Why the imam guidelines?

Integrated management of malnutrition (IMAM) aims at maximizing coverage and

access to care of malnutrition through timely detection and appropriate management.
IMAM has four components:
1) Inpatient therapeutic care (ITC) for patients with acute malnutrition and medical
complications and infants less than 6 months of age who have visible signs of acute
malnutrition or who have failed to feed
2) Outpatient therapeutic care (OTC) for acute malnutrition with no medical
complications
3) Supplementary feeding program (SFP), used in difficult circumstances
4) Community linkage for early identification, referral, and follow-up of acutely
malnourished cases
Patients can be transferred from one type of care to another, depending on medical
complications, response to treatment, availability of functional community structures
and programs.

Advantages of Integrated Management

 Reduces unnecessary exposure to additional infection risks in health facilities
 Results in caregiver spending less time in hospital, away from home and family
 Causes less disruption of caregiver’s economic activities
 Reduces congestion in the health facility and health worker workload
 Reduces health facility costs and allows reallocation of resources to other priorities
 Contributes to early diagnosis of HIV infection for better care and outcome

Let examine the Outpatient Therapeutic Care (OTC)

Outpatient Therapeutic Care (OTC) Session
OTC provides home-based treatment and rehabilitation for children, adults, and pregnant/
lactating women who are severely acutely malnourished, moderately acutely malnourished but
have appetite and are free of medical complications.

Remember, OTC is based on three key factors:

1. Absence of medical complications
2. Availability of RUTF
3. Availability of functional community structures

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Visualize the common activities we do at the OTC center

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Management of moderate acute malnutrition at the OTC center

1. What are the primary objectives of Management of moderate acute malnutrition

at this center?
2. What are the essential components of Moderate Acute Malnutrition (MAM)
management at this center?

Answer: The primary objectives of MAM management are:

To prevent deterioration to Severe Acute Malnutrition (SAM).

To treat Moderate Acute Malnutrition (MAM).

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 To ensure a continuum of care between MAM and SAM treatment services.

The essential components (must do activities) for MAM management at the OTC center
include:

 Nutrition assessment and classification to determine the nutritional status.

 Nutrition counselling and education to inform caregivers about proper feeding

practices.

 Care or referral for other illnesses/conditions that may affect nutritional status.

 Routine medicines to address common health issues that can complicate malnutrition.

 Supplementary feeding to provide additional nutrients (where services exist).

 Food assistance to support the dietary needs of the affected individuals.

 Follow-up and linkage to livelihood programs to support long-term recovery.

 Monitoring for failure to respond to treatment.

 Monitoring and Evaluation to assess the effectiveness of the MAM management

program.

 Follow-up to ensure continued care and support for recovery.

Management of Moderate Acute Malnutrition in Children aged 6-59 months in Normal

Situations

Admission Criteria

All children aged 6 – 59 months and any child with age ≥6 months whose height is
≤120 cm with MAM classified according to Table 3 below should be admitted at the
OTC, located at the health facility or SFP for management
MAM children should have ability to eat or appetite; and no medical complications
according to the IMNCI criteria or WHO guidelines.

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After the client has passed the entry criteria; RUTF IS ADMINISTERED

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Counselling on RUTF Administration

During the initial visit, the service provider should explain the following:

1. Purpose of RUTF:

 Emphasize that RUTF should only be used as medicine to treat the malnourished
client and should not be shared with other members of the family or community
who are hungry.

2. Administration Method:

 Instruct on how to administer doses of RUTF by cutting the packet at one corner
and having the client eat the paste from the sachet or on a clean spoon.

3. Frequency and Consumption:

 Explain that RUTF should be given to the client frequently, and the client should
consume all of the RUTF possible at each feeding.

 Emphasize that the day’s entire dose should be consumed each day before
consuming any other food.

4. Integration with Breastfeeding:

 For children who are breastfeeding, clarify that RUTF should be given soon after
breastfeeding. Breastfeeding should continue even though the child is taking
RUTF.

5. Water Consumption:

 Advise to provide generous amounts of boiled or treated water to the individual

while eating RUTF because it might cause choking.

6. Hygiene Practices:

 Stress the importance of washing the client’s hands with soap and water before
feeding.

7. Storage and Safety:

 Explain that RUTF must be kept in a secure place and out of reach of children or
other people in the house to prevent accidental consumption.

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Trigger actions for the management of children with Moderate Acute Malnutrition
(MAM) who fail to respond to treatment

1. What is the recommended action for a child with MAM who has a MUAC of less than
11.5 cm, no medical complications, and an appetite?

Answer: The recommended action is to transfer the child to Outpatient Therapeutic Care
(OTC).

2. What is the appropriate action for a child with MAM who presents with oedema?

o Answer: Transfer the child to the nearest health facility for further assessment
and treatment.

3. If a child with MAM shows no weight gain for two consecutive visits, what should
be the next step?

o Answer: Transfer the child to the nearest health facility for evaluation.

4. What should be done for a child with MAM who has not recovered after three
months of treatment?

o Answer: Transfer the child to the nearest health facility to investigate possible
underlying causes.

Details of the trigger actions;

Trigger actions for managing children with Moderate Acute Malnutrition (MAM) who fail to
respond to treatment are critical for ensuring timely intervention and preventing the
progression to Severe Acute Malnutrition (SAM). Here’s a summary of the actions to be taken
based on different signs and triggers:

 MUAC (Mid-Upper Arm Circumference):

o <11.5 cm without medical complications and has appetite: Transfer to

Outpatient Therapeutic Care (OTC).

o <11.5 cm with medical complications: Transfer to Inpatient Therapeutic Care

(ITC).

 Oedema:

o Present: Transfer to the nearest health facility for further assessment and
treatment.

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  Any danger sign of medical condition:

o Present: Transfer to the nearest health facility for immediate care.

 Weight changes:

o Weight loss in any follow-up visit: Transfer to the nearest health facility.

o No weight gain for 2 visits or static weight for 3 visits: Transfer to the
nearest health facility for evaluation.

 Non-response:

o Not recovered after 3 months: Transfer to the nearest health facility to

investigate possible underlying causes.

 Absence:

o Absent for one visit: Conduct home visits or phone calls to follow up.

 Default:

o Absent for two consecutive visits: Conduct home visits to re-engage the
patient in treatment.

These actions are designed to escalate care appropriately and ensure that children with MAM
receive the necessary support to recover and thrive. It’s important for healthcare workers to be
vigilant and responsive to these triggers to provide the best possible outcomes for the child.

PREVENTIVE MEASURES EMPAHISIZED IN MAM MANAGEMENT

5. Discuss the importance of the four essential preventive measures in the

integrated management of acute malnutrition for children under two years of
age.
6. Explain how each measure contributes to the prevention of Moderate Acute
Malnutrition (MAM).

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Exclusive Breastfeeding: Exclusive breastfeeding for the first six months of life is crucial
because breast milk provides all the necessary nutrients and antibodies an infant needs. It is
easily digestible, promotes sensory and cognitive development, and protects against infectious
and chronic diseases. By providing optimal nutrition, exclusive breastfeeding helps prevent
MAM by ensuring that infants have a strong nutritional foundation.

Introduction of Nutrient-Dense Foods: At six months, infants require additional nutrients for
growth and development that breast milk alone can no longer supply. Introducing appropriate
energy and nutrient-dense foods, including oils and animal products, supports catch-up growth
and helps meet the increased nutritional demands of growing infants. This transition is vital for
preventing MAM as it ensures that children continue to receive adequate nutrition as they
grow.

Hand-Washing Practices: Hand-washing with soap before eating and after using the toilet is
a simple yet effective way to prevent the spread of infections. Good hygiene practices reduce
the incidence of diarrheal diseases and other infections that can lead to malnutrition or
exacerbate existing malnutrition. By preventing illness, hand-washing contributes significantly
to the prevention of MAM.

Recognizing Danger Signs: Educating caregivers to recognize the early signs of malnutrition
and other health issues enables timely intervention. Early detection and treatment of MAM can
prevent its progression to severe malnutrition, which is more difficult to treat and has long-
term health implications. Understanding and acting upon danger signs is a critical preventive
measure against MAM.