecins Sans Frontières,

MTB Mycobacterium Tuberculosis

MUAC Mid Upper Arm Circumference

N/OGT Naso/Oro-Gastric Tube

NCU Neonatal Care Unit

NSAI Non Steroid Anti-Inflammatory

PCP JiroveCi (former Carinii) Pneumocystis Pneumonia

PICU Paediatric Intensive Care Unit

PO Per Os

PPN Plumpy ‘Nut®

RDS Respiratory Distress Syndrome

RDT Rapid Diagnosis Test

RE Retinal Exam

RUSF Ready to Use Supplementary Food

RUTF Ready to Use Therapeutic Food

SpO2 (pulse oxymeter) Self-Administered Therapy (SAT): Setting up a pulse oxymeter for measuring the transcutaneous oxygen saturation (SpO2) of red blood cells in arterial blood

SC Sub-Cutaneous

SDTM Special Diluted Therapeutic Milk

SFC Supplementary Feeding Centre (Ambulatory Acute Moderate)

SCD / SCA Sickle Cell Disease / Sickle Cell Anemia

SIRS Systemic Inflammatory Response Syndrome

SRV Syncytial Respiratory Virus

TB Tuberculosis

UTI Urinary Tract Infection

VOC Vaso-Occlusive Crisis

W/H Weight / Height

WHO World Health Organization

½ Ringer Lactate + ½

D10%

Solution containing half Ringer Lactate and half D10%

ZC Z-Score


Reminders Type of malnutrition - below three children from the same age:

Stunting (Height/Age) Healthy Wasting: acute malnutrition (Weight/Height)

Only acute malnutrition (wasting and kwashiorkor) can be treated in Therapeutic Feeding Programme (TFP, for treatment of severe acute malnutrition and moderate acute malnutrition with medical complication) and Supplementary Feeding Programme (SFP for treatment of moderate acute malnutrition without medical complication). For stunting we can only put in place preventive activity (specially targeting pregnant and lactating women and children less than 2 years old, as 1000 first day-strategy).

TFP includes two components: the Ambulatory Therapeutic Feeding Centre (A-TFC) and the Inpatient Therapeutic Feeding Centre (I-TFC). There should be as much ATFC as needed according to the context to reach an acceptable coverage (see target in monitoring chapter).

The group targeted by malnutrition is mainly children below 5 years old, and more specifically the group below 2 years old. Nevertheless, in specific food insecurity situation other age groups can suffer of malnutrition. Whatever is the age or status of the person, in health centers and hospitals, severe acute malnutrition should be treated in all patients - older children, adults, elderly, pregnant and lactating women, even if our sensitization action and screening in the community will target less than 5 years old children.


I-TFC: Consists on inpatient 24/24 hours care management of: � Malnourished children of < 6 months and/or with breastfeeding problems. � Severe acute malnutrition with anorexia and /or clinical complications for those beneficiaries fitting in the

I-TFC admission criteria. � Malnourished children (in A-TFC or SFC) with complications that need to be hospitalized. � Non-respondents that need further investigation. A-TFC and TSFC (Targeted Supplementary Feeding Center): Consists on the outpatient management of acute malnutrition (severe in ATFC and moderate in TSFC) for those acutely malnourished patients fitting in the A-TFP admission criteria. These patients are managed at home, given RUTF (Ready To Use Therapeutic Food) plus medical treatment (systematic and specific), regularly (ideally weekly) seen for medical and nutritional follow up and according to established criteria, assigned a home visitor for follow up at home. Usually, the proportion admitted in the ITFC is between 10% and 20% of severe acute malnutrition admitted in TFP.


1. ANTHROPOMETRIC AND CLINICAL ADMISSION CRITERIA FOR I-TFC, A-TFC AND TSFC

CAUTION The age group targeted by malnutrition is children below 5 years old, and more specifically the group below 2 years old. Nevertheless, in specific food security situation other age groups can suffer of malnutrition. Whatever the age or status of the malnourished patient, he should be treated - older children, adults, and the elderly, pregnant and lactating women..

These criteria for children below must be respected to the maximum, but some children may be admitted on medical advice even if they do not fully meet all of the admission criteria.

In context with high stunting rate, 65cm can be used as reference for 6 months (instead of 67cm)

In some situation (as emergency) admission on MUAC/oedema only can be done (admission with <125mm and discharge with >125mm). Moreover, mass approaches of moderate malnutrition treatment, less medicalised, are often chosen by MSF instead of the traditional TSFC approach.

Global acute malnutrition: Children from 6 to 59 months (67-110cm) with:

• W/H < -2 Z-scores (ZC) and/or

• Bilateral oedema and/or

• MUAC < 125 mm.

1. If W/H < -2 ZC and/or MUAC < 125 mm and/or Oedema + or ++, With severe medical pathologies or anorexia,

2. If oedema +++ 3. If anorexia

If W/H < -3 ZC and/or Oedema + or ++, and/or MUAC < 115 mm, Without severe medical pathologies Nor anorexia.

I-TFC Inpatient Therapeutic

Feeding Centre

A-TFC Ambulatory Therapeutic

Feeding Centre

TSFC Targeted Supplementary

Feeding Centre

COMPLICATED MALNUTRITION

SEVERE MALNUTRITION

WITHOUT COMPLICATION

MODERATE MALNUTRITION

WITHOUT COMPLICATION

If W/H [-3 ZC; -2 ZC[ and/or MUAC [115mm; 125 mm[ Without severe medical pathologies Nor anorexia


2. ADMISSION CATEGORIES - DEFINITIONS New admission: An admitted child who has never been in the programme before, or who was discharged from it more than 2 months ago. Relapse: A child who has been discharged as cured from the programme, and is subsequently readmitted into the programme within 2 months. A large number of relapses is often a sign of food insecurity in the community. Re-admission: A defaulter who is readmitted to the programme within 2 months. All admissions are given a new reference number and are cared for in the relevant centre at least until they are stable, before being referred to another centre if necessary.


3. MOVEMENTS BETWEEN I-TFC AND A-TFC

3.1 MOVEMENTS FROM I-TFC � A-TFC for less than 6 months

CAUTION The movement I-TFC � A-TFC can be carried out regardless the W/H ratio or MUAC, and without minimum stay in the I-TFC, but does require medical validation and all the following conditions.

All of these movement conditions must be met: Nutritional conditions: • A child with a good appetite and eating ready-to-use therapeutic food (RUTF), • Child’s weight is stable or rising, no oedema +++ (Kwash + and ++ may be followed in A-TFC, with

medical approval, CAREFULL with Kwash ++ (and even +), make really sure they have a good evolution with RUTF and good general condition before transfer to ATFC – make also sure the ATFC function well enough…).

Medical conditions (to be verified by a complete medical examination): • Absence of acute medical problems, not injectable antibiotics or injectable anti-malarial drugs, • Normal temperature, • Vaccinations up to date: Vaccines suitable in I-TFC have been done. Mother’s capability (to be evaluated with her): • She must be able to bring the child to A-TFC for each visit, • She must understand how to use RUTF at home, • She must be able to give the oral medical treatments correctly. 3.2 MOVEMENTS FROM A-TFC � I-TFC for less than 6 months Nutritional reasons: • Anorexia / Refusal to take RUTF (failure to appetite test). • Apparition or increase of oedema. • Sudden or progressive weight loss (except for kwashiorkor). • Stagnating weight curve after 4 weeks in A-TFC (or gain of weight very low, <5g/kg/d) (the reason for

the lack of weight gain should be investigated medically, psychologically and socially, and a movement to I-TFC should be instigated if the situation has not improved by the fourth week.

Severe medical condition : • Severe anaemia • Severe LRTI • Severe malaria • Diarrea with dehydration • Abnormal consciousness • Vaso-occlusive crisis in SCA (painful crisis) • Other infections / Sepsis.

ATTENTION

Infants below 6 months should not be treated in ambulatory but should be systematically referred to I-TFC. On the other side, one time they are cured, they should be referred to A-TFC-SFP in order to ensure adequate / normal breastfeeding / feeding and growth.


4. DISCHARGE CRITERIA FOR I-TFC, A-TFC AND TSFC 4.1 CURED / RECOVERY CRITERIA: All of the following criteria must be met.

Discharge as cured from the I-TFC, A-TFC AND TSFC: The child no longer presents any anthropometric or clinical signs of acute malnutrition: • W/H > -2 Z-scores on 2 consecutive visits (that means 2 consecutive weeks if the child was having

weekly consultations). • Absence of oedema, for at least 7 days. • MUAC > 115 mm for ITFC/ATFC (then refer the child to TTSFC) and MUAC >125 for TSFC on 2

consecutives visits. • Absence of acute medical pathologies requiring close medical attention or non-oral treatment (IV, IM,

ophthalmology…). • Child has an adequate appetite and food consumption. • Vaccinations up to date: vaccines suitable in I-TFC, A-TFC or TTSFC have been done. The child is

referred to the nearest health centre to complete his vaccination calendar if needed. Discharged ‘stabilised’ of the I-TFC (transfer to A-TFC): • Marasmus: stable weight or gaining weight (whatever are the WHZ and MUAC) and medical

complications treated. • Kwashiorkor: decrease of oedema (whatever are the WHZ and MUAC) and medical complications

treated. 4.2 DEFAULTER CRITERIA

A child is considered as a defaulter when s/he has not attended the: • I-TFC for 3 consecutive days (discharge the 3rd day). • A-TFC/TSFC for 3 consecutive visits (discharge the 3rd week). – if the consultations take place every

two weeks: then discharge after 2 consecutive visits (discharge the 4th week).

Children absent from the I-TFC, A-TFC and TSFC should be sought as soon as they are absent by community health workers.

4.3 DEATH CRITERIA to be attributed to the programm e

A child is considered as a death within the programme when s/he died in the: • I-TFC or at home within a period of 3 days of non-attendance. • A-TFC/TSFC or at home within a period of 3 weeks of non-attendance.

4.4 TRANSFER CRITERIA

A child transferred to another medical facility (non-nutritional) for specific treatment linked to: • A chronic pathology or a congenital malformation which the TFC medical team are not able to treat. • Acute medical problem requiring surgical intervention (e.g. fracture, burn, acute abdominal pain).

In all these cases, the child will be registered as transferred, even if nutritional support is still provided to him within the other institution. If the child comes back in the program he will be consider as a new admission or readmission depending of the duration after the transfer.


4.5 NON-RESPONDANT CRITERIA

• A child who does not improve the nutritional status after having ensured that appetite is good, no underlying medical condition is present, and no other reasons for the non-improvement have been detected during a maximum length of stay of 3 months.

Steps to follow before classifying a child as non-respondent: • Beneficiaries with no weight gain during two weeks need to be evaluated in the facility (appetite test,

medical check-up and caretaker’s interview). • If no medical problem is detected, consider to organize a home visit to find out the eventual social

causes. • If one week later, weight is still stagnant or lost or there is a deterioration of medical condition, the

beneficiary should be transferred to the I-TFC for further investigation: To observe feeding and tolerance, to evaluate clinical condition of the patient (signs of chronic pathology such us TB, HIV…), to evaluate other causes

• If the patient doesn’t have any medical problem and increases weight in the ITFC probably the cause of not gaining weight was a social problem as sharing the RUTF.

• Sensitization and home visits by the community health workers should be organized to the homes of these children.

• In the I-TFC and after having medically investigate and/or treated the patient, the doctor should decide regarding a continuation of nutritional treatment or its discharge as a non-respondent.


5. YOUNG INFANTS PROGRAMME 1 to 6 MONTHS

Newborn babies less than 28 days old are treated by a neonatal service. If there is no such service, they are admitted on a case-by-case basis in I-TFC. The programme for young infants is only developed if there are no other structures already providing care for them.

YOUNG INFANTS 1 TO 6 MONTHS

1. If the infant is <-2 ZC and:

- Anorexia or

- Too weak to suckle or

- Medical complication or

- Severe visible wasted or

- Oedema +, ++, +++

And/or

2. If Mother/wet nurse has

- Medical complication or

- Insufficient breast milk

1. The infant is <- 3 ZC with

- Appetite and

- No medical complications and

- Good suckling

And

2. If Mother / Wet nurse has

- No medical complications

- Enough breast milk

Young infant ward

of I-TFC

To handle problems

Follow-up of weight growth and

immunization in I-TFC or A-TFC or OPD

up to the age of 6 months

COMPLICATED MALNUTRITION NON COMPLICATED

MALNUTRITION

Young infant ward

(breastfeeding corner)

of I-TFC

To observe weight gain and

Discharge when:

- Weight gain with exclusive BF

- No medical problem

- Mother / Wet nurse knows about Kangaroo method


Introduction

Malnutrition that targets young infants is specific as related to particular history and the huge need to promote breastfeeding or sometime to find a substitute. The global objective of the care is:

• Reduce morbidity and mortality of young infants by providing them with the specific and/or intensive care that they need until they have recovered.

• To ensure that the young infants leave the programme feeding on breast milk only: to re-establish, preserve or improve the mother’s lactation. In a few cases– no breast milk and high HIV+ prevalence or congenital malformation…- a substitute should be provided.

One has categorised this malnutrition in 2 categories and 3 types of treatment: 1. Malnutrition Acquired before birth:

2 categories: - Intra-uterine growth retardation (IUGR), due to maternal malnutrition or anaemia, malaria or various infections. The cause of IUGR should be assessed, to be solved if possible. IUGR young infant will follow his own growth curve without catching up the normal one.

- Pre-term infant (< 27 weeks). With good support, young infant will cat up the growth curve quite easily. The objective of the management is to observe the mother-child couple in order to detect some complications, to set-up standardised basic infant- mother care and to organise a monthly follow-up of the growth and immunization.

In this case and with our help, the infant will follow his own growth curve without catching up the normal one.

2. Malnutrition acquired after birth. It’s due to a lack of breast milk, a congenital malformation, a disease... or a preterm or IUGR complicated by a medical problem. The objective of the management is to treat young infant malnutrition, to re-establish breastfeeding and to organise a monthly follow-up of the growth and immunization. In the case of acquired malnutrition, the young infant catches up more quickly and rapidly the normal growth curve. Two managements are possible regarding the availability or not of breastfeeding. Young infant are hospitalised in their own ward. Indeed, they are not mixed with older kids as one would like to protect them against


5.1 SYSTEMATIC MEDICAL AND NUTRITIONAL CARE 5.1.1 Admission criteria The decision to admit or discharge a young infant always involves consideration of clinical criteria, systematic observation of breastfeeding and/or evaluation of the growth curve. • W/H is <-3 z-score (MUAC cannot be used for children < 6months).

• W/H between >-3 z-score and <-2 z-score with associated illness.

• Bilateral oedema due to malnutrition (routinely check for absence of anaemia).

• For children less than 45cm: confirmed weight loss of more than 10% (prior weight need to be available).

• Feeding problems due to problems such as:

o Infant too weak to suckle, o Illness or absence of the mother, o Insufficient breastfeeding (mother / wet nurse having little or no milk).

In case there is medical complication with signs of severity � Refer to intensive care. Medical history and physical examination

• Age of young infants to be investigated with the local events calendar • Medical histories of infant and caretaker, • Presence (absence) and attitude of the caretaker • Breast-feeding history:

o Frequency, o Duration, o Breast-milk given in last 24 hours, o Food other than breast milk (sugared water, porridge etc.)

• Condition of young infant (hungry, satisfied) • Good flow of breast milk (to be checked manually), • Check the technique used to put the young infant to the breast, • Check the duration and quality of suckling. Is the infant able to suckle efficiently for several minutes?

5.1.2 What to do

• Young infants must be hospitalised for care as they can’t be treated in outpatient at first.

• If the mother has died, a suitable solution must be found to feed the infant. o Wet nurse:

� Take care that this is acceptable in the community. � Take care in countries with a high prevalence of HIV/AIDS.

o Food substitute (formula milk, or goat’s milk as last option): � MSF will supply the caretaker with the necessary equipment: saucepan, small ladle, etc. � It is necessary to ensure that the supplies of the substitute are assured for the young infant until

the age of 6 months. � Specific health educational sessions will enhance caretaker’s ability to prepare the milk

hygienically, in sufficient quantities and using the equipment given to them. • In the case of hospitalisation a separate area must be provided away from other children, where calm

and the special skills acquired by staff must be combined.

• The duration of a stay must be as short as possible so as to avoid hospital-acquired infections to which young infants are very susceptible.

• Make sure that the area is warm, with a warm room (see below).


• The mother / wet nurse should sleep with the young infant in order to prevent hypothermia.

• Impregnated mosquito nets must be supplied.

• No feeding bottles, teats or teaspoons should be used.

REMEMBER Young infants are very susceptible to hypothermia. Always keep them warm, otherwise they are using all their energy in an attempt to produce heat, and there is none left for growth. The surface area of the head is very large compared with that of the body; therefore it is a major source of heat loss. • Cover the head with a cap made

of stretch jersey fabric. • Use the kangaroo method

(natural incubation pouch): o Removes mother and infant

inner clothing, o Place the infant against the

belly of the mother / wet nurse, with direct skin contact.

o Place the baby in such a way that the breast is always within reach of the young infant’s mouth.

o Use a cloth to secure the baby and wrap the pair with a cover wrapped around the mother / wet nurse.

• Settle them into a warm room. • Ask the mother to sleep in a

semi-lying position in order to reduce the gastric reflux of the young infant especially preterm infant.

5.1.3 Monitoring • Check the weight using 5 to 10 gr precision manual or electronic scales for babies.


• If a young infant’s weight stagnates or goes down on 3 consecutive days, look for weight loss caused by dehydration before reaching the conclusion that there is real weight loss or stagnation. Then: o A medical and/or psycho-social problem should be suspected. o Or an insufficient amount of nourishment is being offered and needs to be increased.

• Provide nappies while explaining to the mothers / wet nurses how to monitor and indicate when urine and stools are passed.

Check:

Young infant phase Weight Every day Height At admission Oedema Every day

Temperature Every morning and evening or more often

Heart rate, respiration rate Every morning and evening or more often

CRT (capillary refill time) Every morning and evening or more often Medical examination Every day Observation at feeds At every feed

Note any diarrhoea, vomiting etc. At each event

5.1.4 Hygiene • Hygiene education for mothers / wet nurses

o Wash hands before eating, after using the toilet, before and after every breastfeed. o Wash the breast with water (no soap) to prevent the loss of the natural oils of the nipple

because the skin dries and cracks. • A daily bath is not recommended for young infants weighing less than 1500 g. Such young

infants would lose too much heat and they would expend too much energy. It is necessary to clean the folds in the neck, the groin and the bottom every day. Babies weighing more than 1500 g can be given 1 or 2 baths each week, during the hottest hours of the day.

• Staff must wash their hands with soap before and after caring for each baby. • Make sure that cups and tubes (to be rinsed with water after each feed with a syringe) are kept

rigorously clean, keep them in a sheltered place, inside a medication bag, and change them regularly.

5.1.5 Criteria for discharge • Maternal breast-feeding must have been taking place for 5 days, with a rising weight curve and a

weight gain of 10 g / kg / day. • Good general condition, no medical problems • Check that all the child’s vaccinations are up to date and refer the child to the nearest

vaccination centre to complete the vaccination, if necessary. • Check that the mother’s vaccinations are up to date, and refer her to the nearest vaccination

centre if necessary. • Make an appointment for the follow-up (either in I-TFC or A-TFC or OPD).


CAUTION

All young infants admitted to the program must be monitored until the age of 6 months. The monitoring should be adapted each week or month regarding the needs. 5.2 SYSTEMATIC MEDICAL TREATMENT OF YOUNG INFANTS

Pathologies Treatment D1 D2 D3 D4 D5 D6 D7 Phase II

Infection diseases Amoxicillin + + + + + + + + + +

Amoxicillin shouldn’t be prescribed to pre-term infant.

Anaemia / iron deficiency

Ferrous fumarate powder +

Malaria Systematic RDT in endemic area +

Treat if positive See details below

Prevention Vaccination See vaccination table below

Prevention HIV transmission

Counselling and testing (mother and child)

+

Treatment/PMTCT if positive

See details below And PMTCT MSF guidelines

NB : Albendazole : No albendazole for under 6 months with breastfeeding.

Amoxicilline tablet dispersibles 250mg (80 à 100 mg / kg / day)

weight (kg) Amoxicilline 250 mg dispersible tablets

< 1.3 1/4 tab x 2 1.3 – 1.5 1/4 tab x 2 1.6 – 2 1/4 tab x 2 2.1 – .4 1/2 tab x 2 2.5 – 2.9 1/2 tab x 2 3 – 3.4 3/4 tab x 2 3.5 – 3.9 3/4 tab x 2 4 – 4.9 3/4 tab x 2 5 – 5.9 1 tab x 2

FUMAFER, Ferrous fumarate, 140mg/5ml (eq. iron 45 mg/5 ml) oral sol., fl - DORAFERS2S- Should be given where there is no acute progressive infectious pathology, or for clinically stable infants.

1 000 – 1 300g 2.0 mg = 0.2 ml

1 400 – 1 600g 2.8 mg = 0.3ml

1 700 – 1 900g 3.4 mg = 0.3ml

2 000 – 2 300g 4.0 mg = 0.4 ml

2 400 – 2 600g 4.8 mg = 0.5 ml


2 700 – 2 900g 5.4 mg = 0.5ml

3 000 – 3 300g 6.0 mg = 0.6 ml

> 3 400g 7.0 mg = 0.7 ml

Malaria If positive RDT: ASAQ = ARTESUNATE 4 MG/KG/DAY + AMODIAQUINE 10 mg B ASE/KG/DAY for 3 days o Infant HIV positive under ART � Coartem o AS-AQ is contraindicated in South East Asia because of resistance � Coartem o Infants > 2 months AND < 5 kg in ambulatory � Coartem Weight Tablets AS-AQ D1 D2 D3 ≥ 2 months And < 5kg ADMISSION � AS-AQ except contraindications

25 mg Artesunate / 67.5 mg Amodiaquine * See below how to give the

requested amount

≥ 2 months And < 5kg ADMISSION � COARTEM if indicated (loco-regional epidemiology, HIV positive under ART, MoH policy)

20 mg Artemether / 120 mg Lumefantrine

1 / 2 tab x 2

1 / 2 tab x 2

1 / 2 tab x 2

≥ 2 months And < 5kg AMBULATOIRE

in this group, always COARTEM replaces AS-AQ

1/ 2 cp x 2

1/ 2 cp x 2

1/ 2 cp x 2

5 – 8.9 kg 25 mg Artesunate / 67.5 mg Amodiaquine

1 tab 1 tab 1 tab

* Blister AS-AQ (AS 25 mg / AQ base 67.5 mg) for children from 2 to 11 months, 1 to 5 kg : This pharmacological presentation is poorly adapted for children less than 5 kg, especially in ambulatory since you should open the blister and make a dilution. Nevertheless this treatment Artesunate-Amodiaquine might be given orally in hospitalization following the table below, for 3 days maximum.

Artesunate-Amodiaquine (AS-AQ): Artesunate-Amodiaquine (AS-AQ): Blister for children from 2 to 11 months: Blister with three tabs (AS 25 mg / AQ base 67.5 mg diluted in 5 ml of normal saline solution) 1 kg 0.8 ml

1.25 kg 1.0 ml

1.5 kg 1.2 ml

1.75 kg 1.4 ml

2 kg 1.6 ml

2.25 kg 1.8 ml


2.5 kg 2.0 ml

2.75 kg 2.2 ml

3 kg 2.4 ml

3.25 kg 2.6 ml

3.5 kg 2.8 ml

3.75 kg 3.0 ml

4 kg 3.2 ml

4.25 kg 3.4 ml

4.5 kg 3.6 ml

4.75 kg 3.8 ml

COARTEM = Tablets (20 mg Artemether + 120 mg Lumefantrine) for 3 days maximum

Weight Coartem Tablets D1 D2 D3 ≥ 2 months And < 5kg ADMISSION


1 / 2 tab x 2

1 / 2 tab x 2

1 / 2 tab x 2

≥ 2 months And < 5kg AMBULATORY or ADMISSION

1 / 2 tab x 2

1 / 2 tab x 2

1 / 2 tab x 2

5 – 9.9 kg 1 tab x 2 1 tab x 2 1 tab x 2

Prophylaxis treatment by Cotrimoxazole « UNIVERSAL » prophylaxis

• All severely or moderately malnourished children MORE THAN 6 weeks of age WITHOUT ANY EXCEPTION should receive Cotrimoxazole if they are HIV positive, exposed as infected one.

• When to stop Cotrimoxazole:

o Exposed HIV positive: Immediately after exclusion of the disease (negative virological test or negative rapid antibody test after 18 months of age in the total absence of breastfeeding since at least 6 weeks) – see HIV chapter.

o Confirmed HIV positive (with the disease) : - After a minimum of 6 months under ART + good clinical response to treatment + CD4 >

350/mm3 x 2 at 6 month-interval.

- In all other case and/or not available CD4, never before 5 years old.

COTRIMOXAZOLE (CTX)

DORACOTR2S1 COTRIMOXAZOLE, 200mg/40mg/5ml, powder oral susp. Oral suspension 100 ml, fl

DORACOTR1T- COTRIMOXAZOLE, 100 mg / 20 mg, tab.

DORACOTR4T- COTRIMOXAZOLE, 400 mg / 80 mg, secable


tab.


Single daily dose Oral suspension (5 ml = 200 mg/40 mg)

Pediatrics tablets (100 mg/20 mg)

Adults tablets (400 mg/80 mg)

5 weeks and < 6 months (or < 5 kg)

2.5 ml (½ coffee spoon)

1 tab Not applicable in this age group

6 months to 5 years (or 5 to 15 kg)

5 ml (1 coffee spoon)

2 tabs ½ tab

6 to 14 years (or 15 to 30 kg)


4 tabs 1 tab

> 14 years (or > 30 kg)

N/A N/A 2 tab

INH prophylaxis treatment (IPT) 10 mg/kg (max 300 mg) x 1/j x 6 months + 5 to 10 mg/d of Vitamin B6 in one single oral dose • All children from 0 to 15 years old in confirmed contact with a lung tuberculosis

disregarding the HIV status: INH x 6 months (after exclusion of TB disease, which would justify a complete treatment).

• All HIV positive (exposed or sick) children from 1 to 15 years old: INH x 6 months every 3 years (after exclusion of TB disease, which would justify a complete treatment) disregarding the history of contacts.

• All HIV positive (exposed or sick) children from 0 to 15 years old: restart INH x 6 months IMMEDIATELY after successful completion of their TB treatment.

Vaccination table for young infants in I-TFC

Antigens Age at 1st dose

Number of doses

Minimum interval between 2doses

Considerations

Pentavalent DPT (Diphtheria, Pertussis, Tetanus), Hép B, Hib

6 weeks 3 doses 4 weeks

Maximum age: 5 years

Pneumococcal (PCV 13)

6 weeks 3 doses if age ≤ 11 months

4 weeks



2 doses if age > 11mois

8 weeks

Polio (OPV) 6 weeks 3 doses 4 weeks


In ITFC : give only at discharge (not during hospitalization to avoid contamination of other children who may be HIV+)

All young infants must be vaccinated on admission and at discharge before being referred to the national EPI unless a vaccination card can be presented to prove that the vaccination schema has been completed.

HIV: Prevention mother to child transmission (PMTCT) Please refer to the 2015 PMTCT MSF international protocol. Breastfeeding by an HIV infected mother not under treatment adds an additional 5-20% risk of transmission to the child (knowing that without intervention, the risk of transmission is 15-30% in non-breastfeeding populations, so with breastfeeding, the overall transmission rate is 20-45%). HIV counselling and testing have to be done as soon as possible for each pregnant woman and re-done during pregnancy and breastfeeding period if negative (and ART has to be given if positive – See PMTCT MSF guideline 2015).

If the mother is HIV positive: maternal breastfeeding (exclusive during the 6 first months) has to be associated with ARV administration to the baby and/or the mother during the breastfeeding period.

In ITFC, we have to make sure regarding the HIV status of the child and the mother.

HIV positive mothers identified postpartum with breastfeeding infants

• The child should be tested with an age appropriate HIV test (DBS if < 18 months; rapid testing algorithm if > 18 months), the mother should be started on ART, and because it will take up to 3 months for the majority of women to achieve virological suppression the baby should receive 12 weeks of NVP syrup (adapt NVP dose to the infant weight).

• If the baby is tested positive (positive DBS if < 18 months, HIV RDT positive test if > 18

months), stop NVP prophylaxis and start ART with a PI based regimen (refer to MSF HIV Pediatric Hand book 2014).

Note:

• The situation is the same if the HIV exposure is first recognized in the infant < 18 months by a serological (antibody) test.

• Before 18 months, only a virological test can be used to confirm infection (with a confirmatory test to exclude lab errors).

• After 18 months, a positive antibody test (with a positive confirmatory test) means the child is infected.

Reminder:


For HIV exposed children: exclusive breastfeeding for 6 months, continued breastfeeding with introduction of food step by step until 12months, then gradual weaning around 12months For more details regarding counselling, testing, treatment and follow up of the mother and the child, refer to the PMTCT MSF clinical guideline and/or HIV pediatrics 2015 and/or Patient Education guideline. You can also find additional information in the WHO HIV and Infant feeding guideline and the WHO clinical guideline on the use of antiretroviral drugs to treat and/or prevent HIV infection. Recommendations for a public health approach-June 2013:

http://apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf.

5.3 NUTRITIONAL TREATMENT FOR YOUNG INFANTS 3 different protocols are used: 1. Young infant admitted with an uncomplicated malnutrition with the possibility to be

breastfed: “The breastfeeding corner” see 5.3.1. 2. Young infant with complicated malnutrition with the possibility to be breastfed

see 5.3.2. 3. Young infant where with complicated malnutrition and no impossibility to be breastfed

see 5.3.3. 5.3.1 Breastfeeding corner The breastfeeding corner, located in the young infant ward but separated, welcomes young infants for a short observation period, admitted with an uncomplicated malnutrition and the possibility to be breastfed and their mother who need support.

The breastfeeding corner is a secure and intimate place to observe the breastfeeding, young infant’s weight gain and mother-child relationship.

The management can be done on a day care if the couple is living close by the I-TFC. Most of the time, the couple is hospitalised for the 3/5 days needed to observe if no adverse events raised before to discharge for the follow-up until the age of 6 months of the infant. Support and education is proposed to mothers:

• To understand and use the Kangaroo method (see 5.2.1).

• To observe and ensure effective suckling.

• To increase breast milk production: 1. Feed the mother in order for her to

feed her infant (see 5.4.1). 2. Give water (> 1L). 3. Put the young infant as soon as

possible to the breast. 4. Mother rest.

• To follow the infant weight every day

• To make a systematic infant (see 5.1) and mother (see 5.4) medical consultation.


5.3.2 Nutrition treatment for a complicated malnutrition with the possibility to be breastfed This group represents the most important number of patients followed in the young infant ward. A 3-phase approach is recommended in order to gradually reduce the supplement (given with TSS – see section 5.4.3) and increase the breast milk. Summary of nutritional treatment

Phase Duration Breast-feeding

Special Diluted Therapeutic Milk supplement (= F100D) or F75 with TSS

Stabilisation Usually 10 days (max. 15 days)

Put to the breast every 3 hours as a minimum, and

more often if wanted

135 ml / kg / d after breast-feed:

100 kcal / kg / d in 8 feeds

Transition 2 - 5 days Put to the breast every 3 hours as a minimum, and

more often if wanted

67 ml / kg / d after breast feed:

50 kcal / kg / d in 8 feeds

Re-nutrition Min. 5 days Breast milk only

CAUTION : If the infant has nutritional oedema, use the F-75 Quantity of milk in line with weight and stage of treatment To obtain a Specially Diluted Therapeutic Milk (SDTM) that provides around 75 Kcal / 100 ml, mix: Or 1 Sachet of 114 gr of F100 with 650 ml of boiled chlorinated water (lukewarm) to make 750 ml of SDTM

Weight / kg SDTM or F75 in ml x 8 feeds

Stabilisation Transition 1.6 - 1.8 kg 30 ml 15 ml 1.9 - 2.1 kg 35 ml 17 ml 2.2 - 2.4 kg 40 ml 20 ml 2.5 - 2.7 kg 45 ml 22 ml 2.8 - 2.9 kg 50 ml 25 ml 3.0 - 3.4 kg 55 ml 28 ml 3.5 - 3.9 kg 65 ml 32 ml 4.0 - 4.4 kg 70 ml 35 ml 4.5 - 4.9 kg 80 ml 40 ml 5.0 - 5.5 kg 90 ml 45 ml 5.6 - 6.5 kg 100 ml 50 ml NB: Undiluted F-100 is never used for young infants During the stabilisation phase, maternal milk is continued and is in addition to the SDTM, which on its own, provides a sufficient quantity of energy and nutrients. During the transition phase the maternal milk secretion generally increases after 10 to 15 days, the infant’s weight gain becomes regular and the quantity of SDTM can be reduced by half.


CAUTION If the young infant loses weight during the 3 days after the SDTM has been halved, do not hesitate to increase the SDTM again by adding 50% of the amount of transition phase milk. However, if too much supplement is given to a young infant s/he will become full, and suckle less, which could cause lactation to reduce, even cease. On re-nutrition , once the weight curve is rising, the SDTM is stopped. The newborn infant is fed solely by breast-feeding. S/he is observed for a minimum of 5 days. If the weight curve is rising and the weight gain is 10 g / kg / day, s/he can leave the program to the follow-up phase. 5.3.3 Nutrition treatment for a complicated malnutrition without possibility to be breastfed Principles of treatment In the rare cases where maternal breast-feeding is not possible (no mother or wet nurse) follow the protocol below. PHASE PERIOD SDTM Stabilisation

Days 1 to 7 (max.) 100 kcal / kg / day = 135 ml / kg / day in 8 feeds

Compulsory transition

Max. 3 days 150 kcal / kg / day = 200 ml / kg / day in 8 feeds

Re-nutrition

14 days 200 kcal / kg / day = 270 ml / kg / day in 8 feeds

Use the SDTM or F75 for a maximum of 3-4 weeks; then replace it with infant formula milk until the age of 6 months (or in last choice if infant formula not available or sustainable replace with goat’s milk if this is accepted in the culture, until 4 months old).

CAUTION During the re-nutrition phase, the recommended quantity of milk is 270 ml / kg / day. The young infant may not be able to drink it all. Nevertheless it is necessary to offer it all, and then measure the amount not taken before throwing it away. The aim of this phase is to put on weight. If the infant is gaining weight (approximately 10 g / kg / day) there is no need to worry about the amount taken. On the other hand if the infant does not take the full amount and is not putting on weight, his/her medical condition should be reassessed. Stimulate the affectionate relationship between the baby and his/her caretaker, promoting the use of skin contact, encouraging the caretaker to stimulate the infant and to feel comfortable in her role of responsibility for the child (refer to the chapter in this protocol).


Quantities of SDTM per feed and per phase Weight Stabilisation Transition Re-nutrition 1.6 - 1.8 kg 30 ml 45 ml 60 ml 1.9 - 2.1 kg 35 ml 50 ml 70 ml 2.2 - 2.4 kg 40 ml 60 ml 80 ml 2.5 - 2.7 kg 45 ml 65 ml 90 ml 2.8 - 2.9 kg 50 ml 75 ml 100 ml 3.0 - 3.4 kg 55 ml 85 ml 110 ml 3.5 - 3.9 kg 65 ml 95 ml 130 ml 4.0 - 4.4 kg 70 ml 110 ml 140 ml 4.5 - 4.9 kg 80 ml 120 ml 160 ml 5.0 - 5.5 kg 90 ml 135 ml 180 ml 5.6 - 6.5 kg 100 ml 150 ml 200 ml NB: Undiluted F-100 is never used for young infant 5.4 MEDICO-NUTRITIONAL SUPPORT OF THE MOTHER / CARE TAKER 5.4.1 Care for the mother / care taker • Medical consultation of the mother or the wet nurse;

• Systematic medical treatment for the breast-feeding mother / wet nurse:

o Multiple Micronutrients : 1 tablet / day up to 6 months old of the young infant.

o Calcium for breastfeeding mother < 18years old: 1g/day up to 6 months old of the young infant.

o Vitamin A (in the 2 months after delivery): 100 000UI in one single dose, at admission if not taken at delivery or in the 2 months after delivery.

o Check the mother’s vaccination record for tetanus.

o Screen and monitor for possible mastitis / cracks.

Anemia management In case of mild or moderate anemia (hemoglobin < 11 or 10 mg/dl respectively), treat lactating women for iron deficiency anemia with therapeutic dose of iron: 1 MMN and 1 or 2 Ferfol / day.

Vaccination for pregnant and lactating women and wet nurse

Tetanus toxoid dose When TT1 As soon as possible during pregnancy TT2 Minimum 4 weeks after TT1 TT3 Minimum 6 months weeks after TT2 (or during next

pregnancy) TT4 Minimum 1 year after TT3 (or during next pregnancy) TT5 Minimum 1 year after TT4 (or during next pregnancy)


• Take the mother’s MUAC:

o If MUAC < 230 mm and/or edema � malnutrition � treatment: 2 RUSF / day (Afya P&L).

o If mother < 18 years old � 2 RUSF / day (Afya P&L).

• Give to mothers sufficient (2500 kcal / d) and balanced (with vitamins and minerals) food

• Give to mothers as much fluid as they want to drink, more than 3 litres a day (1 cup before each breast-feed).

• Explain to the mother what is expected of her and the aim of the treatment.

• Ensure monitoring and psychological supports for maternal breast-feeding (listen to any problems, assess breast-feeding practice, and help with breast-feeding). The mother needs a lot of reassurance in her role as mother; if worried about her ability to feed her baby, she will continue to think that her milk is insufficient. This confidence crisis can manifest itself in many ways (including an apparent attitude of rejection). An essential part of the work is to re-establish this confidence and this bond.

• Encourage the mother to have skin to skin contact with her baby (kangaroo method) and to rest.

• Encourage the mother to play with and sing to her child.

5.4.2 Restarting and supporting breast-feeding

REMEMBER The best quality food for babies is mother’s milk. One should do our best to restore and support breast-feeding to reduce morbidity and mortality of young infants The aim of all such undertakings is to return a young infant to exclusive and sufficient breast-feeding. It is essential to explain this to the mother or wet-nurse, thus boosting her morale in her essential role. The aim is to stimulate the secretion of breast milk and to supplement the young infant’s feeds until sufficient milk is being secreted to allow the young infant to grow properly. Insufficient milk secretion is often due to insufficient stimulation on the part of the young infant. • Stimulate lactation by putting the young infant to the breast as often as possible, at least every 3

hours, for at least 20 minutes (10 minutes each breast), and always before (about 30 to 60 minutes giving the SDTM supplement).

• Before each breast-feed, give the mother a cup of water (500 ml).

• Feed the young infant with the SDTM using the supplement suckling technique. The infant takes several days to get used to this.

• Check that the young infant is correctly positioned when s/he is put to the breast.

• Check the condition of the women's nipples, and apply thick layers of Vaseline or a tulle gras dressing in cases of redness, cracks or splits (to be cleaned off with water before breast-feeding).

• Explain to the mother the relationship between: eating + drinking + and resting + putting the child to the breast often � meaning good quantity and quality of milk.

• Encourage the women and give them confidence in themselves.


What to do What to explain. 1. Continue maternal breast-

feeding in all circumstances � Do not stop maternal breast-feeding if the young

infant has diarrhoea

� Do not stop maternal breast-feeding if the mother is ill.

2. Stimulate maternal lactation � Put the infant frequently to the breast

� Ensure that the mother drinks fluids (at least 3 litres / day)

� Feed the mother

� Use the “Supplementing Suckling” (SS) technique

�

�

�

�

Do not allow maternal lactation to cease due to lack of breast-feeds.

Do not neglect the mother’s hydration, this has a direct effect on the quantity of milk produced.

Do not neglect the mother’s nutritional condition, this has a direct effect on the quality of the milk she produces.

Do not allow her to think that her lactated milk is insufficient, when this is not the case.

3. Treat any illness in the mother �

�

Do not allow the mother to think her milk is bad because she is ill, or that there is little of it.

Do not allow the mother to think that it is her milk that is making the young infant ill.


Preservation of Breastmilk :

Temperature > 22°C 1 hour maximum

Temperature 19 à 22°C 4 à 6 hours (maximum 8 hours)

Temperature 15°C 24 hours

Temperature 0 to 4°C (fridge) 8 days

5.4.3 The “Supplemental Suckling” technique The milk is given to the young infant with the aid of a no. 8 gastric tube (a n°5 tube is too small).

• Cut the end of the tube (+/- 1 cm from the small holes) and remove the plug from the other end.

• Place the end of the tube into the cup into which the SDTM has been placed. The other end of the tube is fixed to the breast at the nipple with a plaster.

• When the young infant suckles at the breast, it is also suckling at the tube which is in its mouth. The young infant thus sucks the milk in the cup through the tube. It is as if the young infant was drinking its milk through a straw.

• Control the flow of the milk so that the infant suckles for about 30 minutes at each feed. Raising the cup makes the feed flow faster; lowering the cup makes it flow more slowly. As the infant gains strength, the mother can slow down the flow through lowering the cup so the infant suckles the breast longer.

• To start with the mother needs help in holding the cup and the tube in place. Encourage the mother and give her confidence.

• The best person to demonstrate this technique is a mother, who has, herself, successfully used the technique. From this moment, the other mothers find that the technique is easy, and copy her.

• The young infant may need 2 to 3 days to adjust to this system. Sometimes s/he notices the difference in taste between breast milk and SDTM and refuses to take it, but it is necessary to persist.

• If, during the first few days, the young infant does not “suckle” all the milk in the cup through the tube, and s/he is not full, the rest should be given directly in the cup (not by a teaspoon, or a feeding bottle).


5.4.4 Breast milk substitute The wet nurse A wet nurse breastfeeds infant where is not her own. She could be a woman from the family or outside it.

In some cultures, orphans arrive in the I-TFC with wet nurses but in other context it’s not accepted.

If the wet nurse is available, one should offer her a first voluntary and confidential counselling pre-test, an HIV test and a post-test counselling to announce the result. If the test is positive, one should propose the treatment and refuse her to breastfed the infant.

REMEMBER All women can start to breastfed at all periods of her life. Woman motivation, breast stimulation by sucking and psycho-social and nutritional supports are the 3 main conditions of success. It’s more difficult to launch breastfeeding in very young or old women. It’s not recommended to launch breastfeeding in malnourished women. If the orphan has no wet nurse, MSF will not push to find one but will prefer to feed the infant with formula milk Infant Formula milk

REMEMBER The best food for young infant is the breast milk. The Infant formula milk is the 2nd option but in hazardous situations in which we work, it is often not possible to combine the hygienic conditions and resources to offer formula milk. MSF should involve itself to provide the formula milk for the 1st 6 month of the infant’s life. The 3rd option less recommended is the diluted goat milk. It’s affordable for families and could prevent an early weaning.


• Make sure that the supply can be maintained for the first 6 months of life.

• Train the mother to make sure that hygienic conditions are respected.

• Given by small ladle or by cup in semi-reclining position.

• No feeding bottles, teats or teaspoons should be used. Goat’s milk

It could be considered when the 2 first options are not possible. • Make sure that the supply can be maintained for the first 6 months of life � give a goat

• Train the mother to make sure that hygienic conditions are observed,

• Given by small ladle or by cup in semi-reclined position.

• No feeding bottles, teats or teaspoons should be used.

Recipe to prepare 100 ml of ready-to-use goat’s milk:

• Mix 50 ml of goat’s milk with 50 ml clean water.

• Boil it.

• Add one level tablespoon of sugar and one teaspoon of oil.

• Allow to cool.


6. INPATIENT THERAPEUTIC FEEDING CENTRE: I-TFC 6.1 SYSTEMATIC MEDICAL AND NUTRITIONAL CARE 6.1.1 Admission Screening:

• All patients are quickly checked with the ETAT. • Severe cases are immediately sent to intensive care. • All other children receive a cup of sugar water. • Their weight, height, MUAC and oedema are measured. • If necessary, the children are admitted and registered. • They are oriented into phase 1 or intensive care. Anthropometric measurements:

• Weight (to nearest 100 g). • Height (to nearest 0.5 cm). • MUAC (in mm, left arm). Tests for bilateral oedema:

Check the bilateralism and the severity: +: Oedema of the feet / internal malleolus is present ++: Oedema of the feet and the shins is present +++: Oedema of the feet, the shins and of the face is present

Medical, feeding and family history:

• Family medical history (TB, HIV, other diseases and treatment). • Child’s medical history:

o Vaccination, Vitamin A supplement, (vaccination card?). o Recurrent illness, recent weight loss. o Traditional consultations and treatments. o Allopathic consultations and treatments.

• History of breast feeding. • Eating habits:

o Number of meals per day. o Content of meals.


• Family information: o Composition of the family (at home). o Immunization status of accompanying caretaker (+/ – other children). o Situation of the child among his siblings…

Complete medical examination looking for signs of severity (see ETAT)

• Respiratory examination (distress, frequency…) • Circulatory examination (pulse, CRT…) • Neurological examination with rapid test to detect systematic malaria (RDT) • Anthropometric measurements (MUAC, weight, height, W/H, oedema, target weight) • General examination:

o Temperature o Skin, hair and skin appendage o Eyes and ENT o Ganglions, liver, spleen o Mouth: look at gingivitis (see Noma in medical part) o Vaccinations o Appetite…

TO DO AFTER THE ORIENTATION OF THE CHILD o Give an explanation of the child’s clinical condition, and an outline of the medical and

nutritional treatments, to the accompanying caretaker. o Register the patient. o Fill in the I-TFC form (A3). o Prescribe the systematic and/or specific treatments. o Prescribe the child’s dietary regime depending on his weight and his age. o Give the child an identity bracelet showing his name and identification number, if this

is culturally acceptable. o Give non-food items (blanket, soap, bednet…). o Start feeding as soon as possible (F75) and propose sugared water.

6.1.2 Discharge The majority of children leave to go to the A-TFC (see ‘Movements from I-TFC � A-TFC). • Some children leave as cured from I-TFC because there is no A-TFC near their home, or

because they have suffered from medical complications. Their weight, height, W/H, MUAC and oedema must therefore be checked.

• A complete check of the child’s immunization status must be carried out, with referral to the nearest vaccination centre if necessary.

• A check must be carried out to determine the immunization status of the caretaker, with referral to the nearest vaccination centre if necessary. Ensure that the caretaker has received the child’s vaccination card.

• Organisation of follow-up care for the child if s/he is receiving anti-tuberculosis treatment. 6.1.3 Hospitalisation The admission room should allow space to carry out ETAT screening and take anthropological measurements. These anthropological measurements are essential in monitoring the child. The material must be carefully maintained and checked every day: the scales for babies and children must be calibrated, the basins in which the children are weighed (more reassuring for the children and more hygienic


than trousers) must be cleaned and disinfected, defective MUAC bracelets must be changed and measurement boards must be checked. Monitoring the weight curve of patients is essential to assess the effectiveness of treatment. For a case with stagnant weight or weight loss the medical team should look immediately for signs of infection in children as well as problems related to treatment adherence.

Intensive care Phase 1 and transition Phase 2

Weight

Specific

monitoring

on

medical

prescription

Every day Every 2 days MUAC Once a week Once a week Height At admission Once a month Oedema Every day Every 2 days

Temperature Every morning and evening, or more often

Every morning and evening, or more often

Heart rate, respiration rate


Every morning, or more often

CRT (capillary refill time)


Every morning, or more often

Medical consultation Every day Every 2 days Observation of meals At each meal time At each meal time Take note of any diarrhoea, vomiting

Each time it happens Each time it happens

CAUTION

Regular monitoring of vital signs can provide early warning of deterioration of the child and thus promote an appropriate reaction.

Hypothermia is a major risk among malnourished children. Once the child has been seen by a doctor to eliminate medical complications, the child and his caretaker will be accommodated in a warm room to warm up the child in addition to kangaroo method. Warm room welcoming mother and child is set up in intensive care, phase 1 and young infants ward to complement kangaroo mother care. For children in intensive care, nappies should be given to the caretaker as well as explanations about how to monitor and record the emission of urine and stools.


6.2 SYSTEMATIC MEDICAL TREAT MENT Prevention of Pathology

Treatment Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Infections Amoxicillin + + + + + + + + + +

Vit A deficiencies

Screen for Xerophtalmia

+

Treat if signs of xerophtalmia, measles or noma (haemorrhagic or necrotic acute gingivitis)

See treatment in the corresponding chapter in the medical part

If no sign but no digestive feeding possible rapidly

+

Digestive parasites

Albendazole +

Malaria Systematic RDT in endemic area

+

Treat if RDT positive

See treatment in the medical part

TB diagnosis TB decision tools + Repeat every 2 weeks Treat if positive See treatment in the medical part

HIV diagnosis

HIV counselling + testing if agreed

In the 5 days of admission (counselling for mother, other children and father if positive)

Treat if positive See treatment in the medical part Diseases preventable by vaccination

Vaccination See vaccination table

Amoxicillin tablet, 250 mg (80 mg / kg / day) twice a day for 5 days

Weight Dose for 5 days < 4kg ½ tablet twice a day 4 - 7.9 kg 1 tablet twice a day 8 - 11.9 kg 1 ½ tablet twice a day ≥ 12 kg 2 tablet twice a day

NB: This antibiotherapy has to be adapted to the child pathologies (see medical part). Vit A (Retinol) 200 000 UI Capsule - single dose – If no digestive feeding possible. Do not treat if the child has already received Vitamin A in the previous 4 months.

Weight Day 1 – single dose < 6 kg 2 drops (50 000 IU) 6 - 8 kg 4 drops (100 000 IU) ≥ 8 kg 1 capsule (200 000 IU)

Albendazole tablet, 400 mg single dose o Do not treat children < 6 months o If the child is still in intensive care on day 8, give Albendazole when s/he leaves intensive care.

Weight Day 8


< 8 kg ½ tablet, single dose ≥ 8 kg 1 tablet, single dose

Malaria If positive RDT: ASAQ = ARTESUNATE 4 MG/KG/DAY + AMODIAQUINE 10 mg B ASE/KG/DAY for 3 days o Infant HIV positive under ART � Coartem o AS-AQ is contraindicated in South East Asia because of resistance � Coartem o Infants > 2 months AND < 5 kg in ambulatory � Coartem Weight Tablets AS-AQ D1 D2 D3 ≥ 2 months And < 5kg ADMISSION

25 mg Artesunate / 67.5 mg Amodiaquine * See below how to give the

requested amount


1 tab 1 tab 1 tab

9 – 17.9 kg 50 mg Artesunate / 135 mg Amodiaquine

1 tab 1 tab 1 tab


1 tab 1 tab 1 tab

25 – 35.9 kg 1 tab 1 tab 1 tab

> 36 kg 2 tab 2 tab 2 tab

* Blister AS-AQ (AS 25 mg / AQ base 67.5 mg) for children from 2 to 11 months, 1 to 5 kg : This pharmacological presentation is poorly adapted for children less than 5 kg, especially in ambulatory since you should open the blister and make a dilution. Nevertheless this treatment Artesunate-Amodiaquine might be given orally in hospitalization following the table below, for 3 days maximum.


1.25 kg 1.0 ml

1.5 kg 1.2 ml

1.75 kg 1.4 ml

2 kg 1.6 ml

2.25 kg 1.8 ml

2.5 kg 2.0 ml

2.75 kg 2.2 ml

3 kg 2.4 ml

3.25 kg 2.6 ml

3.5 kg 2.8 ml

3.75 kg 3.0 ml

4 kg 3.2 ml

4.25 kg 3.4 ml

4.5 kg 3.6 ml


4.75 kg 3.8 ml


Weight Blisters Tablets D1 D2 D3

≥ 2 months And < 5kg ADMISSION


1 / 2 tab x 2 1 / 2 tab x 2

1 / 2 tab x 2

5 – 9,9 kg 20 mg Artéméther / 120 mg Luméfantrine

1 tab x 2 1 tab x 2 1 tab x 2

10 – 14,9 kg 1 tab x 2 1 tab x 2 1 tab x 2

15 – 24,9 kg 2 tab x 2 2 tab x 2 2 tab x 2

25 – 34,9 kg 3 tab x 2 3 tab x 2 3 tab x 2

> 36 kg 4 tab x 2 4 tab x 2 4 tab x 2








COTRIMOXAZOLE (CTX)




tab.











2 tabs ½ tab



4 tabs 1 tab

> 14 years (or > 30 kg)

N/A N/A 2 tab





Vaccination table for children from 6 to 59 months in I-TFC Antigens Age at 1st

dose Number of doses

Minimum interval between 2 doses

Considerations

Measles Except for HIV positive or CD4 < 25%

If intensive care: do the vaccination after

6 months for malnourished children

2 (or 3 doses)

4 weeks For malnourished children, Measles-Containing Vaccine (MCV) should be given at 6-8months but is not considered as the 1st dose (it has to be repeated at 9months with minimum 4 weeks interval). 1st dose (MCV1) : ≥ 9 months 2nd dose (MCV2) : > 15months

Maximum age : 5 years (until 15years if possible)



Maximum age : 5 years





4 weeks

8 weeks


Polio (OPV) 6 weeks 3 doses 4 weeks


In ITFC : give only at discharge (not during hospitalization to avoid contamination of other children who may be HIV+)

* The catch up of Pentavalent for children more than one year old is usually not part of national EPI but strongly recommended by MSF (up to three, and ideally up to the age of five) and can be negotiated on each individual programme.

All children must be vaccinated on admission and at discharge before being referred to the national EPI unless a vaccination card can be presented to prove that the vaccination schema has been completed. 6.3 NUTRITIONAL TREATMENT 6.3.1 Case management

Phase 1* Stabilisation

Usually up to 7 days but might be longer depending of the severity at admission

o Direct admission for anorexia, serious illness, severe anaemia, kwashiorkor ++ and +++.

o Child in phase 2 or A-TFC , who develops a serious pathology or oedema, goes back to phase 1. Objectives: � Restore basic metabolism. � To manage vital distresses. � To diagnose, stabilize and start the treatment of severe medical complications.

F-75 milk - 6months to 10years: 100 kcal / kg / day (130 ml / kg / day) - 10 to 18 years: 55 Kcal / kg / d (75 ml / kg / d) - Adults and elderly: 40 kcal / kg / d (55 ml / kg / d)

8 meals per day

Phase T Transition If necessary, usually 1 to 3 days

All children pass through the transition phase for at least 2 or 3 meals. Some children need this phase for up to 3 days, it is usually the case of: o Kwashiorkor +++ on admission, who have not completely lost oedema after phase 1, o Children who suffer from diarrhoea in phase 2, o Children in intensive care with a serious pathology, who need a long period of care and on

RUTF (or F-100) - 6months to 10years: 130 kcal / kg / day (130 ml / kg / day) - 10 to 18 years: 75 Kcal / kg / d (75 ml / kg / d)


medical advice Objectives: � To confirm appetite. � To confirm improvement of clinical status. � To prepare to ATFC.

-Adults and elderly: 55 kcal / kg / d (55 ml / kg / d)

6 meals per day

Phase 2 Re-nutrition

Majority of children will do the whole phase 2 in ATFC. Only few of children will need to start phase 2 in ITFC (or even to stay in ITFC until being cured) o Children who still require treatment by injections, o Children who are not suited to ambulatory treatment (distance, social problems, security), o Children who do not respond to ambulatory care, for whom medical evaluation or observation of dietary intake is necessary (no need to restart from phase 1 for them). Objectives: � Weight gain � Meet the demands of growing bodies

RUTF (or F-100 for special cases) 6-59months: 200 kcal / kg / day RUTF: <6 kg: 2 sachets / day 6-10 kg: 2 sachets/day >10 kg: 4 sachets /day 6 meals per day

* When the children are put into intensive care, their nutritional care is identical to that in Phase 1. This may move towards the transition phase if the child spends more than 7 days in intensive care, only on prescription for the doctor. 6.3.2 Products used, and their preparation F-75 milk:

• Phase 1, intensive care; first phase of nutritional treatment for children with severe or moderate malnutrition and serious medical complications. These children need a dietary regime whose primary objective is not weight gain, but to restore basic metabolism.

• F75 can also be used for children less than 6months.

• Packaging: 102.5 g sachet: Dilute in 500 ml of boiled chlorinated water (lukewarm) to make 600 ml of F-75.

• Do not keep for more than 2/3 hours.

• Administer by NGT, “small ladle” or directly into a cup.

• Never use a teaspoon because it can cause food aspiration. F-100 milk:

• Stabilisation and re-nutrition for young infants in condition that it is diluted differently (see protocol for Specially Diluted Therapeutic Milk - SDTM).

• For special cases: transition phase and phase 2; treatment phase for severe malnutrition - whose primary objective is weight gain.

• 2 packaging: o 456 g sachet – dilute in 2 litres of boiled chlorinated water (lukewarm) to make 2.4

litres of F-100.


o 114 g sachet - dilute in 500 ml of boiled chlorinated water (lukewarm) to make 600 ml of F-100.

• Do not keep for more than 2/3 hours.

• Never use a teaspoon because it can cause food aspiration (food into lungs).

TO DO

Therapeutic milk preparation:

• It is possible (according to the number of children in different services) to calculate and to prepare the number of sachets of different milk products and the quantity of water necessary.

• If the number of patients is small and the smaller sachets are not available, the F-75, F-100 and the oral rehydration salt can be prepared in small quantities with the help of the red “dosette”. (Annexe 1)

• An open milk sachet should always be kept in its original packaging. The milk can be kept for 48 hours after opening, provided that the sachet was sealed after expelling any air, and provided it was kept in hermetic box.

• The preparation of different milks can be done directly in buckets with lids with corresponding colours of the relevant milk sachets (blue for F-100 milk, orange or red for F-75 milk, and green the specially diluted therapeutic milk (SDTM) for young infants, which is prepared from F-100 milk).

Ready to Use Therapeutic Food (RUTF) for example Plumpy’Nut ® (PPN) or Eezeepaste® (EZP) or Imunut:

• RUTF used in Phase 2 and in A-TFC.

• Provide the nutrients necessary for weight gain, adapted for severely malnourished children.

• Packaged in individual sachets of 92 g (500 kcal), with the same micronutrients that are found in F-100 milk, plus iron.

• Do not give to children in phase 1 as it contains iron.

• Do not give to children less than 6 months old as they cannot swallow it.

• Adapted for children, less appreciated by adults who prefer BP100.

BP-100®:

• RUTF used when PPN or EZP are refused in Phase 2 and in A-TFC.

• Provides the nutrients necessary for weight gain, adapted for severely malnourished children.

• Hard biscuits, difficult to eat for children but less sickly than PPN/EZP for adults.

• 2 biscuits = 1 bar = 300 kcal, with the same micronutrients as F-100 milk, plus iron.

• Do not give to children in phase 1 as it contains iron.

• Do not give to children less than 6 months old as they cannot swallow it.


10% sugar water:

• Solution for hydration and prevention of dehydration in all circumstances and all aspects of nutritional care: waiting room, screening space, all phases of I-TFC especially when the weather is hot, diarrhoea without dehydration…

• Prepared daily in the kitchen from boiled chlorinated and cooled down water, add 10% sugar: 5 g (1 level soup spoon) of sugar to 50 ml or 100 g of sugar / 1 litre or 1kg of sugar / 10 litres.

• Do not keep for more than 24 hours.

• Clean the buckets or jerrycans every day. ReSoMal®:

• Rehydration solution specially adapted for severe malnutrition.

• To be used when dehydration has been proven.

• Do not use to prevent dehydration, give 10% sugar water instead.

• Boiled chlorinated (lukewarm) water.

Electrolytes SRO low omolarity RéSoMal Na+ 75 45 K+ 20 40 Chlorure 65 70 Glucose, Anhydre 75 125

Citrate 10 7 Zinc Ø 0,3 Mg Ø 3 Cuivre Ø 0.045 Osmolarity 245 300

TIP

o Never force a child to eat, use his appetite as a guide. o Maintain and encourage breastfeeding. The child should be breastfed 30 minutes before each

meal of therapeutic milk. o If the child wants more, consider whether it may be due to thirst and give him sugar water,

and if necessary give a small quantity of supplementary milk and monitor his food intake. o RUTF is to be taken with a glass of water (this food is thick and doughy so it will make the

child thirsty). 6.3.3 Phase 1 (intensive care or phase 1) usually of 7 days All patients admitted to I-TFC for severe pathologies or anorexia must be admitted to phase 1:

100 kcal / kg / day which means 130 ml / kg / day In 8 meals of F-75 milk / 24 hours (i.e. every 3 hours)

Only children with a stagnant weight curve in A-TFC can be directly admitted to phase 2, if no severe pathology has been identified.


Example meal times: 3 am, 6 am, 9 am, 12 midday, 3 pm, 6 pm, 9 pm, 12 midnight

Weight in kg F-75 in ml x 8 meals Weight in kg F-75 in ml x 8 meals 3 50 9 150 3.5 60 9.5 160 4 65 10 165 4.5 75 10.5 175 5 80 11 180 5.5 90 11.5 190 6 100 12 200 6.5 110 12.5 210 7 115 13 215 7.5 125 13.5 225 8 130 14 230 8.5 140 14.5 240

The use of a nasogastric tube is only recommended if the child:

• Doesn’t finish ¾ of his quantity of milk. • Vomits repeatedly. • Cannot drink, eat or swallow. • Have painful lesions in his mouth preventing him from eating. • Is too weak, or unconscious. • Is severely dehydrated. • Has a severe respiratory infection. Management:

• Take time to explain to the mother why the NGT is necessary. • Installing and using the NGT is a nurse’s job. When the siting of the NGT has been checked, the

act of tube-feeding is the responsibility of the nutritional assistant (if he has been appropriately trained)

• Try to feed the child by mouth before every tube-feed unless RDS present, never force a child and use his appetite as a guide.

• When tube-feeding, the child should be half sitting up, using gravity: do not inject the milk with a syringe because this causes vomiting when the stomach fills too quickly.

• Change the tube every 72 hours changing the nostril to avoid scare (paid very attention to the fixation, avoid pressure) – picture below.


• Carry out an oral eating test every meal. The child can only pass to transition phase when:

• His appetite has returned (feeding tubes cannot be present in Phase T). • And there is no longer any diarrhoea or vomiting. • And the child is alert and lively. • And the oedema has started to reduce in the case of Kwashiorkors. • And all illnesses are under control (infections)?

6.3.4 Transition phase: from 2 meals to 3 days maximum

The objective of this phase is to ensure that the child can tolerate food with higher osmolarity and with a high energy and protein content. 130 kcal / kg / day (if F100: 130 ml / kg / day) In 6 meals of RUTF (or F-100 milk) / 24 hours (i.e. every 3 hours) Example meal times: 3 am, 6 am 9 am, 12 midday, 3 pm, 6 pm, 9 pm, 12 midnight

Weight (kg)

Transition Phase

Weight (kg)

Transition Phase

RUTF RUTF sachet / day sachet / day 6 meals / day 6 meals / day

3.0-3.4 1/day 10-10.9 3 / day 3.5-3.9 1 / day 11-11.9 3 / day 4,0-4.4 1 / day 12-12.9 3.5 / day 4.5-4.9 1.5 / day 13-13.9 3.5 / day 5.0-5.4 1.5 / day 14-14.9 4 / day 5.5-5.9 1.5 / day 15-15.9 4 / day 6.6.9 2 / day 16-16.9 4.5 / day 7-7.9 2 / day 17-17.9 4.5 / day 8-8.9 2.5 / day 18-18.9 5 / day

9-9.9 2.5 / day 19-19.9 5 / day *Quantity calculated for RUTF of 500 kcal/sachet ALWAYS GIVING WATER TO DRINK DURING RUTF MEAL

Options in case of refusal of RUTF type paste (ex : PlumpyNut) for transition phase:

Weight (kg) RUTF type bar (BP-100) (quantity per day)

F-100 (ml for 1 meal – 6 meals per day)

3.0-3.4 1.5 bars/ day 70 ml

3.5-3.9 1.5 bars/ day 85 ml

4,0-4.4 2 bars/ day 95 ml

4.5-4.9 2 bars/ day 100 ml

5.0-5.4 2.5 bars/ day 110ml


5.5-5.9 2.5 bars/ day 120 ml

6.6.9 3 bars/ day 150 ml

7-7.9 3.5 bars/ day 160 ml

8-8.9 3.5 bars/ day 180 ml

9-9.9 4 bars/ day 210 ml

10-10.9 4.5 bars/ day 230 ml

11-11.9 4.5 bars / day 260 ml

12-12.9 6 bars/ day 280 ml

13-13.9 6 bars/ day 300 ml

14-14.9 6 bars/ day 320 ml

15-15.9 7 bars/ day 340 ml

16-16.9 7 bars/ day 360 ml

17-17.9 7 bars/ day 380 ml

18-18.9 7 bars/ day 400 ml

19-19.9 7 bars/ day 420 ml

FOR MEMORY: ALWAYS GIVING WATER TO DRINK DURING RUTF MEAL The majority of children only have 2 or 3 meals in transition phase. If phase 1 has truly allowed the child’s metabolism to return to normal, the child will no longer have any diarrhoea or vomiting in phase T and will pass quickly to phase 2 / ATFC.

In case of extreme heat: propose water to all children between meals (if milk meals: in a different cup).

If the child completes phase T with F100, do appetite test to continue to phase 2/CNTA (see appetite test explanation in ATFC part).

ATTENTION

Some children in transition phase or phase 2 may need to go back to phase 1 if: • Anorexia • Severe medicale complication • Diarrhea due to re-nutrition • Signs of fluid overload such as increase of edema or appearance of edema.

To manage the complications the child needs to be back in phase 1. 6.3.5 Phase 2: special case The whole phase 2 should be done in ATFC (with RUTF). However some special cases may need to start phase 2 in ITFC (and sometimes even to stay in ITFC until being cured). The objective of the phase 2 is to gain weight. As soon as it is possible the child should be refer to ATFC to continue the phase 2 in ambulatory.

At least 200 kcal / kg / day in minimum 6 meals


Even in ITFC phase 2 should be done with RUTF when possible. But if needed it can also be done with F100 or with both (F100 and RUTF).

You can use RUTF in paste (as Plumpy Nut) or in bar as BP 100® (usually preferable for adolescent and adults).

Quantity of RUTF paste to be given: < 6 kg: 2 packs/d, 6-10 kg: 3 packs/d, 10 kg: 4 packs/d.

• In phase 2 you can increase the quantity if the child wants more.

• If the child is completely refusing all king of RUTF, then treat him with F100 until being cured (in ITFC only). But in this case: give iron supplement to the child (or fortify F100 with iron)

• If the child refuses any therapeutic food, the cause is not usually nutritional. The health educator should discuss it with the child’s mother in order to try to identify any possible psychological causes, and the doctor should look into possible medical reasons.

• In any case, do not give family meal of CSB porridge to the children in I-TFC. Regarding children coming from ATFC to ITFC to investigate too slow improvement:

• They can go directly to phase 2 if no severe medical complication.

• You can use RUTF only or RUTF+F100 (100 à 150 kcal / kg / day of F100 minimum to limit anorexia). In phase 2, do not hesitate to increase the quantities of milk if the child wants more.

Exemple of timetable and type of meals:

6h RUTF, 9h F100, 12h F100, 15h F100, 18h F100, 21h RUTF

Weight (kg)

F-100 x 4 meals + ATPE* x 2 meals = 6 meals / day

Weight (kg)

F-100 x 4 meals + ATPE* x 2 meals = 6 meals / day

3 100 ¼ RUTF 10 300 1 RUTF 4 150 ¼ RUTF 11 350 1 RUTF 5 150 ½ RUTF 12 350 1 RUTF 6 200 ½ RUTF 13 400 1 RUTF 7 250 ½ RUTF 14 450 1 RUTF 8 300 ½ RUTF 15 500 1 RUTF 9 300 1 RUTF *The quantities are calculated based on RUTF having 500kcal/sachet

FOR MEMORY: ALWAYS GIVING WATER TO DRINK DURING RUTF MEAL

ATTENTION

Some children in transition phase or phase 2 may need to go back to phase 1 if: • Anorexia • Severe medicale complication • Diarrhea due to re-nutrition • Signs of fluid overload such as increase of oedema or appearance of oedema.

To manage the complications the child needs to be back in phase 1.


6.4 Meals for the caregivers � As a general rule, only one person should remain with the I-TFC beneficiary. � In general, caregivers require a minimum of 2100 kcal per day (2-3 meals per day) � Usually these meals are a combination of cereal, pulse and condiment or sauce. � Many caregivers are lactating mothers, so attempt to provide a daily ration of 2500-2700 kcal/day. � One option is to give them complementary food as RUSF or BP5 for exemple to supplement the ration and account for increasing nutrient needs due to lactation. � Assure that the daily ration is providing a correct and balanced amount of micronutrients in addition to energy, fat and protein. � The easiest way to assure adequate micronutrient intake is to fortify the ration. For example, with TopNutri®, QB-Mix® or Micronutrient Powder (MNP) as MixMe® � If Super cereal (CSB +) or Super cereal + (CSB ++) is used, it is not necessary to add micronutrients � We can also add vegetables to the ration Examples of rations: Total kcal: 2,170 Kcal � Morning:

� Lunch and Dinner (two rations)


7. AMBULATORY - THERAPEUTIC FEEDING CENTRE: A-TFC Reminder: example of patient and activity flow in an ATFC:

7.1 SYSTEMATIC MEDICAL AND NUTRITIONAL CARE 7.1.1. Admission Screening:

When many children arrive for admission to the A-TFC: • A screening system quickly assesses the health condition of all the children,

o Those considered to be severe cases (serious illness, young infants..) are immediately referred for medical examination (see ETAT) then placed in an observation room and if necessary referred to the I-TFC.

o MUAC (mid-upper arm circumference) checks are made on other children measuring more than 65 cm: � If MUAC < 135 cm (red, yellow and orange)� W/H and admission to A-TFC if

necessary. � If MUAC > 135 mm (green) � check immunization and send home.

• All children and their caretakers receive a cup of 5% sugared water. • All sick children are treated by MSF, or referred to the health centre if operational. Anthropometric measurements:

• Weight (accurate to 100 g) • Height (accurate to 0.5 cm) • MUAC (left arm)

TO DO

• During the distribution process, regularly monitor the place where children are waiting in order quickly to identify sick or weak children who need medical assistance.

• The system must be efficient so as to avoid children having to wait more than 2 hours at each visit.


Tests for bilateral oedema:










o Temperature o Skin, hair and skin appendage o Eyes and ENT o Ganglions, liver, spleen o Mouth: look at gingivitis (see Noma in medical part) o Vaccinations o Appetite

TO DO AFTER THE ORIENTATION OF THE CHILD


• Give an explanation of the child’s clinical condition, and an outline of the medical and

nutritional treatments, to the accompanying caretaker. • Register the patient. • Fill in the TFC form (A3). • Prescribe the systematic and/or specific treatments. • Prescribe the child’s dietary regime depending on his weight and his age. • Give the child an identity bracelet showing his name and identification number, if this is

culturally acceptable. Appetite test

The result of the appetite test makes it possible to direct the child, after the medical examination, either to an outpatient treatment centre, or to a hospital admission. For treatment at home, the child must be capable of absorbing a sufficient quantity of RUTF. • The appetite test must be carried out in a quiet place.

• Explain to the caretaker the aim of the test and how it will be carried out.

• The caretaker and the child must first of all wash their hands.

• The caretaker must be comfortably seated with the child on her knee.

• The caretaker gives a small quantity of RUTF either directly from the sachet, or using her finger. This must be done gently, while encouraging the child.

• If the child refuses the RUTF, the caretaker should continue gently to encourage the child, taking her time to do so. The test normally takes only a short time, but it can last up to one hour maximum. The child must not be forced to take the RUTF.

• Water must be offered to the child in a cup throughout the entire test.

• The result of the appetite test is noted on the reference sheet (good appetite, anorexic, vomiting, poor appetite).

Weight of child Minimum quantity that the malnouris hed child must absorb in order to pass the appetite test

Less than 4 kg 1/8 of the sachet 4 - 6.9 kg ¼ of the sachet 7 - 9.9 kg 1/3 of the sachet 10 – 14.9 kg ½ of the sachet 15 – 29 kg ¾ of the sachet Over 30 kg At least 1 sachet


7.1.2 Weekly monitoring at the A-TFC

• Systematically - temperature, respiratory rate, heart rate and CRT. • Weight and weight curve analysis. • Height and MUAC every 2 weeks. • Appetite and food intake. A poor appetite or loss of appetite can be symptoms of an under-lying

disease requiring an in-depth assessment. • Distribute the RUTF in the waiting room (15 - 30 minutes before the examination) to test the

appetite and to provide systematic verification of potential anorexia. • Medical examination and a check for oedema in all children. • Observation room to verify bloody diarrhoea, dehydration, monitoring before decision to

transfer to the I-TFC, • Provide the caretaker with an explanation of the assessment of the child and of the continued

treatment.

REMEMBER systematically give sugared water (10%)

7.1.3 DISCHARGE • Weight, height, calculate z-scores, MUAC, oedema. • Check vaccination status of child. • Check vaccination status of caretaker, and refer to the nearest vaccination centre if necessary. • Organise monitoring of the child if s/he is undergoing anti-tuberculosis treatment. 7.2 SYSTEMATIC MEDICAL TREATMENT Pathologies Treatment Day

1 Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Infections Amoxicillin + + + + + + + + + +

Vitamin A deficiency

Screen for Xerophtalmia

+

Treat if signs of xerophtalmia, measles, or noma (haemorrhagic or necrotic acute gingivitis)

See treatment in the medical part

Digestive parasites

Albendazole +

Malaria Systematic RDT + Treat if positive See treatment in the medical part

TB diagnosis TB decision tools

+ Repeat every month

Treat if positive See treatment in the medical part Diseases preventable by vaccination

Vaccination See vaccinations table below


Amoxicillin tablet, 250 mg (80 mg / kg / day) twice a day for 5 days

Weight On admission for 5 days < 4 kg ½ tablet twice a day 4 - 7.9 kg 1 tablet twice a day 8 - 11.9 kg 1 ½ tablets twice a day ≥ 12 kg 2 tablets twice a day

Folic acid tab, 5 mg, one single dose

Weight Day 1 one single dose All children 1 tablet

Vit A (Retinol) 200 000 UI Gel in one single dose Ne pas traiter si l’enfant a déjà reçu de la vitamine A dans les 4 mois précédents. Weight Day 1 one single dose < 6 kg 2 drops (50 000 IU) 6 - 8 kg 4 drops (100 000 IU) ≥ 8 kg 1 caps (200 000 IU)

Albendazole tablet, 400 mg in a single dose, Do not treat children < 6 months old

Weight Day 8: < 8 kg ½ tablet, single dose ≥ 8 kg 1 tablet, single dose

Malaria If positive RDT: ASAQ = ARTESUNATE 4 MG/KG/DAY + AMODIAQUINE 10 mg B ASE/KG/DAY for 3 days o Infant HIV positive under ART � Coartem o AS-AQ is contraindicated in South East Asia because of resistance � Coartem o Infants > 2 months AND < 5 kg in ambulatory � Coartem Weight Tablets AS-AQ D1 D2 D3 ≥ 2 months And < 5 kg AMBULATORY

in this group, COARTEM always replaces AS-AQ


1/ 2 tab x 2

1/ 2 tab x 2

1/ 2 tab x 2


1 tab 1 tab 1 tab


1 tab 1 tab 1 tab


1 tab 1 tab 1 tab

25 – 35.9 kg 1 tab 1 tab 1 tab

> 36 kg 2 tab 2 tab 2 tab

* Blister AS-AQ (AS 25 mg / AQ base 67.5 mg) for children from 2 to 11 months, 1 to 5 kg : This pharmacological presentation is poorly adapted for children less than 5 kg, especially in ambulatory since you should open the blister and make a dilution. Nevertheless this treatment


Artesunate-Amodiaquine might be given orally in hospitalization following the table below, for 3 days maximum.


1.25 kg 1.0 ml

1.5 kg 1.2 ml

1.75 kg 1.4 ml

2 kg 1.6 ml

2.25 kg 1.8 ml

2.5 kg 2.0 ml

2.75 kg 2.2 ml

3 kg 2.4 ml

3.25 kg 2.6 ml

3.5 kg 2.8 ml

3.75 kg 3.0 ml

4 kg 3.2 ml

4.25 kg 3.4 ml

4.5 kg 3.6 ml

4.75 kg 3.8 ml


Weight Blisters Tablets D1 D2 D3

≥ 2 months And < 5kg ADMISSION


1 / 2 tab x 2 1 / 2 tab x 2

1 / 2 tab x 2

5 – 9,9 kg 1 tab x 2 1 tab x 2 1 tab x 2

10 – 14,9 kg 1 tab x 2 1 tab x 2 1 tab x 2

15 – 24,9 kg 2 tab x 2 2 tab x 2 2 tab x 2

25 – 34,9 kg 3 tab x 2 3 tab x 2 3 tab x 2

> 36 kg 4 tab x 2 4 tab x 2 4 tab x 2









COTRIMOXAZOLE (CTX)




tab.










2 tabs ½ tab



4 tabs 1 tab

> 14 years (or > 30 kg)

N/A N/A 2 tab






Vaccination table for children from 6 to 59 months in A-TFC

Antigens Age at 1st dose

Number of doses


Considerations



2 (or 3 doses)

4 weeks For malnourished children, Measles-Containing Vaccine (MCV) should be given at 6-8months but is not considered as the 1st dose (it has to be repeated at 9months with minimum 4 weeks interval). 1st dose (MCV1) : ≥ 9 months 2nd dose (MCV2) : > 15months

Maximum age : 5 years (until 15 years if possible)







4 weeks

8 weeks


Polio (OPV) Except for HIV positive or CD4 < 25%



* The catch up of Pentavalent for children more than one year old is usually not part of national EPI but strongly recommended by MSF (up to three, and ideally up to the age of five) and can be negociated on each individual programme.

All children must be vaccinated on admission and at discharge before being referred to the national EPI unless a vaccination card can be presented to prove that the vaccination schema has been completed.

Mothers can also be referred to the EPI to complete their vaccination against tetanus if they received less than 5 doses (TT2 after 4 weeks, TT3 after 6 months, TT4 & TT5 each after 1 year).


7.3 NUTRITIONAL TREATMENT • At each visit the child receives a ration of RUTF.

• The RUTF currently used is Plumpy’Nut® (PPN) or Eezeepaste® (EZP). BP 100® may also be used if the child refuses PPN/EZP (2 biscuits = 1 bar = 300 kcal).

Weekly treatment ration Child weighing less than 8 kg

Child weighing 8 kg or more

2 RUTF* per day

So a total of:

14 RUTF per week

3 RUTF per day

So a total of: 21 RUTF per week

*The quantities are calculated based on RUTF having 500kcal/sachet The RUTF used to test the child’s appetite is subtracted from the quantity given for the week, meaning that the child will only take home 13 or 20 RUTF.

TO DO

• Explain to the accompanying caretaker that the child must, as a priority, eat his/her ration of RUTF.

• If the child is still hungry after his/her ration of RUTF, the adult can offer some of the family meal.

• Provide a week’s supply of RUTF when the child leaves the programme (final visit) to allow a gentle withdrawal of the RUTF and transition to the family diet.

• Protection rations - a weekly ration given at each visit to supplement the family’s diet, protect

their other children from malnutrition and ensure that the RUTF is given to the malnourished child.

• And/or discharge rations - a ration given when the child is cured to encourage completion of the treatment and support the food security of families in order to avoid relapses.

Protection rations and discharge rations may be given in certain situations. They are not systematic. The decision is made by the head quarter.

TIP

After each distribution, identify absent children or those who have abandoned the programme and organize a home visit to find them.


8. TARGETED SUPPLEMENTARY FEEDING CENTRE: T-SFC

New less medical mass approaches to treat moderate malnutrition are often preferred in OCG comparing with SFC traditional approach.

8.1 SYSTEMATIC MEDICAL AND NUTRITIONAL CARE 8.1.1 Admission Screening:

When many children arrive for admission to the TSFC: • A screening system quickly assesses the health condition of all the children,

o Those considered to be severe cases (serious illness, young infants..) are immediately referred for medical examination (see ETAT) then placed in an observation room and if necessary referred to the I-TFC.

o MUAC (mid-upper arm circumference) checks are made on other children measuring more than 65 cm: � If MUAC < 135 cm (red, yellow and orange)� W/H and admission to TSFC if

necessary. � If MUAC > 135 mm (green) � check immunization and send home.

• All children and their caretakers receive a cup of 5% sugared water. • All sick children are treated by MSF, or referred to the health centre if operational. Anthropometric measurements: see annexe

• Weight (accurate to 100 g) • Height (accurate to 0.5 cm) • MUAC (left arm)

TO DO

• During the distribution process, regularly monitor the place where children are waiting in order quickly to identify sick or weak children who need medical assistance.

• The system must be efficient so as to avoid children having to wait more than 2 hours at each visit.

Tests for bilateral oedema:











o Temperature o Skin, hair and skin appendage o Eyes and ENT o Ganglions, liver, spleen o Mouth: look at gingivitis (see Noma in medical part) o Vaccinations o Appetite

TO DO AFTER THE ORIENTATION OF THE CHILD • Give an explanation of the child’s clinical condition, and an outline of the medical and

nutritional treatments, to the accompanying caretaker. • Register the patient. • Fill in the TFC form (A3). • Prescribe the systematic and/or specific treatments. • Prescribe the child’s dietary regime depending on his weight and his age.


• Give the child an identity bracelet showing his name and identification number, if this is culturally acceptable.

Appetite test

The result of the appetite test makes it possible to direct the child, after the medical examination, either to an outpatient treatment centre, or to a hospital admission. For treatment at home, the child must be capable of absorbing a sufficient quantity of RUTF. • The appetite test must be carried out in a quiet place.

• Explain to the caretaker the aim of the test and how it will be carried out.

• The caretaker and the child must first of all wash their hands.

• The caretaker must be comfortably seated with the child on her knee.

• The caretaker gives a small quantity of RUTF either directly from the sachet, or using her finger. This must be done gently, while encouraging the child.

• If the child refuses the RUTF, the caretaker should continue gently to encourage the child, taking her time to do so. The test normally takes only a short time, but it can last up to one hour maximum. The child must not be forced to take the RUTF.

• Water must be offered to the child in a cup throughout the entire test.

• The result of the appetite test is noted on the reference sheet (good appetite, anorexic, vomiting, poor appetite).

Weight of child Minimum quantity that the malnouris hed child must absorb in order to pass the appetite test

Less than 4 kg 1/8 of the sachet 4 - 6.9 kg ¼ of the sachet 7 - 9.9 kg 1/3 of the sachet 10 – 14.9 kg ½ of the sachet 15 – 29 kg ¾ of the sachet Over 30 kg At least 1 sachet


8.1.2 Monitoring every two weeks at the TSFC • Temperature, respiratory rate, heart rate and systemic CRT. • Weight, MUAC and oedema at each visit, and analysis of weight curve. • Height once a month. • State of appetite and willingness to eat meals. A poor appetite or loss of appetite may indicate an

underlying illness and necessitate a thorough assessment. • Distribution of RUSF in the waiting room (15-30 minutes before the consultation) to test for

appetite. • Medical consultations for all children on admission, when being discharged, and if necessary

during their stay. • Refer cases of bloody diarrhoea, or dehydration, to the observation room to be checked. Keep

the patient under observation before deciding whether to refer to I-TFC. • Give the caretaker an explanation about the assessment of the child and the continuation of

treatment.

REMINDER: Give sugar water (10%) systematically. 8.1.3 DISCHARGE • Weight, height, calculation of z-scores, MUAC, oedema. • Check that all the child’s vaccinations are up to date. • Check that the mother’s vaccinations are up to date, and refer her to the nearest vaccination

centre if necessary. • Organize monitoring of the child if s/he is being given anti-tuberculosis treatment. 8.2 SYSTEMIC MEDICAL TREATMENT � Children

Pathologies Treatment D1 D2 D3 D4 D5 D6 D7 D8

Vitamin A deficiency Screen for xerophtalmia

+

Treat if sign See medical part Digestive parasites

Albendazole +

Diseases preventable by vaccination

Vaccination See vaccinations table

Antibiotic treatment and RDT should not be used routinely, but only in response to clinical symptoms. Albendazole tablet, 400 mg as a single dose Do not treat children in less than 6 months

Weight Day 1 < 8 kg ½ tablet, single dose ≥ 8 kg 1 tablet, single dose

In areas where malaria is endemic, a mosquito net must be given to all children on their first visit.









COTRIMOXAZOLE (CTX)




tab.










2 tabs ½ tab



4 tabs 1 tab

> 14 years (or > 30 kg)

N/A N/A 2 tab






Vaccination table for children from 6 to 59 months in TSFC Antigens Age at 1st

dose Number of doses


Considerations



2 (or 3 doses) 4 weeks For malnourished children, Measles-Containing Vaccine (MCV) should be given at 6-8months but is not considered as the 1st dose (it has to be repeat at 9months with minimum 4 weeks interval). 1st dose (MCV1) : ≥ 9 months 2nd dose (MCV2) : > 15months

Maximum age : 5 years (until 15years if possible)







4 weeks

8 weeks


Polio (OPV) Except for HIV positive or CD4 < 25%



* The catch up of Pentavalent for children more than one year old is not part of national EPI but strongly recommended by MSF (up to three, and ideally up to the age of five) and can be negotiated on each individual programme.


All children must be vaccinated on admission and at discharge before being referred to the national EPI unless a vaccination card can be presented to prove that the vaccination schema has been completed.

Mothers can also be referred to the EPI to complete their vaccination against tetanus if they received less than 5 doses (TT2 after 4 weeks, TT3 after 6 months, TT4 & TT5 each after 1 year). � Femmes enceintes ou allaitantes

Systematic medical treatment for breastfeeding or pregnant women Albendazole At admission but NOT in the 1st trimester neither after 2

months after delivery MultiMicroNutrients (MMN) 1 tab / day Calcium 1 tab / day for adolescents Vaccination See table below

• Iron and folic acid supplementation (Ferfol)

When the MMNs are not available, Ferfol treatment should be given even if other micronutrients are not covered. The Ferfol dosage in anaemia prevention is 60mg iron (3mg of elemental iron/kg) + folic acid PO once daily.

• Anaemia management

If case of anaemia (haemoglobin < 110) due to iron deficiency: PLW receive the therapeutic dose of iron. The treatment is 1 MMNs and 1 or 2 Ferfol/day;

If MMNs are not available, give 2 Ferfol/day.

• Vitamin A

o Vitamin A is present in MMNs and in the food supplements. No supplementation is required. PLW should not receive vitamin A to avoid the potential teratogenic effects.

o At delivery and during the following two months 200 000 IU as single dose (1 capsule) should be given.

• Vitamin D for PLW could be considered in areas with high prevalence of vitamin D deficiency.

• Anthelminthic

Albendazole should not be given to pregnant women in the 1st trimester in case of teratogenicity. A one-time dose can be administered any time after the first trimester up until two months after delivery.

Vaccination for pregnant and lactating women

Tetanus toxoid dose When TT1 As soon as possible during pregnancy TT2 Minimum 4 weeks after TT1 TT3 Minimum 6 mois weeks after TT2 (or during next pregnancy) TT4 Minimum 1 year after TT3 (or during next pregnancy) TT5 Minimum 1 year after TT4 (or during next pregnancy)


8.3 NUTRITIONAL TREATMENT

� Children

At each visit the child receives a ration of RUSF (as Plumpy’sup ®, Eezee RUSF…) or of SuperCereal+. Treatment ration for children RUSF 2 RUSF / day (28 RUSF / 2 weeks) SuperCereal+ 200g / day (3 Kg / 2 weeks) *The quantities are calculated based on RUSF having 500kcal/sachet The RUSF used to test the child’s appetite is subtracted from the quantity given for the week, meaning that the child will only take home 27 for 2 weekser week.

� Pregnant and lactating women

At each visit the child receives a ration of RUSF (as Plumpy’sup ®, Eezee RUSF,…) or of SuperCereal with oil (if possible prepared as premix), or BP100. Product Quantity per day Energy RUSF 2 packs/day

(28 packs / 2 weeks) 500 kcal/pack � 1000 kcal/day

SuperCereal + oil SuperCereals: 200g/day Oil: 25ml

SuperCereals (200g) + oil (25ml) � 1000 kcal

RUTF biscuit (BP 100)

3 bars of BP100 (21 bars / week)

300 kcal/bar � 900 kcal/day

TO DO

Provide a week’s supply of RUSF when the child leaves the programme (final visit) if the food security is insecure.

• Protection rations - a weekly ration given at each visit to supplement the family’s diet, protect their other children from malnutrition and ensure that the RUSF is given to the malnourished child.

• And/or discharge rations - a ration given when the child is cured to encourage completion of the treatment and support the food security of families in order to avoid relapses.

Protection rations and discharge rations may be given in certain situations. They are not systematic. The decision is made by the cell.

TIP

After each distribution, identify absent children or those who have abandoned the programme and organize a home visit to find them.


9. MONITORING / SURVEILLANCE / EVALUATION Introduction

The aim of a surveillance system in a feeding programme is to assess how well the programme is functioning internally (quality, effectiveness, accessibility, coverage and acceptability) and to monitor the evaluation of the nutritional situation.

The surveillance system forms part of the project cycle (evaluation, analysis, action) and it must be monitored for the entire duration of the programme. It is an essential tool for evaluating the programme’s progress and enabling us to adapt it in unstable situations. Objectives

• To follow trends in the nutritional situation. • To evaluate the functioning and efficacy of the programme and allow prompt adaptation. • To provide data for advocacy, lobbying. Two approaches are used:

• Data collection from feeding centres with Nutridata, the OCG database. To obtain the most recent version, which is adapted to fit the patients’ A3 form, contact: [email protected]

• Observation and supervision of the way feeding centres are functioning (see format in appendix). Data collection from all feeding centres allows us to make a complete analysis and draw conclusions concerning the overall functioning of the feeding programme and changes in the nutritional situation.

The regular data collection enables us to make calculations with all the different indicators used, in order to analyze the programme’s performance. The indicators must be compared with reference values which have been developed for children of 6 to 59 months. For a correct interpretation, the indicators must be calculated separately for each age group.

Data entry can be time consuming in large program. A data entry manager should be employed and supervised by the medical responsible person. 9.1 REFERENCE VALUES OF MAIN INDICATORS • All indicators are calculated automatically using Nutridata and reports are created automatically.

• If the reference indicators are not met, this must be explained on the automatic reports in the spaces created for this purpose.

• Each indicator must be interpreted in relation to the others and with information/observations.

• Indicators must be monitored monthly and compared with previous months/years.


Reference values for the main indicators and their interpretation (children 6-59 months)

Main indicators Main interpretations I-TFC A-TFC / TSFC

Admission and exits � Total number of

admitted patients � Direct admissions � Total number of

patients in the programme

� Relapse � Readmissions

� Nutritional situation

evolution � Trend in food security � Workload and size of

programme

….. 10-20% ….. < 5 % ….

….. 80-90% ….. < 5 % ….

Outcome indicators in % of the total number of exits � Cured/Recovered % � Defaulter % � Death % � Transfer % � Non-respondent %

� % reference from

ATFC to ITFC � % reference from

ITFC to ATFC

� Quality � Accessibility,

acceptability � Quality of care

> 80 % < 5 % < 10 % …….. <3% >80%

> 80 % < 15 % < 2 % …….. <3% <3%

Mean length of stay � I-TFC � A-TFC, TSFC

� Quality of care (medical

and nutritional)

Cured < 30 days Stabilised < 12 days

A-TFC < 40 days TSFC < 45 days

Average weight gain for cured � I-TFC (for cured in

ITFC) � A-TFC, TSFC �

� Quality of care (medical

and nutritional)

≥10 g / kg / day

≥5g/kg/day

Attendance rate � Accessibility, acceptability

> 95 % > 85 %

Immunisation coverage � Quality 100 % 100 % HIV counselling � Quality 100% … Programme coverage � Accessibility,

acceptability In camps: >90% In urban area: >70% In rural area: >50%


9.2 INDICATORS 9.2.1 Admissions* The admissions represent the number of newly registered patients during the relevant period and reflect the importance of nutritional problem in the community.

9.2.2 Discharges* Analysis of discharged children is based on the total numbers of discharges of the programme. Each month, the proportion of children who are cured/recovered, default, died, transferred and non-respondent is expressed as a percentage of the total number of discharged patients. Calculating indicators (example: Defaulter rate):

Number of defaulter Defaulter percentage = --------------------------------- x 100% Number of discharges 9.2.3 Average length of stay * Calculation of the average length of stay is based on the number of children who are discharged as cured over a given period. The required information is obtained from well-kept registers.

Sum of individual lengths of stay of discharged as cured Average length of stay = --------------------------------------------------------------------------- Number of children discharged as cured Factors which may influence the average length of stay: • Quality of medical and nutritional care • Quantity and acceptability of the feeding ration • For an TSFC: the availability of food at home 9.2.4 Average weight gain* The average weight gain is an indicator of the quality of the programme. It is calculated once a week/month based on patients who are “discharged as cured”. For a child with marasmus, weight gain is calculated from his/her passage to phase 2 until s/he is discharged, i.e. the period during which the child gains weight. For a child with kwashiorkor, it is calculated from the disappearance of all traces of oedema until s/he is discharged. W2 - W1 Weight gain = --------------------------- = …….. g / kg / d W (T2 -T1) W1 = weight in grams the day of admission to phase 2 or weight on the day of disappearance of oedema W2 = weight in grams the day of discharge from the programme


W = weight in kg the day of admission to phase 2 or weight on the day of disappearance of oedema (T2 - T1) = Number of days between W1 and W2 Sum of individual weight gains Average weight gain = ----------------------------------------------- = …….. g / kg / d Total number of children cured 9.2.5 Attendance rate The attendance rate is a percentage based on the number of beneficiaries registered and the number actually present at the centre on the relevant day. This indicator provides information about the accessibility and acceptability of the programme. Number of children present Attendance rate = ----------------------------------------------------------- x100% Number of children expected/registered 9.2.6 Vaccination coverage* Calculated for all vaccinations performed by MSF on its feeding programme Number of patients vaccinated Vaccination coverage = --------------------------------------------------- x 100% Number of patients admitted * Data calculated automatically using Nutridata.


10. PSYCHOSOCIAL WELL-BEING AND MENTAL HEALTH Please refer to 2013 ACF guideline: “Manual for the integration of child care practices and metal health into nutrition programs” 10.1 PSYCHOSOCIAL SUPPORT* A strong maternal-infant (or caretaker-infant) bond provided through psychosocial stimulation is essential for positive child development. The formation of this bond at the beginning of life is an essential step that sets the stage for cognitive, emotional, and social development later in life. Feeding and other care practices provide opportunities for psychosocial stimulation and help to establish a positive attachment between caretaker and child. The first two years of life are critical periods in which the brain and physical growth are most active. Nutritional and psychosocial deficits during this time period can result in lifelong impairment and disability. Cultural habits of food distribution, in some contexts, can leave infants and young children the last to receive aid, which can increase their risk for malnutrition. Many caretakers are unavailable or unable to provide psychosocial stimulation to their children during food crises due to their own poor physical or mental health. A lack of psychosocial stimulation has adverse consequences for children’s development (cognitive, motor, language) and mental health. The combination of malnutrition and a lack of psychosocial stimulation are particularly harmful. Improving both nutritional status and stimulation has an added impact on a child's development and recovery. Therefore nutritional and psychosocial interventions should be integrated. Combination nutrition/stimulation programs that emphasize appropriate feeding practices and responsive parenting (e.g., proactive stimulation and appropriate responses) have a greater impact than either intervention alone. Indeed, nutrition programs that contain a psychosocial component are more effective in promoting growth and positive child development than nutritional programs without a psychosocial component. Guidance to improve child- caretaker interaction and to increase the physical stimulation provided by the environment appears in the table below. These principles aim to help caregivers feel positive about themselves, feel positive about their children, and encourage them to have positive interactions with each other. Please refer to the table of neurodevelopment in children below:


DEVELOPMENTAL MILESTONES Reproduced with permission from Lucci Lugee Liyeung http://artlog.liyeung.com/

Age Gross motor Fine motor Cognitive, linguistic and

communication Social and emotional

2 months

2 months lifts head 45° 3 months lifts head 90°

Follows past midline

Laughs and vocalizes

Smilea responsively and spontaneously

4 months

Rolls over

Grasps rattle

Turns to rattling sound

Moves eyes to look at objects

6 months

Sits without support

Points with index finger

Turns to voice and familiar sounds

Places everything in mouth

9 months

Pulls to stand

Pincer grasp

Dada mama non-specific

Stranger anxiety

Age Gross motor Fine motor Cognitive, linguistic and

communication Social and emotional

1 year

Walks alone

Bangs two cubes

Imitates vocalization/sounds Understands several words Speaks at least 1 word

Waves bye-bye

15 months

Walks backwards

Scribbles

1-3 words

Drinks from cup


18 months

Runs

Scribbles to and fro

Points to at least 1 body part 3-6 words

Feeds self with spoon

2 years

Walks up steps

Scribbles in a circle

Names familiar objects

Feeds self without spilling 2 1/2 years

Walks down stairs 1 foot at a time

Turns pages in a book

Speech half understandable

Washes and dries hands

3 years

Balances on each foot for 1 second

Draws a person very simple

Speech all understandable Gives name, age, sex

Interactive play

4 years

Hops on one foot

Draws a person with 3 parts

Names 4 colours

Dresses and undresses- simple clothing

5 years

Can walk a straight line

Copies a triangle and a square

Asks meaning of abstract words

Dresses and undresses alone


Type of stimulation What to do Examples

Emotional stimulation: Interventions to improve child-caretaker interactions are important in order to facilitate children’s emotional, social, and language development. This can be accomplished through educating caretakers on the importance of emotional communication.

Express warmth and affection to the child in a manner consistent with cultural norms

Encourage caretakers to look into the child's eyes, smile at him or her, especially during breastfeeding. Express physical affection to the child (e.g. hold and cuddle the child).

Encourage verbal and non-verbal communication between the child and caretaker

Communicate with the child as much as possible. Ask the child simple questions and respond to his or her attempts to talk. Try to get a conversation going with sounds and gestures (smiles, glances). Get the child to laugh and vocalize. Teach the child words with activities. For example, say “bye” when waving goodbye.

Respond to the needs of the child

Respond to the child’s sounds and interest. Be attentive to his or her needs as indicated by his or her behaviour (e.g. crying, smiling).

Show appreciation for what the child manages to do

Provide verbal praise for the child’s accomplishments. Also, show non-verbal signs of appreciation and approval (e.g. clapping, smiling).

Physical stimulation: Children need a physically stimulating environment in order to develop their psychomotor and language skills and to enhance cognitive development.

Ensure that the environment provides adequate sensory experiences for the child

Provide opportunities for the child to see, hear, and move. For example, place colourful objects around the child and encourage the child to reach or crawl to them. Sing local songs and play games involving fingers and toes.

Provide play materials Inexpensive and fun toys such as a puzzle and a rattle can be made out of cardboard boxes and plastic bottles. See below for examples.

Provide meaning to the child’s physical world

Help the child to name, count, and compare objects. For example, give the child plastic bottle caps and teach him/her to stack them. Older children can sort bottle tops by color and learn concepts such as “high” and “low”. Describe to the child what is happening around him or her.

Provide opportunities to practice skills

It is important to play with each child individually at least 15-30 minutes per day, as well as to provide opportunities for play with other children.


10.1.1 Psychosocial activities at health facilities/therapeutic feeding centres include the following: • Educate caretaker and healthcare providers about the negative consequences of sensory

deprivation in a culturally sensitive matter. • Explain that children need to have physical contact with the environment around them to

stimulate their development. • Practices that involve wrapping or tying an undernourished child to prevent movement or

covering the child’s face should be discouraged with the understanding that they limit this needed contact and therefore limit psychosocial stimulation. In cultures where traditional practices involve restricting child movement (e.g. swaddling) this issue will need to be dealt with in a sensitive manner so that the caretaker’s confidence and role are not undermined. Advice about this issue should be given to all members of the family, including the extended family as appropriate.

• Ensure that a caretaker is present in the feeding centre and encourage the caretaker to feed, hold,

and play with the child as much as possible. Activities for older siblings who are not malnourished should also be provided at the feeding centre to encourage women to attend who otherwise might not be able to because of commitments to other children. It may be helpful for these activities to contain an educational component on nutrition since older children may play a role in the feeding of younger children at home.

• Make the environment as stimulating as possible with bright colours, homemade mobiles and a

radio for music if possible. • Ensure that children spend time with other children in informal playgroups. A nurse or a

volunteer should be responsible for developing a curriculum of play activities. Activities should be selected to develop motor and language skills


10.1.2 Toys for severely malnourished children*

Source; Mental health and psychosocial well being among children in severe shortage situations; World Health Organization


10.2 MENTAL HEALTH Caretakers who look after children and who have mental health problems need additional support to enable them to care for their children.

Indicators of mental health problems for adults accompanying malnourished children may include:

• Rejection of the child

• The desire to leave instead of spending time with the child

• Complaints about the child

• Being alone most of the time, keeping a distance from other people

• Being sad and tearful

• Being depressed

How should we approach these issues? Professional staff trained in mental health counselling is best qualified to deal with these problems. These professionals should provide counselling to get to the root of problems and once these have been identified, work with the mothers to find the best ways of tackling them. Where programmes are found to have cases of children or accompanying adults with mental health problems, the desk must be approached for help to establish a framework of mental health support.


11. HEALTH EDUCATION DEFINITION Educational action for health is the use of situations, actions, communications and ideas to allow every individual to develop. When we speak of education, we are taking the point of view of the educator, the health professional. When we speak of apprenticeship, we are taking the point of view of the target audience. Educational action takes place within an existing cultural and social context with its own knowledge, behaviours, norms and values. Education for health is developed in relation to other factors such as personal emancipation and the ability to make choices for their one. Education for health aims to place individuals within the process of change. In this instance, we are referring to educational activities for health organised within medical institutions, such as mobile clinics and hospitals. 11.1 PRINCIPLES The cultural context in which the relevant population lives must be taken into account in the preparation and setting up of the health education programme. Look for positive behaviour and strengths which exist in the child’s family circle. Identify problems within the child’s community.

Practices are grouped together into 4 categories:

• Care practices:

o A positive interaction between the child and his caretaker promotes the child’s emotional and psychological development: frequent verbal interactions, demonstrations of attention and affection towards the child, sharing out of household chores, the place of fathers (cultural factor).

• Hygiene practices:

o Personal, food and environmental hygiene all contribute to general good health and to the prevention of diarrhoea and parasitic illnesses.

• The use of health services:

o Importance of the vaccination schedule in the child’s first year.

o Seeking support in the case of illness, recognizing that babies who are ill may need treatment outside home

o Pre- and post-natal consultations for the mother. Feeding practices

• Feeding practices


o Introduction of a varied range of foodstuffs from the age of 6 months, in addition to breastfeeding.

o Continuing to feed a sick child.

o Taking special care of a child who has lost his/her appetite.

o Providing physiological and psychological support for breastfeeding.

11.2 METHODS AND TOOLS

• Focus group discussion, support groups. • Theatre, role play, songs, puppets, shadow puppets. • Approaching local craftsmen/women for the creation of tools.

If more information and support are needed, ask the desk and the medical department (Health Promotion) for the various guidelines/protocols. 11.3 TRAINING REQUIREMENTS FOR HEALTH EDUCATION WOR KERS Training objectives

• To define educational actions for health within the context of malnutrition. • To define the relevant audience and the materials and equipment to be used: what should an

educator consider when preparing health education sessions? • To be aware of the advantages and limitations of each of the different tools, and think of how to

use them. • To reflect upon, talk about and share one’s previous experiences in health education. • To learn how to use a flipchart. 11.4 ASSESSMENT AND SUPERVISION How does one assess educational actions for health? It is impossible to assess those using purely epidemiological indicators, such as mortality.

The changing of attitudes and behaviours is multifactor.

Health education requires us to take duration into account.

The assessment will not only seek to identify the changes produced, but will also try to track the process that make these changes possible.

In health education, it is hoped that these changes are productive of good health.

It is difficult to show significant differences in the ways the groups develop, except by looking at learning progression.

There is a great temptation to focus only on the process rather than the results.

For all these reasons, it is important to assess the various sessions directly and to supervise, on a regular basis, the health education activities that take place.


These protocols are written and regularly updated with respect to international and WHO recommendations but they are adapted as best as possible to be feasible in MSF contexts and working programs.

We thank you to respect it as well as possible because they are a precious support even if a certain flexibility is always possible, case by case, for a qualified practitioner at the bedside of his patient.

Some drugs (i.e. adrenalin, calcium gluconate, potassium…) have RESTRICTED INDICATIONS in these protocols and they should not be overpassed. In some difficult / precarious situations (poor qualification of staff, overload of work…) they can even be more restricted.

Ventilation by Ambu bag with plain OXYGEN and chest compression should only be done in possible acute accidental situations (inhalation or other) for cases that should recuperate or improve fast or to newly arrived children before initiating any care. PLEASE in any cases, no excessive therapeutic efforts for exhausted children who are close to the end, after one or several days with our care (e.g. respiratory exhaustion, confirmed shock with prolonged cerebral suffering, brain death, etc….).

Keep in mind mortality in intensive phase will never be reduced to zero in the MSF working conditions. Medical doctors are not “God” capable to do miracles but just humans trying to do their best to decrease mortality and morbidity and, alleviate human suffering.

Do your best as rapidly as possible with the available means but with the same tightness and quality of care as if you were in your country of origin. Once everything has been done and well done, keep in mind the feeling of the accomplished good work even in case of death.

Mortality data are crucial but they have goodness only after data analysis and interpretation of causes and reasons… They should be reliable since they are essential tool for quality of care analysis and potential reorientation of programs. So report your deaths cautiously. .

We wish this guideline has responded and is still responding to your expectations.

Before leaving you, we greatly wish you to apply to the pediatrics / pediatrics in nutrition and neonatal care learning and teaching program adapted for MSF programs. To aim this goal, have a look on the training program proposed by the Training Unit (TU).

A last warmy thank to the colleagues who helped for this guideline edition, especially Mireille Lador, Knowledge management responsible and Patricia Armada, Page Layout & Editing.

Excellent progresses in Pediatrics…


OCG NUT-PAEDIATRICS TEAM

Marie-Claude Bottineau, International MSF Pediatrics WG and OCG Women and Children Health Pool Leader, [email protected]

Nathalie Avril, Nutrition Advisor, [email protected] Nicolas Peyraud, Pediatrics & Vaccination Advisor, [email protected]

Roberta Petrucci, Pediatrics Support to the Operations, MOSU, [email protected]

Alejandra Garcia Naranjo, Elisabeth Canisius & Anne Pittet, Pediatrics Coaching & Training, [email protected], [email protected],

[email protected]

OCBA NUT-PAEDIATRICS TEAM

Candella Lanusse, Référente Nutrition, [email protected],

Nuria Salse, Référente Nutrition, [email protected] Daniel Martinez, Paediatrics Advisor, [email protected],

Laurent Hiffler, Paediatrics Advisor, [email protected], Nadia Lafferty, Mobile Paediatrics Implementer, [email protected],

,


ANNEX 1: ADMISSION & DISCHARGE CRITERIA

• For children >5years old, MUAC cut off can be increase -> please contact [email protected]

• If you program is on MUAC/oedema criteria only (no WHZ), then MUAC admission should be <125mm (it can be discussed according to the context: -> please contact [email protected]), and discharge criteria will be MUAC >125mm on 2 consecutive visits

• For Adults, BMI can also be use: admission for SAM with BMI<16 (or BMI betwwen 16 and 17 with medical complications) and discharge with BMI > 17 on 2 consecutive visits


ANNEX 2: QUALITY INDICATORS 1. Staff ratio

Phase Nutritional assistants

Nurses Doctors

Intensive care without O2

1 / 10 patients 1 / 10 patients 1 / 25 patients

Intensive care with O2 1 / 5 patients 1 / 5 patients 1 / 10 patients Phase 1 1 / 20 patients 1 / 20 patients 1 / 50 patients Transition phase / Phase 2

1 / 30 patients 1 / 30 patients 1 / 50 patients

Small infants phase 1 / 10 patients 1 / 10 patients 1 / 25 patients 2. Buildings

Total area = 20 m² / patient. Some references ... • Area of hospitalizations = 2 m² for 1 couple caretaker + child • Registration approx. 30 m² • Pharmacy approx. 30 m² • Stock approx.30 m² • Kitchen approx. 80 m² • Preparation room for milk approx. 20 m² • Food stock approx. 30 m² • Fuel stock approx. 35 m² • Dishwashing zone approx. 10 m² • Different laundry areas of 10 m² 3. Logistics

Stock • The space between each pile is 70 cm, allowing passage. • Each pile consists of a single product. • The piles are placed on a pallet. • The piles are made for the number of packets is counted quickly. • The piles are stable. • Damaged goods are separated and burnt if not consumable. Kitchen

It is preferable that the kitchen operates on gas rather than wood to avoid deforestation. A stove is necessary for 25 to 50 children (2 x 50 l or 100 l). Pharmacy

The pharmacy must be conditioned for proper preservation of drugs. The pharmacy must be accessible every time so all drugs are accessible. During the night the key is kept by the team.


4. Water, Hygiene and Sanitation Quantity of water needed: Minimum = 30 l / person / day Ideal = 50 l / person / day Including: 5 l for meal preparation.

5 l of drinking water 40 l for showers, cleaning the centre...

Water Chlorination Beverages: 0.3 to 0.5 mg / litre Cleaning solution soil: 0.1% Latrines Adults = 1 / 15 people Children = 1 / 30 children The pots are distributed to all children under 2 / 3 years. Shower 1 shower / 30 people Waste Medical and non-medical wastes are collected separately. - Hole for organics - Hole for sharps - Incineration of remaining medical equipment - Hole for dirty water


ANNEX 3: INPATIENT THERAPEUTIC FEEDING CENTRE CARD


ANNEX 4: USING THE “DOSETTE” TO PREPARE SMALL QUANTITIES OF RESOMAL, F75, F100 For preparing small volumes of ReSoMal or F-75 and F-100 therapeutic milk, use a Nutriset “dosette” to measure the quantities of powder.

CAUTION The information given is only valid when using the Nutriset “dosette” and Nutriset products.

Nutriset “dosette” are easily recognisable. They are red and marked NUTRISET on the handle. Catalogue code: NFOSTHMI1S

Preparation of ReSoMal: Mix one levelled-off dosette of ReSoMal with 140 ml of water. Preparation of F-75 therapeutic milk: Mix one levelled-off Nutriset dosette of F-75 therapeutic milk with 18 ml of water. Preparation of F-100 therapeutic milk: Mix one levelled-off dosette of F-100 therapeutic milk with 14 ml of water. Preparation of F-100 therapeutic milk specially diluted: Mix one levelled-off dosette of F-100 therapeutic milk with 19 ml of water.

Dilution of F75 in small amounts: 1 level scoopful / 18 ml water

For larger amounts, use a kitchen scale to weight the milk

Water (in ml) Scoops Water (in ml) Scoops Water (in ml) Powder (in gr) 18 1 198 11 400 82 36 2 216 12 500 103 54 3 234 13 600 123 72 4 252 14 700 144 90 5 270 15 800 164 108 6 288 16 900 185


126 7 306 17 1000 205 144 8 324 18 1100 226 162 9 342 19 1200 246 180 10 360 20 1300 267 1400 287 1500 308 Dilution of F100 in SDTM in small amounts: 1 level scoopful / 18,7 ml water

Water (in ml) Scoops Water (in ml) Scoops Water (in ml) Powder (in gr) 19 1 205 11 400 65 37 2 224 12 500 81 56 3 243 13 600 98 75 4 261 14 700 114 93 5 280 15 800 130 112 6 299 16 900 147 131 7 317 17 1000 163 149 8 336 18 1100 179 168 9 355 19 1200 195 187 10 373 20 1300 212 1400 228 1500 244 Dilution of F100 in small amounts: 1 level scoopful / 14 ml water

Water (in ml) Scoops Water (in ml) Scoops Water (in ml) Powder (in gr) 14 1 154 11 400 91 28 2 168 12 500 114 42 3 182 13 600 137 56 4 196 14 700 160 70 5 210 15 800 182 84 6 224 16 900 205 98 7 238 17 1000 228 112 8 252 18 1100 251 126 9 266 19 1200 274 140 10 280 20 1300 296 1400 319

1500 342


ANNEX 5: Anthropometric and oedema measurements & Weight for Height and BMI tables 1. Weight Children

• Install a 25 kg hanging spring scale (graduated by 100 gram). If mobile weighing is needed, the scale can be hooked onto a tree or attached to a stick held by two people.

• Suspend weighing pants from the lower hook of the scale and recalibrate to zero. • Remove child’s clothes and place him/her in weighing pants. • Read scale at eye level and ensure that the child is not holding on mothers, caretakers or

staffs. (If the child is moving and the needle does not stabilise, estimate weight by using the value situated at the midpoint of oscillation.)

• Announce the value to an assistant. The assistant should repeat, verify the value and record.

For children weighing less than 15 kg, preferable use a mechanical or electronic scale precise to 10 grams. Comments


• Cold weather or cultural custom may make it impossible to undress a child. Children can be given a “dress” (i.e. a bag with large holes for the head and arms). Alternatively, the average weight of the child’s clothes should be estimated and deducted from the measurement.

• The scale must be checked weekly against a 5 or 10 kg weight. During a nutritional survey daily! If the measure does not match the weight, the scale should be discarded or the springs must be changed.

• Child can also be measured by being placed in a hanged basin; older children can hang with their hands. The use of a bucket is advised because of hygienic and comfortable measures.

Adolescents and adults

Scales used for adults or adolescents should provide a degree of precision of 500 gram. A mechanical or electronic scale (i.e. Uniscale from UNICEF) can be used, but proper function has to be ensured. Mechanical bathroom spring scales can be easily disturbed and weight variations of for example several kilos are possible. Poor quality electronic scales may have a short lifespan and become imprecise in heat and humidity. 2. Height / Length Children below 87 cm

• Place the measuring board on the ground or on a table; gently lay the child supine in the middle.

• An assistant should hold the side of the child’s head, and position it until it touches the “foot board” (stable end of the measuring board).

• A measurer should position and hold the child’s knees or ankles in a straight line, and place the “cursor” (movable portion) at a right angle against the child’s feet.

• The measurer should read and announce the length to the nearest 0.1 cm. • The assistant should repeat, verify the measurement and record it. Comment In many cultures, the practice of measuring a child while lying down is associated with death (i.e. measuring for a coffin). Education sessions are important in order to prepare caretakers. Children above or equal to 87 cm

• Place the measuring board upright.


• Remove the child’s shoes and stand her/him on the middle of the measuring board. • An assistant should press the child’s ankles and knees against the board, ensuring his/her

head, shoulders, buttocks, knees and heals touch the board. • The measurer should position the head at a right angle to the cursor. • The measurer should read and announce the height to the nearest 0.1 cm. • The assistant should then repeat, verify the measurement and record it. Comment Individuals measured while lying down are taller (in average 0.5 cm) than when standing. Children must be measured in a lying position when they are shorter than 87 cm, and in a standing position when taller than 87 cm. It is important to observe this rule in order to compare lengths and heights with the reference WHO 2006 table. Attention: Some project might use a reference table based on 85 cm threshold. Crosscheck the reference table towards the threshold for adjusting lying and standing position. The height/length is ALWAYS TAKEN WITH TWO PEOPLE! Adolescents and adults

If malnourished adults, elderly or adolescent are too weak to stand, height should be taken later when the person is strong enough to stand. Comment


Different formulas have been developed to calculate height based on (demi-) arm span, which corresponds approximately.


3. MUAC MUAC measurement is fast and simple but not easy and variations in measurements often occur between different measurers. This is mainly due to identified positioning on the mid-upper-arm and how the tape is pulled or “squeezed” around the arm. Taking the MUAC

• Let the left arm hang relaxed at the side of the body. • Place the MUAC measuring tape midway between the elbow and the shoulder and identify

the mid-arm. Also a soft string can be used to do so. • Fit the tape securely around the arm. The tape should not be too slack, nor pulled too tightly. • Read the measurement at the window of the tape and record the millimetres (The complete

number in the window is read.). The MSF MUAC has a precision of 2 mm.

126 mm


112 mm

Comment The brachial perimeter is always taken on the left arm because it is the least developed for the majority of the right-handed population. Other types of MUAC exist. These are most often centimeter tapes and/or the color especially of the moderate category differs. MSF tape:

Malnutrition thresholds:

Severe acute malnutrition

Moderate acute malnutrition

At risk of malnutrition

Normal

< 115 mm 115 to 125 mm 125 – 135 mm > 135 mm

4. Oedema Oedema in malnutrition is always bilateral: both feet, both legs, both hands... • Moderate thumb pressure is applied to lower extremities bilaterally (just above the ankle or the

tops of the feet). • Count 3 seconds (101, 102, 103). • If fingers are removed and a saucer shape persists, oedema is considered.

112 10

11


Oedema is generally first present in the feet/internal malleolus → called seriousness +. Then, oedema develop on the feet and tibias → seriousness ++ and finally, oedema generalizes on the feet, tibias and face → seriousness +++.


WHO 2006 new references in Z-score BOYS Weight for Length (Lying down) GIRLS - 3 - 2 - 1 Median cm Median - 1 - 2 - 3 1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9 1.9 2.1 2.3 2.5 45.5 2.5 2.3 2.1 2.0

2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0 2.1 2.3 2.5 2.7 46.5 2.7 2.5 2.3 2.1

2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2 2.2 2.4 2.6 2.9 47.5 2.9 2.6 2.4 2.2

2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3 2.3 2.6 2.8 3.0 48.5 3.1 2.8 2.6 2.4 2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4

2.5 2.7 3.0 3.2 49.5 3.3 3.0 2.7 2.5 2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6

2.7 2.9 3.1 3.4 50.5 3.5 3.2 2.9 2.7 2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8 2.8 3.1 3.3 3.6 51.5 3.7 3.4 3.1 2.8

2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9 3.0 3.3 3.6 3.9 52.5 3.9 3.6 3.3 3.0

3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1 3.2 3.5 3.8 4.1 53.5 4.2 3.8 3.5 3.2

3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3 3.4 3.7 4.0 4.4 54.5 4.4 4.0 3.7 3.4 3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5 3.7 4.0 4.3 4.7 55.5 4.7 4.3 3.9 3.6 3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7 3.9 4.2 4.6 5.0 56.5 5.0 4.5 4.1 3.8 4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9 4.1 4.5 4.9 5.3 57.5 5.2 4.8 4.4 4.0 4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1 4.4 4.7 5.1 5.6 58.5 5.5 5.0 4.6 4.2 4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3 4.6 5.0 5.4 5.9 59.5 5.7 5.3 4.8 4.4 4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5 4.8 5.2 5.6 6.1 60.5 6.0 5.5 5.0 4.6 4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7 5.0 5.4 5.9 6.4 61.5 6.3 5.7 5.2 4.8 5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9 5.2 5.7 6.1 6.7 62.5 6.5 5.9 5.4 5.0 5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1 5.4 5.9 6.4 6.9 63.5 6.7 6.2 5.6 5.2 5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3 5.6 6.1 6.6 7.1 64.5 7.0 6.4 5.8 5.4 5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5 5.8 6.3 6.8 7.4 65.5 7.2 6.6 6.0 5.5 5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6 6.0 6.5 7.0 7.6 66.5 7.4 6.8 6.2 5.7 6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8 6.2 6.7 7.2 7.9 67.5 7.6 7.0 6.4 5.9


WHO 2006 new references in Z-score

BOYS Weight for Length (Lying down) GIRLS - 3 - 2 -1 Median cm Median - 1 - 2 - 3 7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1 7.6 8.2 8.8 9.6 75.5 9.2 8.5 7.8 7.1 7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2 7.7 8.3 9.0 9.8 76.5 9.4 8.6 7.9 7.3 7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4 7.9 8.5 9.2 10.0 77.5 9.6 8.8 8.1 7.4 7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5 8.0 8.7 9.4 10.2 78.5 9.8 9.0 8.2 7.6 8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7 8.2 8.8 9.5 10.4 79.5 10.0 9.1 8.4 7.7 8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8 8.3 9.0 9.7 10.5 80.5 10.2 9.3 8.6 7.9 8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0 8.5 9.1 9.9 10.7 81.5 10.4 9.5 8.8 8.1 8.5 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1 8.6 9.3 10.1 10.9 82.5 10.6 9.7 8.9 8.2 8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3 8.8 9.5 10.3 11.2 83.5 10.9 9.9 9.1 8.4 8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5 9.0 9.7 10.5 11.4 84.5 11.1 10.2 9.3 8.6

9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7

9.2 9.9 10.7 11.6 85.5 11.3 10.4 9.5 8.8

9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9

9.4 10.1 11.0 11.9 86.5 11.6 10.6 9.8 9.0

6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0 6.4 6.9 7.5 8.1 68.5 7.9 7.2 6.6 6.1 6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1 6.6 7.1 7.7 8.3 69.5 8.1 7.4 6.8 6.2 6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3 6.7 7.3 7.9 8.5 70.5 8.3 7.6 6.9 6.4 6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5 6.9 7.5 8.1 8.8 71.5 8.5 7.7 7.1 6.5 7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6 7.1 7.6 8.3 9.0 72.5 8.7 7.9 7.3 6.7 7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8 7.2 7.8 8.5 9.2 73.5 8.9 8.1 7.4 6.9 7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9

7.4 8.0 8.7 9.4 74.5 9.1 8.3 7.6 7.0



BOYS Weight for Height (Standing up)

GIRLS - 3 - 2 - 1 Median cm Median - 1 - 2 - 3 9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2

9.7 10.5 11.3 12.3 87.5 12.0 11.0 10.1 9.3

9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4

9.9 10.7 11.6 12.5 88.5 12.3 11.2 10.3 9.5

10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6

10.1 10.9 11.8 12.8 89.5 12.5 11.5 10.5 9.7

10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8

10.3 11.1 12.0 13.0 90.5 12.8 11.7 10.7 9.9

10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0

10.5 11.3 12.2 13.2 91.5 13.0 11.9 11.0 10.1

10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2

10.7 11.5 12.4 13.5 92.5 13.3 12.1 11.2 10.3

10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4

10.9 11.7 12.7 13.7 93.5 13.5 12.4 11.4 10.5

11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6

11.1 11.9 12.9 13.9 94.5 13.8 12.6 11.6 10.7 11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8 11.2 12.1 13.1 14.2 95.5 14.0 12.8 11.8 10.8 11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9 11.4 12.3 13.3 14.4 96.5 14.3 13.1 12.0 11.0 11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1 11.6 12.5 13.6 14.7 97.5 14.5 13.3 12.2 11.2 11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3 11.8 12.8 13.8 14.9 98.5 14.8 13.5 12.4 11.4 11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5 12.0 13.0 14.0 15.2 99.5 15.1 13.8 12.7 11.6 12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7 12.2 13.2 14.3 15.5 100.5 15.4 14.1 12.9 11.9 12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0 12.4 13.4 14.5 15.8 101.5 15.7 14.3 13.1 12.1 12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2 12.6 13.7 14.8 16.1 102.5 16.0 14.6 13.4 12.3 12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4 12.9 13.9 15.1 16.4 103.5 16.3 14.9 13.6 12.5 13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6 13.1 14.2 15.4 16.7 104.5 16.6 15.2 13.9 12.8 13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9 13.3 14.4 15.6 17.0 105.5 16.9 15.5 14.2 13.0 13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1 13.5 14.7 15.9 17.3 106.5 17.3 15.8 14.5 13.3 13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4 13.8 14.9 16.2 17.7 107.5 17.7 16.1 14.7 13.5 13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7 14.0 15.2 16.5 18.0 108.5 18.0 16.4 15.0 13.8 14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9


14.3 15.5 16.8 18.3 109.5 18.4 16.8 15.4 14.1 14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2 14.5 15.8 17.1 18.7 110.5 18.8 17.1 15.7 14.4 14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5 14.8 16.0 17.5 19.1 111.5 19.2 17.5 16.0 14.7 14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8 15.0 16.3 17.8 19.4 112.5 19.6 17.9 16.3 15.0 15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1 15.3 16.6 18.1 19.8 113.5 20.0 18.2 16.7 15.3 15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4

15.6 16.9 18.5 20.2 114.5 20.5 18.6 17.0 15.6


BOYS Weight for Height (Standing up)

GIRLS

- 3 - 2 -1 Median cm Median - 1 - 2 - 3 15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7 15.8 17.2 18.8 20.6 115.5 20.9 19.0 17.3 15.9 16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0 16.1 17.5 19.2 21.0 116.5 21.3 19.4 17.7 16.2 16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3 16.4 17.9 19.5 21.4 117.5 21.7 19.8 18.0 16.5 16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6 16.7 18.2 19.9 21.8 118.5 22.2 20.1 18.4 16.8 16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9 16.9 18.5 20.2 22.2 119.5 22.6 20.5 18.7 17.1

17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3


RECONSTRUCTED FROM BMI charts: height between 120,5 and 140,0 cm

Reconstruction based on WHO 2007 references Older children from 60 months to 10 years (110,0 - 140,0 cm)

MALE Weight-for-Height (Standing up) FEMALE -3 -2 -1 Median cm Median -1 -2 -3 14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2 14.5 15.8 17.1 18.7 110.5 18.8 17.1 15.7 14.4 14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5 14.8 16.0 17.5 19.1 111.5 19.2 17.5 16.0 14.7 14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8 15.0 16.3 17.8 19.4 112.5 19.6 17.9 16.3 15.0 15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1 15.3 16.6 18.1 19.8 113.5 20.0 18.2 16.7 15.3 15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4 15.6 16.9 18.5 20.2 114.5 20.5 18.6 17.0 15.6 15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7 15.8 17.2 18.8 20.6 115.5 20.9 19.0 17.3 15.9 16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0 16.1 17.5 19.2 21.0 116.5 21.3 19.4 17.7 16.2 16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3 16.4 17.9 19.5 21.4 117.5 21.7 19.8 18.0 16.5 16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6 16.7 18.2 19.9 21.8 118.5 22.2 20.1 18.4 16.8 16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9 16.9 18.5 20.2 22.2 119.5 22.6 20.5 18.7 17.1 17.1 18.6 20.4 22.4 120 22.8 20.7 18.7 17.2

17.5 19.0 20.6 22.4 120.5 22.8 20.8 18.8 17.3

17.9 19.2 20.8 22.5 121 22.9 20.9 18.9 17.3

18.0 19.3 21.0 22.9 121.5 23.0 20.9 19.0 17.4

18.3 19.6 21.1 23.1 122 23.1 21.0 19.1 17.6

18.5 19.8 21.3 23.3 122.5 23.3 21.1 19.2 17.7

18.6 20.0 21.6 23.4 123 23.4 21.2 19.4 17.9

18.8 20.1 21.8 23.8 123.5 23.6 21.4 19.5 18.0

18.9 20.3 22.0 24.0 124 23.8 21.5 19.7 18.1

19.1 20.5 22.2 24.2 124.5 24.2 21.7 19.8 18.3

19.2 20.6 22.3 24.4 125 24.4 22.0 20.0 18.4

19.4 20.8 22.5 24.6 125.5 24.6 22.2 20.3 18.7

19.7 21.1 22.7 24.9 126 24.9 22.4 20.5 18.9

19.8 21.3 23.0 25.1 126.5 25.1 22.6 20.6 19.0

20.0 21.5 23.2 25.3 127 25.3 22.7 20.8 19.2

20.2 21.6 23.4 25.7 127.5 25.5 23.1 21.0 19.3

20.3 21.8 23.6 25.9 128 25.9 23.3 21.1 19.5

20.5 22.0 23.8 26.1 128.5 26.1 23.4 21.5 19.6

20.6 22.3 24.1 26.3 129 26.3 23.6 21.6 20.0

21.0 22.5 24.3 26.7 129.5 26.7 24.0 21.8 20.1

21.1 22.6 24.5 26.9 130 26.9 24.2 22.0 20.3

21.3 22.8 24.7 27.1 130.5 27.1 24.4 22.1 20.4

21.5 23.0 24.9 27.3 131 27.5 24.5 22.5 20.6


21.6 23.2 25.2 27.7 131.5 27.7 24.9 22.7 20.9

21.8 23.5 25.4 27.9 132 28.1 25.1 22.8 21.1

22.1 23.7 25.6 28.1 132.5 28.3 25.3 23.0 21.2

22.3 23.9 25.8 28.5 133 28.5 25.6 23.3 21.4

22.5 24.1 26.2 28.7 133.5 28.9 25.8 23.5 21.6

22.6 24.2 26.4 28.9 134 29.1 26.0 23.7 21.9

22.8 24.6 26.6 29.3 134.5 29.5 26.4 23.9 22.1

23.1 24.8 27.0 29.5 135 29.7 26.6 24.2 22.2

23.3 25.0 27.2 29.9 135.5 29.9 26.8 24.4 22.4

23.5 25.2 27.4 30.1 136 30.3 27.2 24.6 22.8

23.7 25.5 27.6 30.4 136.5 30.6 27.4 25.0 22.9

23.8 25.7 28.0 30.8 137 31.0 27.6 25.2 23.1

24.2 25.9 28.2 31.0 137.5 31.2 28.0 25.3 23.3

24.4 26.3 28.6 31.4 138 31.6 28.2 25.5 23.6

24.6 26.5 28.8 31.7 138.5 31.8 28.4 25.9 23.8

24.7 26.7 29.0 32.1 139 32.3 28.8 26.1 24.0

25.1 26.9 29.2 32.3 139.5 32.5 29.0 26.3 24.1

25.3 27.2 29.6 32.5 140 32.9 29.4 26.7 24.5


Weight adaptations between 140,0 (BMI charts WHO 2007) to 145,0 cm (NCHS 1982)

Reconstruction based on NCHS-CDC-WHO 1982 references Adolescents from 10 to approx 18 years (140,0 - 165,0 cm)

MALE Weight-for-Height (Standing up) FEMALE 70% 80% 85% Median cm Median 85% 80% 70% 25.1 27.2 29.6 32.5 140 32.9 29.4 26.7 24.5

25.2 27.4 29.7 33.0 140.5 33.2 29.6 26.8 24.7

25.2 27.6 29.9 33.4 141 33.6 29.8 27.0 24.9

25.3 28.0 30.0 33.8 141.5 33.8 30.2 27.4 25.0

25.4 28.2 30.2 34.1 142 34.1 30.4 27.6 25.2

25.4 28.4 30.3 34.7 142.5 34.8 30.7 27.8 25.6

25.5 28.8 30.5 35.0 143 35.6 31.1 28.0 25.7

25.6 29.0 30.6 35.3 143.5 36.0 31.3 28.4 25.8

25.6 29.1 30.8 35.7 144 36.4 31.4 28.6 25.9

25.7 29.2 30.9 36.1 144.5 36.9 31.5 29.1 26.0

25.8 29.2 31.0 36.5 145 37.1 31.5 29.7 26.0

25.8 29.5 31.3 36.8 145.5 37.4 31.8 29.9 26.2 26.0 29.7 31.6 37.2 146 37.8 32.1 30.2 26.5 26.3 30.0 31.9 37.6 146.5 38.1 32.4 30.5 26.7 26.5 30.3 32.2 37.9 147 38.4 32.6 30.7 26.9 26.8 30.6 32.5 38.3 147.5 38.8 33.0 31.0 27.2 27.0 30.9 32.8 38.6 148 39.1 33.2 31.3 27.4 27.3 31.2 33.1 39.0 148.5 39.5 33.6 31.6 27.7 27.5 31.5 33.4 39.3 149 39.8 33.8 31.8 27.9 27.8 31.7 33.7 39.7 149.5 40.1 34.1 32.1 28.1 28.0 32.0 34.0 40.0 150 40.5 34.4 32.4 28.4 28.3 32.3 34.3 40.4 150.5 40.8 34.7 32.6 28.6 28.5 32.6 34.7 40.8 151 41.2 35.0 33.0 28.8 28.8 32.9 34.9 41.1 151.5 41.5 35.3 33.2 29.1 29.1 33.2 35.3 41.5 152 41.9 35.6 33.5 29.3 29.3 33.5 35.6 41.9 152.5 42.3 36.0 33.8 29.6 29.6 33.8 35.9 42.3 153 42.6 36.2 34.1 29.8 29.8 34.1 36.2 42.6 153.5 43.0 36.6 34.4 30.1 30.1 34.4 36.6 43.0 154 43.4 36.9 34.7 30.4 30.4 34.7 36.9 43.4 154.5 43.8 37.2 35.0 30.7 30.7 35.0 37.2 43.8 155 44.2 37.6 35.4 30.9 30.9 35.4 37.6 44.2 155.5 44.6 37.9 35.7 31.2

31.2 35.7 37.9 44.6 156 45.1 38.3 36.1 31.6

31.5 36.0 38.3 45.0 156.5 45.5 38.7 36.4 31.9

31.8 36.3 38.6 45.4 157 46.0 39.1 36.8 32.2

32.1 36.7 38.9 45.8 157.5 46.5 39.5 37.2 32.6

32.4 37.0 39.3 46.2 158 47.0 40.0 37.6 32.9

32.7 37.3 39.6 46.6 158.5 47.6 40.5 38.1 33.3

33.0 37.7 40.0 47.1 159 48.2 41.0 38.6 33.7

33.3 38.0 40.4 47.5 159.5 48.9 41.6 39.1 34.2


33.6 38.4 40.8 48.0 160 49.7 42.2 39.8 34.8

33.9 38.7 41.1 48.4 160.5 50.5 42.9 40.4 35.4

34.2 39.1 41.5 48.8 161 51.6 43.9 41.3 36.1

34.5 39.4 41.9 49.3 161.5 52.8 44.9 42.2 37.0

34.8 39.8 42.3 49.8 162 54.5 46.3 43.6 37.8

35.1 40.2 42.7 50.2 162.5 56.1 47.7 44.9 38.3

35.5 40.5 43.1 50.7 163 56.4 47.9 45.1 38.8

35.8 40.9 43.5 51.1 163.5 56.7 48.2 45.4 39.0

36.1 41.3 43.9 51.6 164 57.0 48.4 45.6 39.5

36.5 41.7 44.3 52.1 164.5 57.3 48.7 45.8 39.8

36.8 42.1 44.7 52.6 165 57.6 48.9 46.0 40.0


BODY MASS INDEX (ADULTS) (=W/H 2, height in metres) Body weight corresponding to specified BMI, for given height

Height BMI

(cm) 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


BODY MASS INDEX (ADULTS) (=W/H 2, height in metres) Body weight corresponding to specified BMI, for given height

Height BMI

(cm) 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 56.0 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 50.1 178 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


Interpretation:

BMI INTERPRETATION

< 16.0 Severe thinness 16.0 - 16.9 Moderate thinness 17.0 - 18.4 Marginal thinness

18.5 - 24.9 Normal range for an individual

20 - 22 Normal range for mean or median of an adult population


ANNEX 6: HEALTH PROMOTION Messages to caretakers

1. On admission

� In ITFC � The child will receive therapeutic milk as the only food and in addition to breastfeeding. The child cannot receive anything else other than water if he/she is thirsty. Breastfeeding should be maintained. As the child’s condition improves and he/she recovers his/her appetite, RUTF will be introduced and the child will continue his treatment at home with a weekly follow-up in the ATFC. � Reminder the importance of breastfeeding � The mother or the caretaker will have to stay with the child until his/her discharge. Her presence at meal times is essential. � The child will be seen every day by the health staff, even several times per day if needed. � The clinician will monitor the child’s general health status.

� In ATFC: � The child will have to come back with his mother/caretaker every week until discharged

� Agreements can be made between beneficiary/caretaker and the consultant if living far away (to come every second week).

� He will be seen weekly by the health staff.

� The weight, MUAC and edema will be monitored.

� The consultant will examine the general health status.

� RUTF for a week's consumption will be received. Ask if there are other children with a similar illness in the village where he/she comes from.

2. Health promotion to be given at first consultation

The following messages should be given to the caretaker by the person who did the medical consultation (doctor or nurse).

� In ITFC � The caretaker should inform the nurse or nutritional assistant if the child’s condition has changed.

� The caretaker should inform the nurse if the child has diarrhoea and should show her/him the stools. The caretaker should also inform the nurse in case of vomiting.

� Inform the caretaker that loose stools are common in malnourished children

� In phase 1, baths should not be given in the morning or evening, but rather during the warmer hours of the day. Warm water should be used to wash the child.


� The messages concerning therapeutic milk and the importance of meals should be reinforced.

� In ATFC � If diarrhoea:

o NEVER stop feeding.

o Give EXTRA food (in small and frequent meals): Avoid food with high glucose content such as fruit juices or carbonate soft drinks (cocacola etc) as they might increase diarrhea by osmotic effect.

o Give EXTRA (clean) water. o Breastfeed more often.

� Inform mothers that loose stool is common in malnourished children

� If the condition of the child deteriorates (e.g. diarrhoea, vomiting, fever, increase in oedema), or if the child loses appetite, s/he should immediately come back to the therapeutic feeding centre or to the health centre for medical care.

� In both ITFC and ATFC explains that: � Severely malnourished children get cold quickly:

� Cover the child and keep him/her warm during night and especially during the morning hours.

� If the ambient temperature feels good for you, it is too cold for the child. If you feel hot, the temperature is good for the child.

3. Health promotion to be given for RUTF � RUTF is a medicine: RUTF is part of the medical treatment and should only be given to the sick child. Not to be shared with the rest of the family. If the mother thinks other brothers or sisters need RUTF, she can bring them to the consultation to evaluate their nutritional status.

� It is important that RUTF rations are delivered together with the drugs for medical treatment, to support the explanation that RUTF is a medicine.

� General rules of hygiene and a healthy diet: � Use soap to wash the caregiver’s hands and child’s hands and face before feeding.

� Keep the food clean and covered. If the entire contents of a sachet are not consumed, it can be kept up to a maximum of 24 hours, to avoid any deterioration of its organoleptic qualities. It is recommended that RUTF should be kept in its original sachet. This product, although designed to resist bacterial contamination, is very attractive to flies and other insects.

� It is also important to divide stated quantities throughout the day in small frequent feeds. Children should as much as possible make 5 to 6 meals per day plus one night snack (to avoid hypoglycaemia) RUTF is the main food for the child, should be eaten before or between the family meals. Other foods (porridge, some local meal) should only be given after the RUTF is consumed.

� Plenty of water should be given because RUTF doesn’t contain water and the child becomes thirsty when eating RUTF.

� “Breastfed children should continue breastfeeding, always before the RUTF meal.


� BP-100 can be eaten as a biscuit directly from the pack, or crumbled into water and eaten as porridge. To make a porridge use 2 dl of boiled drinking water per "meal pack" consisting of two BP-100 tablets (2X28.4 g). One bar (two tablets) of BP-100 contains 300 kcal, which is comparable to 300 ml F-100 milk. For each bar of BP-100 consumed the drinking water intake should be at least 2,5 – 3 dl. For children between 6 and 24 months of age BP-100 should preferably be given as porridge.

4. Health promotion on feeding practices To get information on the feeding habits and process of the locality where their work to be able to adapt the health promotion messages and some of the meals.

F. Promotion regarding appropriate feeding practices should be provided to caregivers

5. Health promotion on hygiene During all the duration of treatment give messages on hygiene, and the importance of washing hands (caretaker’s and the child’s) before providing the meals.


ANNEX 7: SUPERVISION FORM INPATIENT – THERAPEUTIC CENTRE I-TFC

This form allows the supervision of a I-TFC. It should be completed with the staff during the field visit of a supervisor (supervisor of the centre, field coordinator, medical coordinator…). It can stimulate a discussion to: • Evaluate the quality of the functioning of the I-TFC in ensuring that the staff carries out their

activities efficiently and develop their skills, • Motivate and encourage the staff • Identify problems and propose solutions

For questions with an "*" are standard for MSF, please refer to the end of the questionnaire.

Check "yes" or "no." The "no" answers are potential difficulties to improve.

1. Staff: Yes / No * There is enough staff in: • Intensive care ❏ ❏ • Phase 1 ❏ ❏ • Transition phase ❏ ❏ • Phase 2 ❏ ❏ • Small infants phase ❏ ❏ There is a job description for each category of staff ❏ ❏ There is a yearly evaluation of the staff ❏ ❏

A staff training program has been established ❏ ❏

Date: ..................................... Location: .......................................................... Name of the centre : ............ .......................................................................... Maximal capacity of the centre : ................................................................... Current number of patients: ........................................................................ Name of the superviseur: .... ..........................................................................


2. The CNT-H buildings Yes / No * The surface area of the structure is sufficient to receive all the children present also during periods of high prevalence ❏ ❏ * The arrangement of the structures is functional ❏ ❏ The different phases of the centre are separated (intensive care, ph 1, T et 2, small infants) ❏ ❏ There is a game, developmental psycho-motor room ❏ ❏ Each bed has storage for cups, clothes... ❏ ❏ Each bed is equipped with a mosquito net ❏ ❏ There is a warm room in intensive care, ph 1 and small infants ❏ ❏ 3. Logistics

Stock of the I-TFC The warehouse is big enough, in good condition and well-ventilated ❏ ❏ * The storage of the goods complies with the following rules: • Stacks of goods are differentiated for each product ❏ ❏ • Damaged goods are stored separately ❏ ❏ • The older products are used first ❏ ❏ • Incoming / outgoing goods are well marked on stock cards ❏ ❏ • Expiry date of food items is checked. ❏ ❏

Milk preparation room The milk preparation room is different from the food preparation room ❏ ❏ The milk is prepared on clean surfaces ❏ ❏ The preparation material is clean ❏ ❏ The milk is prepared with chlorinated water, boiled and cooled to 40 °? ❏ ❏ The different milks are stocked in buckets with lids of different colours to identify the different milks ❏ ❏ The milk is thrown away after 2 hours ❏ ❏ Kitchen The kitchen is big enough, in good condition and well-ventilated ❏ ❏ Yes / No


* The kitchen works with gas ❏ ❏ * The ratio: number of stoves/number of patients is respected ❏ ❏ There is an area for washing and drying for the dishes and cooking instruments? ❏ ❏

Food is protected from flies ❏ ❏ Pharmacy * The pharmacy is air conditioned ❏ ❏ The products are alphabetically stored on shelves by differentiating different dosage forms Incoming / outgoing goods are well marked on stock cards ❏ ❏ * The pharmacy is accessible 24H / 24H ❏ ❏ Expiry date of items is systematically checked ❏ ❏ 4. Water, Hygiene and Sanitation * Enough water is available for the given number of patients ❏ ❏ * All the water used in the CNT-H is chlorinated ❏ ❏ Water is available in each building ❏ ❏ There is a sink for staff in every infirmary? ❏ ❏ There are hydro-alcoholic solutions available ❏ ❏ * There are enough latrines ❏ ❏ The latrines are clean ❏ ❏ * There is a laundry area ❏ ❏ * There are enough showers ❏ ❏ * The floor of each service is washed daily with chlorinated water ❏ ❏ Medical and non-medical waste is collected separately ❏ ❏ The "sharps" are collected in suitable boxes ❏ ❏ Yes / No


Medical waste is incinerated ❏ ❏ 5. Quality of care Admission * Medical Triage (ETAT) is made upon arrival of patients ❏ ❏ Patients requiring care are immediately transferred to the service ❏ ❏ The medical and nutritional information are written on the A3 sheet? • Previous history ❏ ❏ • Systematic treatment ❏ ❏ • Specific treatment ❏ ❏ • Vaccination ❏ ❏ • Nutritional treatment ❏ ❏ • Medical history ❏ ❏ The medical-nutritional admission criteria are respected? ❏ ❏ The caretaker receives non-food items needed during her stay (blankets, cup, chamber pot) ❏ ❏ Explanations concerning the child’s stay are given to the caretaker ❏ ❏ Phases A daily medical visit is organized in intensive care, phase 1, T and small infants ❏ ❏ * The monitoring by the nurses is made at the recommended frequency ❏ ❏ The alert is given in time in case of deterioration of a patient ❏ ❏ The doctors are going to see the patients in the different phases in case of problems ❏ ❏ Weighing is done daily and the weight curve is drawn correctly ❏ ❏ Sugar water is available ❏ ❏ ReSoMal ® is given only on prescription ❏ ❏ Drugs are distributed correctly. Times and prescriptions are respected ❏ ❏ Milk is given on time and in quantities prescribed ❏ ❏ Children drink directly from a cup or small ladle ❏ ❏ Yes / No


The siting of the nasogastric tube is routinely checked before tube feeding ❏ ❏ The tube feedings are made by gravity ❏ ❏ The transition to the next phase is decided at the right time ❏ ❏ In case of a medical problem, the patient returns to phase 1 ❏ ❏ Educational sessions on health and nutrition for mothers are organized ❏ ❏ The department are decorated in a children friendly way ❏ ❏ Games are available for convalescent children ❏ ❏ Activities are proposed to mothers (songs, dance, crafts ...) ❏ ❏ Children are stimulated by their caretakers and staff to promote ❏ ❏ their psycho-motor development? Discharge * The discharge criteria are respected for : • Cured ❏ ❏ • Stabilized ❏ ❏ • Defaulter ❏ ❏ • Non respondent ❏ ❏ • Dead ❏ ❏ * The vaccination scheme is completed for the patients ❏ ❏ The vaccination scheme is completed for the caretakers ❏ ❏ Organisation A weekly medical meeting (doctors, nurses) is organised ❏ ❏ Deaths are discussed by the medical team (doctors, nurses) to understand the reasons and improve care? ❏ ❏ * Children who abandoned the program are immediately traced ❏ ❏ A3 sheets are properly maintained for all treatments and the follow up of the child in the A-TFC ❏ ❏ A3 sheets are given immediately to the data entry person after the discharge of the child ❏ ❏ Yes / No


A hygiene committee is put in place and functional (monitoring the situation, proposals for improving ...)? ❏ ❏ An animation committee is put in place and functional (Organizations of small parties and activities for caretakers…) ❏ ❏ Mothers are involved in the running of the centre (helping in the kitchen or laundry, supporting caretakers in difficulty, animation ...) ❏ ❏


ANNEX 8: Insertion of a Naso-Gastric Tube 1. Objectives

Nasogastric intubation provides access to the stomach via a tube. • To provide nutritional and fluid intake. • To aspirate the content of the stomach. 2. Indications

Nasogastric tube (NGT) feeding is used for: • Providing fluids and food to patients unable to feed themselves normally due to prolonged coma,

anorexia related to complicated acute malnutrition, septicemia, etc. Specialized food, therapeutic milk, artificial milk and medication can all be given using a NGT.

• Aspiration of stomach content, if needed, in case of intestinal obstruction, peritonitis, gastrointestinal bleeding, etc.

• Prevention of vomiting after surgery, until intestinal transit resumes. In a nutritional centre, nasogastric intubation should be used only to verify if milk is well digested, or in children meeting any of the following criteria: • Is taking less than 75% of prescribed diet • Has repeated vomiting • Has painful lesions in the mouth • Is too weak or unconscious • Is severely dehydrated • Has a severe respiratory infection • For infants: if too weak for breastfeeding Limit the use of NGT in the inpatient therapeutic feeding centre (ITFC) to cases of strict necessary and use in Phase 1 only. 3. Inserting a gastric tube It is important to propose feeding by mouth before inserting a tube and before any feeding by tube. Materials

• Hand disinfectant • Clean tray • Gastric tube measured according to the weight of the child. • 2ml syringe for infants, 5ml syringe for children (to verify the placement) • Stethoscope • Vaseline to lubricate or water to moisten the tube • Non-sterile compresses • Adhesive tape (to cut beforehand for fixation) • Non-sterile disposable gloves


• Glass of sugar water, syringe with 1ml of sugar water Placement technique Except in emergencies, NGTs are placed in a fasting patient or long after the patient's last meal, to avoid aspiration. • Explain the procedure to the patient/caretaker. • Position the patient as follows:

o If conscious: in a semi-upright position. o If unconscious: in a lateral decubitus position, head turned to the side. o For infants: in a proclive position; if necessary envelop the upper part of the body.

• Wash your hands, or disinfect them with an alcohol-based solution. • Lay out the materials on the tray. • Put on non-sterile gloves. • Examine the patient's nostrils to see if there is any malformation or obstruction. • Determine the length of tube to insert: using the tube itself, measure the distance from the bridge

of the nose to the earlobe, then from the earlobe to the epigastric fossa.

• Mark the length of tube to insert with a piece of adhesive tape. • Lubricate or moisten the tip of the tube. • Support the patient's head by placing a hand behind the neck. • Insert the tube into one nostril, keeping the patient's head bent slightly forward to facilitate its

passage. • Ask the conscious patient to swallow (e.g. provide a little sugar water) while advancing the tube

up to the predetermined length – as marked by the adhesive tape. If the patient starts to cough, becomes nauseated, or has trouble breathing, remove the tube and let the patient recover before starting over. Re-lubricate the tube and switch to the other nostril.

• In children, hold the head firmly, insert the tube through one nostril and push it in gently. Normally there is no resistance when the tube enters the stomach.

• In case of respiratory distress, abnormal crying or cyanosis, remove the tube immediately and let the child recover before starting over.

• Check to make sure that the tube is correctly placed. There are two techniques for doing this: a. Quickly inject air with the syringe (20-30ml in adults, a few ml in children), with the

stethoscope against the patient's stomach: a characteristic gurgle should be hear. b. Aspirate with the syringe: gastric juices should appear in the tube.


• Attach the tube securely to the patient's nose and cheek with adhesive tape, making sure that the tube is not in the patient's field of vision.

• Reposition the patient • Depending on the indication, begin tube feeding or connect the collection bag or suction device • Dispose of waste • Remove gloves • Wash your hands or disinfect them with an alcohol-based solution • Record the procedure in the patient's chart • For conscious children between 1 and 5 years, it is recommended that you make ‘boxing hands’

(put cotton in the hands and make a bandage around it), to prevent them from taking out the tube. Tube changing and tube removal The NGT must be removed as soon as it is no longer needed. If insertion is still necessary, change the tube every 72 hours and does an oral appetite test in between two meals. If the test fails, introduce a NGT again. • Wash your hands or disinfect them with an alcohol-based solution • Put on non-sterile gloves • Clamp the tube with a Kocher forceps to prevent any fluid leak • Remove the tube while clamped, gently but with a rapid movement, and wipe the patient's nose

with a compress • Discard the tube immediately • Remove gloves • Wash your hands or disinfect them with an alcohol-based solution • Record the procedure in the patient's chart 4. Nasogastric feeding in a feeding centre Materials

• Alcohol-based solution • Therapeutic milk • Stethoscope • Syringe of 5 or 10ml to verify the position of the tube • 60 or 20 ml syringe (Luer or conical tip) fitted to the tube • Non-sterile compresses


Technique • Verify the amount of milk to administer. Every child with an NGT should be offered

breastfeeding or milk before tube feeding. The rest of the milk will be offered through the tube • Explain the procedure to the caretaker and encourage them to participate in giving food. Explain

the procedures of care needed when handling an NGT. • Place the patient in a semi-upright position. • Wash your hands, or disinfect them with alcohol-based solution; ask the caretaker to wash their

hands. • Verify correct placement of the tube. If there is any doubt about the tube's position, pull it out

and insert another. • At the same time: check the presence of non-digested milk in the stomach. If milk is present,

aspirate and measure the quantity: o If it is less than 50% of the quantity received in the previous meal re-give it, and complete

with ‘new’ milk until the volume required is reached. o If there is more than 50% of the quantity received the meal before, do not overload the

stomach as the capacity to digest the food can be assumed to be limited; re-give this quantity and give 10% sugar water (to prevent hypoglycemia) until the next meal.

• Remove the plunger from the syringe. • Clamp the tube by kinking it to prevent air from entering. • Remove the stopper from the tube. • Attach the syringe, without its plunger, to the tube, and fill it with milk. • Feed the child in semi upright position. • Ask the mother to hold the syringe 10cm above the patient's head, unclamp, and let the milk flow

by gravity. Do not inject the milk: this risks vomiting due to rapid filling of the stomach. • Clamp the tube and repeat the operation until all the milk has been administered. Pause between

each syringe of milk and watch for regurgitation.

• Using this method, each feeding should take 10 to 15 minutes. If the flow of milk is too fast,

slightly pinch the tube below the syringe to slow down the flow. Flush the tube with 5 to 10 ml of water to prevent obstruction.

• Wash your hands, or disinfect them with an alcohol-based solution.


• Record the quantity of milk administered on the monitoring sheet. Caution: • While feeding and for 2 hours after feeding, a conscious child should sit in semi upright position;

a child that is unconscious should be fed on his/her side (in lateral position) to avoid reflux. • Therapeutic milk should be consumed within 2 hours of reconstitution to avoid bacterial

contamination. 5. Risks and complications While placing and using a NGT is a relatively simple procedure, it should not be trivialized. This is particularly true of tube feeding in pediatric units and feeding centers, where the major complication remains incorrect placement (tube-fed fluids going into the lungs) with the attendant risk of aspiration pneumonia or even death by suffocation. Major incidents and what to do: • Incorrect placement with tube fed fluids going into the lungs: STOP the feed immediately; if

possible aspirate the liquids and inform the physician without delay. • Obstruction of the tube: Try to rinse the tube with water. If there is no result, take out the tube

and replace it through the other nostril. • Vomiting: stop the feed immediately and rinse the tube verify that it is not obstructed. If there is

no result, take out the tube and replace it. • Gastrointestinal problems: inform the physician. • Placement of the tube in the tracheo-bronchial tree (indicated by cough, abnormal crying,

respiratory distress and/or cyanosis): remove the tube; let the patient recover before reinserting a new tube.

6. Care and monitoring

Hand hygiene

Wash your hands or disinfect them with an alcohol-based solution each time before handling the tube, and put on non-sterile gloves if necessary.

Confirm proper tube position before using the tube, and in case of coughing or vomiting: • Verify that the tube is still securely attached with adhesive tape. • Verify that the tube is well placed by injecting air or by aspirating gastric liquid.

Prevent dryness of mucous membranes • Do a mouth wash and care of the nose at least once a day • As soon as possible, deliver fluid and nutritional intake by mouth.

Prevention of complications • Strictly limit the use of a NGT to the minimum necessary.


• Try to have the tube positioned for as short a length of time as is possible. The tube should not be inserted for longer than 3 days and use in the ITFC should be limited to Phase 1 only.

• Prevent the tube changing position: keep the attachment secure and clean; if it is soiled, uncomfortable or not well attached, change the adhesive tape.

• Sores on the outside of the nostril: as soon as the nostril starts to redden, check nostrils every day, remove the adhesive tape and place in different position.

• Gastro-esophageal reflux is dangerous due to the risk of inhalation; position the patient correctly during feeding and for the two hours following a meal.

• Prevent obstruction of the tube: rinse the tube after every feeding. • Note all liquid quantities given, even those from rinsing the tube or treatment fluids. Every

quantity counts. A malnourished child is at risk of over hydration. • If you have done ‘boxing hands’, open the bandage regularly, verify that it is not too tight

(prevention of scare and necrosis).


OCG - OCBA


January 2015

CASE

MANAGEMENT of

HIV PEDIATRICS

2015

protocols for management · 2017. 5. 16. · age acute gastro – enteritis aom acute otitis media...

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