2018 SAM Protocol English
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christina labanREPUBLIC OF RWANDA
MINISTRY OF HEALTH
PROTOCOL FOR THE MANAGEMENT OF
ACUTE MALNUTRITION
FEBRUARY 2018
MINISTRY OF HEALTH
2
Protocol for the Management of Acute
Malnutrition
FEBRUARY 2018
3
4
CONTENTS
Contents.........................................................................................................................................2
5
List of tables ..................................................................................................................................7
9
List of boxes ..................................................................................................................................8
10
List o gures .................................................................................................................................8
10
Acronyms and abbreviations ........................................................................................................9 11
Preace ........................................................................................................................................11
13
Acknowledgements......................................................................................................................12 14
1. Pathophysiology o severe acute malnutrition (SAM) .....................................................14 16
2. Denition o Severe Acute Malnutrition ...........................................................................18 19
3. Management in the Community.......................................................................................21 21
3.1 Community engagement ................................................................................................21 21
3.2 Community screening .....................................................................................................22 22
3.3 Home visits ......................................................................................................................23 23
4. Triage at the health acility ..............................................................................................25 25
4.1 The appetite test..............................................................................................................25 25
4.1.1 The observed appetite test .............................................................................................25 25
4.1.2 Why to do the appetite test? ...........................................................................................25 25
4.1.3 How to do the appetite test.............................................................................................26 26
4.2 Medical history and examination.....................................................................................27 27
4.2.1 Take the history ...............................................................................................................28 27
4.2.2 Examine the child.............................................................................................................28 28
4.3 Decision rom triage criteria on whether to treat as an in- or outpatient .........................29 29
4.4 Classication o nutritional oedema..................................................................................31 30
4.5 Transport o sick patients.................................................................................................31 31
4.5.1 IPF ...................................................................................................................................32 31
4.5.2 OTP .................................................................................................................................32 31
4.5.3 District Hospital Nutrition Ocer (ocal point) and Emergency Department ..................32 31
5. Outpatient management o SAM in children aged over 6 months ..................................34 33
5.1 Tools or OTP ..................................................................................................................34 33
5.2 Initial assessment............................................................................................................35 34
5.3 Ensure decision-making or outpatient or inpatient care was appropriate
during triage ...................................................................................................................35 34
5.3.1 First priorities ..................................................................................................................36 34
5.4 Medical management .....................................................................................................36 35
5.4.1 Treatment to be given in the clinic ..................................................................................36 35
5.5 Dietary treatment in outpatient care ...............................................................................39 37
5.6 Monitoring and ollow-up treatment as an outpatient .....................................................42 39
5.7 Failure to respond to treatment as an outpatient.............................................................45 42
5.8 End o outpatient care treatment ....................................................................................47 44
5.8.1 Criteria or the end o treatment ......................................................................................47 44
5.8.2 Procedures or the end o treatment ..............................................................................48 45
6. Management o complications o severe acute malnutrition in children
over 6 months o age ......................................................................................................50 46
6.1 Emergency Triage Assessment and Treatment in hospital settings ...............................50 46
6.1.1 Principles o ETAT+ .........................................................................................................50 46
6.1.2 Shock ..............................................................................................................................52 48
6.1.3 Dehydration but no shock ...............................................................................................55 50
6.1.4 Hypernatræmic dehydration ..........................................................................................59 53
6.1.5 Respiratory distress ........................................................................................................61 56
6.1.6 Severe pneumonia .........................................................................................................61 56
6.1.7 Congestive heart ailure .................................................................................................62 56
6.1.8 Anaemia ..........................................................................................................................63 56
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6.1.9 Convulsions .....................................................................................................................65 60
6.1.10 Hypoglycaemia ...............................................................................................................66 60
6.1.11 Hypothermia ...................................................................................................................67 61
6.1.12 Eye signs o vitamin A deciency ....................................................................................68 62
6.1.13 Candidiasis ......................................................................................................................69 62
6.1.14 Parasitic inections ...........................................................................................................69 63
6.1.15 Helminthiasis ...................................................................................................................70 63
6.1.16 Persistent diarrhoea .........................................................................................................70 64
6.1.17 Osmotic diarrhoea caused by carbohydrate intolerance (re-eeding diarrhoea) ...........70 64
6.1.18 Cholera or very severe watery diarrhoea ........................................................................71 64
6.1.19 Eye inections ..................................................................................................................71 65
6.1.20 HIV ...................................................................................................................................71
65
6.1.21 Tuberculosis ...................................................................................................................72 65
6.1.22 Malaria .............................................................................................................................72
66
6.1.23 Measles ...........................................................................................................................72 66
6.1.24 Meningitis ........................................................................................................................73 66
6.1.25 Otitis media ......................................................................................................................73 67
6.1.26 Skin inections .................................................................................................................73 67
6.1.27 Inection ater admission .................................................................................................76 69
6.1.28 Re-eeding syndrome ......................................................................................................76 68
6.2 Routine inpatient management o SAM in children aged over 6 months o age .............77 70
6.2.1 Full assessment................................................................................................................77 70
6.2.2 Laboratory and other investigations ................................................................................77 70
6.2.3 Systematic treatment .......................................................................................................78 71
6.2.4 Prevention o hypothermia ...............................................................................................78 71
6.2.5 Management o inections and other medical conditions ...............................................79 71
6.2.6 Electrolyte management and micronutrient supplementation .........................................80 71
6.2.7 Initial re-eeding ...............................................................................................................81 74
6.2.8 Transition phase...............................................................................................................86 77
6.2.9 Rehabilitation in the IPF....................................................................................................88 79
6.3 Failure to respond to treatment in the IPF .......................................................................88 80
6.3.1 Problems with care practices in inpatient care ...............................................................90 81
6.3.2 Problems with the treatment o the child in inpatient care .............................................83 92
7A. Management o SAM in inants aged less than 6 months ...............................................94 85
7A.1 Structure and organisation .............................................................................................95 86
7A.2 Assessment at health-acility level ..................................................................................95 86
7A.3 Activities and tools ..........................................................................................................96 86
7A.3.1 Activities...........................................................................................................................96
86
7A.3.2 Tools ................................................................................................................................96
87
7A.4 Admission criteria or SAM/ lactation ailure in inants aged less than 6 months.............96 87
7A.5 History and examination ..................................................................................................97 88
7A.6 Supplemental eeding technique ....................................................................................97 88
7A.6.1 At the beginning o the SS technique ..............................................................................97 88
7A.6.2 Later, as the inant becomes stronger .............................................................................98 88
7A.6.3 Diet and amounts to give ................................................................................................99 89
7A.6.4 Procedure ......................................................................................................................100 90
7A.7 Routine treatment ..........................................................................................................101 91
7A.7.1 Antibiotics ......................................................................................................................101 91
7A.8 Care or the mothers ......................................................................................................101 91
7A.9 Preparing or discharge rom hospital ...........................................................................102 92
7A.9.1 Health and nutrition counselling ....................................................................................102 92
7A.9.2 Psychological support to the mother or carer, plus health and nutrition support .........102 92
7A.9.3 Criteria or reerral to outpatient inant and young child eeding/nutrition support ........103 92
7A.10 Discharge ........................................................................................................................103 92
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7B. Nutritional support to inants with no prospect o breasteeding ...................................105 94
7B.1 Feeding during stabilization ..........................................................................................105 94
7B.2 Feeding during transition ..............................................................................................105 94
7B.3 Feeding during rehabilitation.........................................................................................105 94
8. Management o SAM in older children, adolescents and adults ...................................107 95
8.1 Principles o management .............................................................................................107 95
8.2 Assessment and classication o malnutrition ...............................................................107 95
8.2.1 School-aged children (5–9 years)..................................................................................107 95
8.2.2 Adolescents (10–18 years) ............................................................................................107 95
8.2.3 Adults (over 18 years) ...................................................................................................108 95
8.3 History and physical examination ..................................................................................108 96
8.4 Initial management ........................................................................................................108 96
8.5 Failure to respond to treatment .....................................................................................109 96
8.6 Preparation or discharge rom hospital and end o treatment .....................................109 97
8.7 Criteria or discharge rom inpatient care, and end o treatment ..................................109 97
9. Emotional and physical stimulation o children .............................................................110 98
9.1 Outpatient care ..............................................................................................................110 98
9.1.1 Child-riendly spaces .....................................................................................................111 98
9.1.2 Mother/carer and baby groups......................................................................................111 99
9.2 Inpatient care ................................................................................................................111 99
9.2.1 The environment ............................................................................................................111 99
9.2.2 Play activities..................................................................................................................11299
9.2.3 Physical activities ..........................................................................................................112 100
10. Counselling on growth and eeding ..............................................................................114 102
11. Counselling and psychosocial support to the mother or carer .....................................116 103
12. Follow up ater the end o treatment ..............................................................................117 103
13. Moderate acute malnutrition ..........................................................................................119 105
13.1 Objectives ......................................................................................................................119 105
13.2 Organisation ..................................................................................................................119 105
13.2.1 Opening and closing a supplementary eeding camp or programme (SFC/SFP) ........119 105
13.2.2 Structure .........................................................................................................................12
106
13.2.3 Stang ..........................................................................................................................121
106
13.3 Admission.......................................................................................................................123 108
13.3.1 Type o admission............................................................................................................123 108
13.3.2 Admission procedure.....................................................................................................123 108
13.4 Diet ................................................................................................................................124
109
13.4.1 Type o supplementary eeding .....................................................................................124 109
13.5 Routine medicine ..........................................................................................................126 110
13.5.1 Vitamin A supplementation ...........................................................................................126 110
13.5.2 Albendazole/mebendazole..............................................................................................126 111
13.5.3 Iron/olic acid supplementation .....................................................................................126 111
13. 6 Surveillance.....................................................................................................................127111
13.7 Diagnosis o ailure-to-respond to treatment...................................................................128 111
13.7.1 Criteria or ailure-to-respond to treatment.......................................................................128 112
13.7.2 Reasons or ailure to respond.........................................................................................128 112
13.7.3 Step-by-step procedure to address ailure to respond ..................................................128 112
13.8 Discharge procedure ....................................................................................................129 113
14. Prevention o malnutrition................................................................................................131 114
14.1 Introduction ....................................................................................................................131 114
14.2 Objectives.......................................................................................................................131 114
14.3 Key interventions ...........................................................................................................131 114
14.4 Further reading..............................................................................................................133 116
15. Monitoring and evaluation..............................................................................................135 117
15.1 Monitoring the eectiveness o treatment .....................................................................135 117
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15.1.1 Supportive supervision ..................................................................................................135 117
15.1.2 Perormance monitoring .................................................................................................136 118
15.2 Monitoring programme coverage ..................................................................................136 118
16. Management o SAM in emergency situations ..............................................................138 119
16.1 General considerations .................................................................................................138 119
16.2 Preparedness/contingency planning..............................................................................38 119
16.3 Emergency response.....................................................................................................139 120
16.3.1 Reinorcing health services or receiving a large infux o children................................139 120
16.3.2 Example or strengthening outpatient care ..................................................................139 120
16.3.3 Example or strengthening inpatient care ....................................................................140 120
16.4 Principles o management .............................................................................................140 121
16.5 Other considerations .....................................................................................................141 121
16.5.1 Community participation ................................................................................................141 121
16.5.2 Early childhood development activities .........................................................................141 122
16.5.3 Inant and young child nutrition .....................................................................................141 122
16.5.4 Expanding associated health activities ..........................................................................142 122
Annexes ....................................................................................................................................143
123
Annex 1: Anthropometric measurement techniques.........................................................144 123
Annex 2. Nutrition screening tally sheet using MUAC.......................................................150 129
Annex 3. Weight-or-height table (WHO, 2006) ................................................................152 130
Annex 4. Weight-or-height: adolescents ..........................................................................155 132
Annex 5 BMI Chart: Adult ................................................................................................158 134
Annex 6. Registration book or OTP and IPF Pages 1 and 2 ...........................................159 135
Annex 7. OTP chart page 1 and 2 ....................................................................................161 137
Annex 8. Transer orm .....................................................................................................163 139
Annex 9: Variable RUTF in OTP ........................................................................................165 140
Annex 10. 5% weight loss and weight gain table .............................................................. 166 141
Annex 11: Weight gain (g/kg per day) ater 14 days interval .............................................167 142
Annex 12. IPF charts or patient and inant less than 6 months o age without
any carer ...........................................................................................................168 143
Annex 13. Critical care chart................................................................................................175 147
Annex 14. How to insert a nasogastric tube........................................................................176 148
Annex 15. The disadvantages o indwelling cannulae .......................................................178 149
Annex 16. History and examination sheet ..........................................................................180 150
Annex 17. SS chart with SS eeding or inants less than 6 months or 3kg ........................184 152
Annex 18. RUTF specications ...........................................................................................185 153
Annex 19. Drug doses in the severely malnourished..........................................................190 156
Annex 20. Registration book or SFP .............................................................................194
160
Annex 21. Card or MAM children ......................................................................................196 161
Annex 22. Advantages and disadvantages o dry and wet eeding ..............................197
162
Annex 23. Nutrient density o RUSP....................................................................................199 163
Annex 24. Laboratory tests .................................................................................................201 164
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LIST OF TABLES
Table 1. Admission criteria or SAM.............................................................................................18 19
Table 2: Amount o RUTF to assess the appetite o severely malnourished children..................27 27
Table 3: Cut-o points or respiration rate in SAM children..........................................................29 28
Table 4. Classication o cases or initial reerral to inpatient or outpatient care.........................30 29
Table 5. Grades o oedema..........................................................................................................31
30
Table 6 Medication or newly admitted OTP patients: omit or patients transerred rom IPF......36 35
Table 7. Mebendazol/albendazol drug dosage ..........................................................................38 36
Table 8. First dose vitamin A beore transer to IPF.....................................................................38 36
Table 9. Recommended dosage o RUTF according to the weight o the child .........................40 38
Table 10. Activities required at ollow-up visits ...........................................................................42 40
Table 11. Action table or ollow-up visits: on ollow-up visits, the danger signs shoul
be reassessed .............................................................................................................43
41
Table 12. Failure to respond criteria ...........................................................................................4542
Table 13. Amounts o IV fuid or children with SAM and shock due to severe dehydration
to give in the rst hour (do not give an initial bolus to SAM children) ........................... 49
Table 14. ‘Look up’ table or the Initial Phase (Phase 1) .............................................................80 74
Table 15: ‘Look up’ table or eeds in Transition Phase ...............................................................84 78
Table 16 Criteria or ailure to respond to treatment.....................................................................87 80
Table 17: Criteria o admission o young inant with a caretaker ................................................94 87
Table 18. Amounts o SS-milk or inants during SS eeding.......................................................98 90
Table 19: Criteria o discharge or inants less than 6 months with a caretaker ........................101 93
Table 20. Classication o thinness in adults by body mass index ...........................................105 96
Table 21: Example o ration required per child per day – strategy 1 initial diet ........................122 110
Table 22: Summary o the surveillance in SFC ..........................................................................124 111
Table 23. Discharge criteria ......................................................................................................126
113
9
LIST OF BOXES
Box 1. Physiological basis or treatment o SAM.............................................................15 17
Box 2. Opportunities or the identication o SAM at community level ...........................23 23
Box 3. Overview o activities in outpatient management o SAM.....................................34 33
Box 4. Treating with RUTF at home: messages or the caretaker.....................................41 39
Box 5. Causes o ailure to respond to treatment as an outpatient..................................45 43
Box 6. Criteria or admission and discharge rom outpatient treatment
(children aged 6–59 mo.).....................................................................................47
44
Box 7. Summary o steps in Emergency Triage Assessment and Treatment (ETAT)......49 46
Box 8. Rehydration solution or malnutrition (ReSoMal) ..................................................55 51
Box 9. Summary o the routine treatment during phase 1...............................................83 76
Box 10. Frequent causes o ailure to respond to treatment in inpatient care ................87 81
Box 11. Inant and young child eeding counselling and support services...................114 104
LIST OF FIGURES
Figure 1: Summary o triage decision-making or IPF or OTP..........................................31 31
89
Figure 2. Supplementary suckling technique..................................................................97
Figure 3: Home-made play items (diagram supplied by
101
Proessor S. Grantham-McGregor).................................................................110
10
ACRONYMS AND ABBREVIATIONS
BMI Body mass index
CHW Community health worker
CSB Corn-soya blend
ECD Early childhood development
ETAT Emergency triage, assessment and treatment
ETAT+ Emergency triage, assessment and treatment plus admission
F100 Ready-to-use ormula or transition and rehabilitation phase o inpatient care
F75 Ready-to-use ormula or phase 1 o inpatient SAM care
FBF Fortied blended ood
Hb Haemoglobin
HIV Human immunodeciency virus
IM Intramuscular
IMAM Integrated management o acute malnutrition
IMCI Integrated management o childhood illnesses
IMPAC Integrated management o pregnancy and childbirth
IP Inpatient
IPF Inpatient acility
IV Intravenous
IYCF Inant and young child eeding
MAM Moderate acute malnutrition
MIYCF Maternal, inant and young child eeding
MNP Micronutrient powder
MUAC Mid-upper arm circumerence
NCHS National Centre or Health Statistics, United States
NFNP National Food and Nutrition Policy
OP Outpatient
ORS Oral rehydration solution
OTP Outpatient therapeutic programme
PRBC Packed red blood cells
ReSoMal Rehydration solution or malnutrition
RUSF Ready-to-use supplementary ood
RUTF Ready-to-use therapeutic ood
SAM Severe acute malnutrition
SFC Supplementary eeding camp
SFP Supplementary eeding programme
SS Supplemental suckling
TB Tuberculosis
WASH Water, sanitation and hygiene
W/H Weight-or-height
W/L Weight-or-length
WHZ Weight or height/length Z-score
WHO World Health Organization
11
12
PREFACE
Malnutrition remains one o the most common causes o morbidity and mortality among
children throughout the world – malnourished children are at risk o death or severe
impairment o growth and psychological development.
This manual is or the treatment o patients with severe acute malnutrition in hospitals and
health centres. It is intended or all health personnel, including paediatricians, doctors,
nurses, nutritionists and all others that care or such patients.
Since the WHO publication Management o severe malnutrition: a manual or physicians
and other senior health workers was produced in 1999, many advances have been made
in the treatment o severe acute malnutrition. New evidence involving the use o ready-
to-use-oods, and greater emphasis on community engagement, has enabled children
with uncomplicated severe acute malnutrition to be treated as outpatients rather than
requiring admission to hospital. Updated growth reerence standards or children have
been universally accepted, and mid-upper arm circumerence has been adopted as a
separate criterion or diagnosing acute malnutrition. There is also a better understanding
o the needs and management o inants aged less than 6 months.
Ater a brie introduction to the pathophysiology, to explain why the treatment or severely
malnourished children diers rom the treatment o normal children, and denitions o
severe acute malnutrition, the guideline’s chapters ollow the normal fow o patients rom
the community to the outpatient treatment in health centres and then to the hospital or
the more serious cases with complications. Additional chapters deal with children under
6 months, older children, adolescents and adults as well as counselling, prevention and
the treatment o moderately malnourished children. Organisational and reporting issues
(including job descriptions, perormance indicators and responsibilities as well as the
Health Inormation Monitoring Services) are not included in this guideline, as they are
integrated with the rest o the health services.
The Government intends that this protocol should replace any existing guide or treating
severely malnourished patients and should be used throughout Rwanda.
Dr Diane GASHUMBA
Minister o Health
13
ACKNOWLEDGEMENTS
The Ministry o Health (MoH) acknowledges the valuable contributions o various
stakeholders in the development o this National Protocol or the Management o Acute
Malnutrition. The process included a series o consultative meetings and workshops in
collaboration with relevant stakeholders in nutrition, who reviewed various materials and
experiences in the management o acute malnutrition in Rwanda and global research
ndings.
We express our sincere gratitude and indebtedness to Rwanda Biomedical Center (RBC),
UNICEF Rwanda and WHO Rwanda or nancial support; and members o the Food
and Nutrition technical working group, the World Food Programme (WFP), Association
des Pédiatres du Rwanda, Rwanda Nutritionists Society (RNS), Catholic Relie Services
(CRS), Netherlands Development Organisation (SNV), USAID, University Central Hospital
o Kigali (CHUK), University Teaching Hospital o Butare (CHUB) and King Faizal Hospital
or technical support in developing and nalizing the National Protocol. Further, we highly
appreciate Pro Michael Golden and Dr Yvonne Grellety or their technical support.
The review o these guidelines was done under the guidance o the Rwanda Biomedical
Centre; the Maternal Child and Community Division under the leadership o Dr. Felix
Sayinzoga is grateully acknowledged.
Dr Jeannine Condo
Director General Rwanda Biomedical Center
14
The MoH would also like to acknowledge the ollowing experts who made technical
contributions to this publication:
List of attendees at the Ruhengeri Workshop
Name ProvenanceAliation Telephone
BWIZA MUHIRE Hippolyte RPA 0788604294
DUKUZEYEZU Diogene HD Kirehe 0788453691
DUSENGIMANA Gratien NEMBA.DH 0788871350
GAKUMBA Alexis RPA/RUSHOGE HOS 0784166771
HABARUREMA Nicodem RBC 0788856694
HAKIZIMANA Placide Hosp.GISENYI 0781050164
KABASHA GASHATI Innocent Karongi 0788481444
KANYANKORE William DH Gisenyi 078 8305785
KARANGWA Valens RPA 0788452796
KARINIJABO Tabaro KFH Kigali 0789055548
KAYITESI Claudette CHUK 0788215425
KAYITESI Diane Patricie RPA 0783016894
KAYUMBA JOSEPHINE UNICEF 0788519361
KENGAYIGA Sapience CHUB-HUYE 0788776232
MUCUMBITSI Alexis RBC 0788585333
MUKESHIMANA Pauline RPA 0787449301
MURERWA ALICE NTURO WFP 0785703163
MWITABAGOMA Augustin BUTARO .DH 0783132943
NIYITEGEKA Jean Paul Ngorororeo 0788669923
NSENGIMANA Thacien DH Gisenyi 0788403616
NTAGANDA JUSTIN RBC/UNICEF 0788489801
NYALIHAMA Alain RPA 0788400424
NYIRASAFARI Rosine RPA 0783016894
NYIRIMANZI Naphtal RPA/CHUB 0783156255
RUGAZA SEBAGABO Nehemie BYUMBA DH 0788446256
RUKABYARWEMA J.Paul RPA 0788809771
RUKUNDO Etienne KABGAYI DH 0788411765
SENKUNDA Vincent Rwamagana Hosp 0788474258
TUYISENGE Anne-Marie RPA 0788571455
UWAMALRIYA Donatille Gisenyi DH 0788684328
UWINEZA Agnes MCCH/RBC 0789921344
UWIRAGIRE Emmanuel RPA 0788568462
YOUSSOUF KOITA UNICEF 07817822798
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1. PATHOPHYSIOLOGY OF SEVERE ACUTE
MALNUTRITION (SAM)
It is important to have specic guidelines or the management o SAM, because o the
proound physiological and metabolic changes that take place when a child becomes
malnourished. A malnourished child’s metabolism reduces activity, to adapt to the lack o
nutrients and energy, and slows down to survive on a limited intake o essential nutrients
in order to preserve essential body unctions. These changes aect every cell, tissue and
system. The process o change is called reductive adaptation.1
The initial reductions do not alter the ability o the body to respond to minor changes but
they impair its capacity to cope with stressul situations (inection, cold, an intravenous
inusion or excessive oral liquids). For example, the circulatory system may be working
properly at rest with no signs or symptoms but it may not be able to cope with a
sudden increase o circulatory volume, such as ater an inusion or a transusion. Since
the physiological responses to this increased volume are impaired, a simple inusion
may result in cardiac ailure, cardiogenic shock and lethal pulmonary oedema. Similar
restriction applies to the digestive system – the amount o protein and other nutrients
that can be absorbed in one meal is limited (so a large bolus o ood my give diarrhoea).
All other body unctions – the immune system and its ability to respond to inection; the
liver’s ability to detoxiy; the kidney’s ability to excrete; and hormonal responses – are
aected too.
Some o these changes in organ and system unctions result in unusual signs and
symptoms. For example, because o the changes in metabolic and physiological
responses, children with SAM oten do not present the typical clinical signs o inection
(such as ever) that well-nourished children show when they are ill. In act, inection
very oten presents with hypothermia. Importantly, the diagnosis o dehydration is
very dicult in the malnourished patient and the signs normally used or diagnosis are
present in the malnourished child that is not dehydrated. Moreover, these children do not
respond to medical treatment in the same way as they would i they were well nourished.
Therapeutic decisions that are liesaving in a well-nourished child can be potentially atal
in the malnourished child. For children with SAM, treatment protocols or some medical
complications, such as dehydration or shock, must be changed rom the treatment
protocols or ill children who are well nourished. Misdiagnosis o clinical signs is common:
medical complications, inappropriate treatment and eeding o children with SAM
contribute to slow convalescence and increased mortality rates. The pathophysiological
responses o children with SAM increase the risk o lie-threatening complications that
can lead to death.
Successul management o SAM in children aims to restore their metabolism through
correction o electrolyte imbalance, reversal o metabolic abnormalities, restoration o
organ unctions, and then provision o balanced nutrition or catch-up growth; it also
treats underlying inections and other medical conditions. Rapid changes (such as rapid
eeding or fuids) beore the physiology is normalised can overwhelm the body systems,
so eeding must initially be slow and increased progressively as appetite increases. The
1 Jackson, A.A & Golden, M.H. (1983). ‘Protein energy malnutrition’. In: Weatherall, D.J., Ed. Oxord Textbook o
Medicine. Oxord University Press. pp 812-21.
16
appetite test is used as the criterion to move to a transition phase.
Nearly all children with severe malnutrition have bacterial inections. However, as a result
o reductive adaptation, the usual signs o inection (infammation or ever) are not usually
present. Common inections in the severely malnourished child are septicaemia, urinary
tract inection and pneumonia. In a child with SAM, it is assumed that inection is present
and, on admission, he or she will be treated with broad-spectrum antibiotics. Particular
inections and medical conditions that are identied (such as Shigella) are also treated
specically.
Great care should be exercised in prescribing drugs to children with SAM because they
will have, or example, abnormal kidney and liver unctions; changed levels o enzymes
that metabolize and excrete drugs; excess entero-hepatic circulation (reabsorption)
o drugs that are excreted in the bile; decreased body at, hence increasing the
concentration o at-soluble drugs in the brain; and, in kwashiorkor, a possibly deective
blood-brain barrier. Few drugs have had their pharmacokinetics, metabolism or side
eects estimated in individuals with SAM. For instance, drugs such as paracetamol can
cause serious hepatic damage, amphotericin B always reduces renal unction, anti-
histamine and anti-vomiting drugs result in severe depression o cerebral unction, and
ivermectin can cause convulsions.
Box 1 summarizes the main alterations in each o the body systems in SAM. Knowledge
o these changes can aid understanding o the evolution and treatment o SAM and its
complications.
Box 1. Physiological basis for treatment of SAM
Cardiovascular system Gastrointestinal system
• Cardiac output and stroke volume are reduced. • Production o gastric acid is reduced.
• Inusion o saline may cause an increase in • Intestinal motility is reduced.
venous pressure. • The pancreas is atrophied and production o
• Any signicant increase in blood volume can digestive enzymes is reduced.
easily produce acute heart ailure; any decrease • The mucosa o the small intestine is atrophied;
will urther compromise tissue perusion. secretion o digestive enzymes is reduced.
• Blood pressure is low. • Absorption o nutrients is reduced when large
• Renal blood fow and circulation time are amounts o ood are eaten.
reduced. • The eyes become sunken because o loss
• Plasma volume is usually normal and red cell o orbital at – this is not a reliable sign o
volume is reduced. dehydration.
Liver function Genitourinary system
• Synthesis o all proteins is reduced. • Glomerular ltration rate is reduced.
• Abnormal metabolites o amino acids are • The capacity o the kidney to excrete excess
produced. sodium, acid or a water load is greatly reduced.
• The capacity o the liver to take up, metabolize, • Urinary phosphate output is low.
and excrete toxins is severely reduced. • Sodium excretion is greatly reduced.
• Energy production rom substrates such as • Urinary tract inection is common.
galactose and ructose is slower than normal.
• Gluconeogenesis is reduced, with high risk o
hypoglycaemia especially during inection.
• Bile secretion is reduced.
17
Metabolism Endocrine system
• Basic metabolic rate is reduced by about 30%. • Insulin levels are reduced and the child has
• Energy expenditure due to activity is very low. glucose intolerance.
• Both heat generation and heat loss are • Insulin growth actor 1 (IGF-1) levels are
impaired; the child becomes hypothermic in reduced, although growth hormone levels are
a cold environment and hyperthermic in a hot increased.
environment. • Cortisol levels are usually increased.
Immune system
• All aspects o immunity are reduced.
• The lymph glands, tonsils and thymus are atrophied.
• Cell-mediated immunity is severely depressed.
• Levels o immunoglobulin A (IgA) in secretions are reduced.
• Complement components are low.
• Phagocytes do not kill ingested bacteria eciently.
• Tissue damage does not result in infammation or migration o white cells to the aected area.
• The acute-phase immune response is reduced.
• Typical signs o inection, such as an increased white cell count and ever, are requently absent.
• Hypoglycaemia and hypothermia are signs o severe inection, usually associated with septic shock
18
2. DEFINITION OF SEVERE ACUTE MALNUTRITION
All patients that ull any o the criteria in Table 1 have SAM.
Table 1. Admission criteria for SAM
HEIGHT (cm) or AGE ADMISSION CRITERIA
LESS THAN 6 MONTHS See separate section for these infants.
45-120 CM IN HEIGHT FOR W/H or W/L < -3 Z-score (WHO 2006 standards unisex table)
W/H Z-SCORE or
6-59 MONTHS FOR MUAC* MUAC < 115 mm
Or
Presence o bilateral oedema
OLDER CHILDREN AND W/H < 70% NCHS
ADOLESCENTS or
120.5-171 CM FOR W/H Presence o bilateral oedema
140-190 CM FOR BMI IF BMI < 16 with recent weight loss
ADULT or
(ADULTS ≥ 19 YEARS) Presence o bilateral oedema (unless there is another clear-cut
cause)
*MUAC = mid-upper arm circumerence
HEIGHT (cm) or AGE ADMISSION CRITERIA
LESS THAN 6 MONTHS See separate section for these infants.
OEDEMA (ALL AGES & ALL patients with bilateral oedema are classied as SEVERELY
HEIGHTS) malnourished, whether or not they also have anthropometric criteria
(unless another pathology causing the oedema has been positively
diagnosed).
CLASSIFICATION BY HEIGHT/LENGTH FOR WHZ AND BMI
HEIGHT (cm) or AGE ADMISSION CRITERIA
CHILD: 45 -120 CM W/H or W/L < -3 Z-score (WHO 2006 standards unisex table)
ADOLESCENT: 120.5-171 CM W/H < 70% National Centre or Health Statistics, United States
ADULT: 140-190 CM (NCHS)
BMI < 16 with recent weight loss
CLASSIFICATION BY AGE FOR MUAC
CHILD: 6- 59 MONTHS MUAC < 115 m
D2 3 4 567
2 See Annex 3: Weight-or-height table
3 See Annex 1: Anthropometric measurement techniques
4 See Annex 4: Weight-or-height table or adolescents
5 See Annex 3: Weight-or-height table
6 See Annex 4: Weight-or-height table or adolescents
7 See Annex 4: Weight-or-height table or adolescents
19
NOTE: it is important to emphasise that the patient is admitted as SAM i they ull ANY
o these criteria (oedema, weight or height/length Z-score (WHZ) or MUAC) – even i the
other criteria are not within the SAM range.
The anthropometric parameters are now used to dene “marasmus”; oedema is used
to dene “kwashiorkor”. I a child has both an anthropometric decit and oedema this
is “marasmic-kwashiorkor”. These terms are commonly used in the older literature and
textbooks. There may be other signs kwashiorkor, but it is now dened ONLY by the
presence or absence o oedema.
All patients with SAM as dened above should be admitted or therapeutic treatment in
either an outpatient therapeutic programme (OTP) or an inpatient acility (IPF), depending
on the presence or absence o medical complications and appetite. Detection o patients
with SAM should be done at all points where the patient has contact with the health
system. This includes all community activities, in all health centres and hospitals; they are
then reerred to the appropriate service.
COMMUNITY
MUAC measurement and
check of nutritional bilateral
oedema
MUAC < 115mm MUAC <115mm MUAC < 125mm
and/or and < 125mm and
bilateral oedema and absence of absence of
bilateral oedema bilateral oedema
Health Center Health Center
OTP OTP/SFP
( Passive screening) ( Passive screening)
20
3. MANAGEMENT IN THE COMMUNITY
Although children with SAM have disturbed physiology and metabolism, many can be
identied in the community beore they develop medical complications. For the majority
o cases identied early, sae and eective treatment can be provided on an outpatient
basis, using ready-to-use therapeutic ood (RUTF), simple medical protocols and weekly
monitoring. The advantages are that eective treatment can be decentralized and oered
close to people’s homes, with minimal disruption to their existing livelihood, and without
risk o cross-inection during inpatient care. The results are that large numbers o children
with SAM can be quite simply treated.
3.1 Community engagement
In many areas most children with SAM are not brought to health acilities. In these
places, only an approach with a strong community component can provide them with an
appropriate intervention.
Community engagement covers a range o activities designed to open a dialogue,
promote mutual understanding and encourage active, sustained engagement rom
the community to understand and tackle malnutrition. This involves actively improving
case-nding and ollow-up. The goal o community engagement is to improve treatment
outcomes and coverage. I community members are unaware o the service, or the type
o children that are malnourished, or are conused or misinormed about the service, they
may not realise the benets or become engaged. Promoting understanding is crucial,
and strategies to engage the community should be planned and implemented beore the
start o treatment activities in health acilities. These should entail:
• Community assessment – interviews and discussion with key community inormants
(e.g. community health workers, positive deviant parents, caregivers, armer promoters,
community health clubs, community leaders, elders and opinion leaders, parents/
women’s groups, national women’s committees, national youth committees, traditional
healers) to determine local understanding o acute malnutrition, and identiy available
community resources (people, groups and communication mechanisms) and the actors
that are likely to aect both service delivery and demand or services.
• Community sensitization, mobilization and dialogue – discussion with community
representatives on the problem o SAM and how it can be easily treated; agreement on
what will be done and who will be involved at community level; and setting up an ongoing
dialogue or getting eedback rom the community about any concerns with the service.
• Development of messages and materials for broader sensitization and mobilization –
the next stage is to develop sensitization messages or SAM and the treatment choices,
or one-to-one communication by the community workorce, using handbills/pamphlets,
community radios/television etc.
• Training for community-level actors – on maternal, inant and young child nutrition
(MIYCN), using Positive Deviance methodology, integrating nutrition into home-based
early child development (ECD) or a better community-based nutrition programme
(CBNP) implementation etc., depending on agreed roles (see below).
21
3.2 Community screening
Systematic case-nding within communities is important to ensure that inants and
children with SAM are identied beore they develop severe medical complications.
In the community, only mid-upper arm circumerence (MUAC) and the presence o
bilateral oedema are used to screen children over 6 months to determine whether or
not they have SAM; children with a MUAC < 115 mm or oedema are then reerred to
the health centre. MUAC is measured with colour-coded tapes (Annex 1) by community
health workers (CHWs), and can even be taken by mothers themselves to monitor their
own children8 and report cases to CHWs or conrmation and reerral. Thereore the
community-based health workorce needs to be trained to identiy the children aected
by SAM with the coloured plastic strips and to recognize bilateral pitting oedema.
This workorce traditionally comes rom and works in the community. It includes:
• Appropriately trained and accredited CHWs
• Trained volunteers (e.g. positive deviant parents, women and youth groups)
• Other community-based organizations that promote health through behaviour-
change communications, health education and social mobilization
• Community-level actors engaged by other programmes (e.g. water, sanitation
and hygiene (WASH) through community health club committees; agriculture
and ood security through armer promoters or instance; and education/early
childhood development), who contribute to promoting and improving community
health
• Heads o households and other household decision-makers (e.g. mothers-in-law).
In order or identication to be “early”, this case-nding, using MUAC and examining
or oedema, must be carried out on a regular basis (either ongoing or monthly), at all
possible opportunities (during campaigns and in the home) at community level (see Box
2). Children identied as suering rom SAM are reerred to the nearest health acility
trained to give inpatient or outpatient therapeutic care.
The CHWs and other community workers should attend the health centre regularly or
coordination meetings and “get to know” the sta and lean how they work with SAM
children. They are also responsible or home visits o deaulters, ailure-to-respond
children and potential deaths. They can undertake ollow-up activities, as SAM children
requently deault and relapse9.
8 Ale F. et al. ‘Mothers Screening or Malnutrition by Mid-Upper Arm Circumerence Is Non-Inerior to Community
Health Workers: Results From a Large-Scale Pragmatic Trial in Rural Niger’. Archives o Public Health 2016, 74:38.
9 Grellety, E. et al. ‘Eects o Unconditional Cash Transers on the Outcome o Treatment or Severe Acute Malnutri-
tion (SAM): a Cluster-Randomised Trial in the Democratic Republic o the Congo’. BMC Medicine 2017. 15:87
22
Box 2. Opportunities or the identication o SAM at community level
• CHW visits, positive deviance health sessions, WASH meetings etc. – basically any activities
the CHW carries out in the community
• Outreach clinics or immunization
• Child health days/weeks
• Health week
• Community-based growth monitoring and promotion activities
• Mothers’ groups
• Early childhood development sessions conducted at community level
The community is not involved with clinical assessment or triage into in- or outpatient
treatment, which occurs at primary health centres. All children with SAM ound in the
community are reerred to the nearest health post/centre with trained sta.
3.3 Home visits
Home visits are carried out by a CHW, community volunteer or outreach worker. The
home visit is an opportunity to assess:
• The carer’s understanding o the messages received in the healthcare centre and
o inant and young child eeding practices.
• Compliance with the treatment (RUTF and medication).
• The availability (and intake i applicable) o micronutrient powders (MNPs), corn-
soya blend (CSB) and ortied blended oods (FBF).
• Cases o deaulters and reasons or non-compliance.
• Cases whose mothers have reused transer to hospital.
• Reasons or non-compliance with treatment, absence or deault.
• The availability o water and sanitation acilities, hygiene and ood-saety practices.
• The medical condition o the child.
• Household ood security, poverty level and coping mechanisms.
• Social problems and amily dynamics (many children eating rom the same plate,
use o traditional porridge, polygamous discrimination o the mother, absent
ather/provider, isolation by neighbours etc.).
• Subscription to “mutuelle de santé” (health insurance).
• Specically, the CHW should:
• Observe the household and assess whether there are any social problems;
possibly interview neighbours.
• Assess hygiene, water management, waste disposal, cooking acilities, where
RUTF is stored (and how much is let), level o poverty and coping strategies,
type and quantity o amily ood present and stored.
• Measure MUAC; weigh the child and determine weight gain; ask about reasons
or deaulting and encourage return to the OTP.
• Where possible, provide support or any problem identied.
• Give counselling on health, and inant and young child eeding practices,
including ood saety.
MUAC screening and testing or oedema will result in children being triaged into those
who do not have severe malnutrition, those with moderate acute malnutrition (MAM) and
23
those with SAM. Children with MAM are eligible or supplementary eeding programme (i
it is available); those with SAM should always be reerred to the health centre or urther
assessment and treatment.
I a MAM programme is not available, those with MAM could be sent to the health centre to
have their weight-or-height/length measured. BUT it is critical that they are not sent away
without any support. Such reusal to reer undermines the credibility o the CHWs and
brings the programme into disrepute with the community. Repeated inaccurate reerrals
should lead to some treatment being given to all reerrals and retraining o the CHW.
24
4. TRIAGE AT THE HEALTH FACILITY
The objective when the SAM patient rst presents is to establish the severity o his/her
condition, whether or not the child has a reasonable appetite or medical complications
and how treatment should be arranged.
The majority o children with SAM should be initially identied and reerred rom the
community. For all children attending the health centre directly, or whatever reason,
the health centre sta should measure their MUAC and weight-or-height/length Z-score
(WHZ) and test or oedema. For those with any o the SAM criteria, the sta will then
test or appetite and the nurse will take a history, do a clinical examination and decide
whether to treat the child in the OTP or reer to the inpatient acility (IPF).
4.1 The appetite test
4.1.1 The observed appetite test
Children with SAM suering rom inections may not show any signs. However, the
major metabolic complications o SAM lead to a loss o appetite. Thereore, a critical
criterion or deciding whether a patient should be sent to inpatient or outpatient care is
the appetite test. Patients with a poor appetite probably have a covert complication or
metabolic disturbance that may not be evident on examination; urthermore, they will
not consume sucient RUTF at home to improve and so are at risk o deterioration and
death and require inpatient care. Appetite is tested by giving RUTF to the carer, who
gently encourages the child to eat, then observing and noting whether the child eats the
minimum amount recommended: this has been calculated as the amount required to
maintain the child’s weight i that amount is taken ve times per day.
4.1.2 Why to do the appetite test?
Reasonably accurate assessment o the appetite is oten the only way to dierentiate
a complicated rom an uncomplicated case o SAM. Other signs (integrated
management o childhood illnesses, IMCI) o severe illness are less reliable in the
severely malnourished child.
By ar the best sign o severe metabolic-malnutrition is a reduction in appetite, and
the appetite test is the most important criterion to decide whether a patient should be
sent or in- or outpatient management.
A poor appetite means that the child has a signicant inection or a major metabolic
abnormality such as liver dysunction, electrolyte imbalance and cell membrane
damage or damaged biochemical pathways. These patients are at immediate risk o
death. Furthermore, a child with a poor appetite will not take sucient amount o the
therapeutic diet at home to prevent deterioration.
25
4.1.3 How to do the appetite test
• The healthcare provider
All children who will have an appetite test are normally tested together in the same
area at the same time. This should be a separate quiet area. Children who have
travelled a long distance should be allowed to rest rst and given water or sugar-water
to drink.
Sometimes a child will not eat the RUTF because she is rightened, distressed or
earul o the environment or sta. This is particularly likely i there is a crowd, a lot o
noise, other distressed children or intimidating health proessionals (white coats, awe-
inspiring tone). I a quiet area is not available then the appetite can be tested outside
under shade. Watching other children take the RUTF gives condence.
Explain to the caretakers the purpose o the appetite test and how it will be carried
out, and wash the hands o both the caretaker and the child. Allow the caretaker to sit
comortably with the child on her lap and oer the RUTF to the child.
Give the RUTF rom medicine-cups or the packet itsel and water to drink in a cup:
Children with SAM suering rom inections may not show any signs. However, the
major metabolic complications o SAM lead to a loss o appetite. Thereore, a critical
criterion or deciding whether a patient should be sent
• The mother
Initially allows her child to play with an RUTF packet or pot and become amiliar with
the environment. This sometimes helps the child become condent.
Either gives the RUTF directly or puts a small amount on her nger and gives it to the
child. The mother/other children/siblings must not consume any o the RUTF. It oten
helps i she pretends to take some and like it; seeing the mother eat the RUTF hersel
is the best way to encourage the child.
I the child reuses, continue to quietly encourage the child and take time over the
test. Do not orce the child to take the RUTF.
The test usually takes about teen minutes, but can take up to one hour with a shy
or upset child or one with a marginal appetite.
The child MUST be oered plenty o water to drink rom a cup during the test.
• The health provider should evaluate the result of the appetite test:
Pass
A child who takes at least the amount shown in the ‘moderate’ column o Table 2 below
passes the appetite test.
26
Table 2: Amount of RUTF to assess the appetite of severely malnourished children
APPETITE TEST
“Moderate” is the minimum amount that malnourished patients should take to pass the appetite
test
BODY WEIGHT PASTE IN SACHETS PASTE IN CONTAINERS
(PROPORTION OF WHOLE SACHET 92 G) (ML or GRAMMES)
Poor Moderate Good Poor Moderate Good
Less than 4 kg <1/8 1/8-1/4 >1/4 <15 15-25 >25
4-6.9 kg <1/4 1/4-1/3 >1/3 <25 25-30 >35
7-9.9 kg <1/3 1/3-1/2 >1/2 <35 35-50 >50
10-14.9 kg <1/2 1/2-3/4 >3/4 <50 50-75 >75
15-29 kg <3/4 3/4-1 >1 <100 100-150 >150
Over 30 kg <1 >1 <150 >150
Note: i dierent sized small medicine cups are used, a new table should be constructed, de-
pending on the size o the cup. The table should be in the number o medicine-cups the child
should take or his/her weight category. The majority o children will be rom 4-6.9 kg so the
minimum test to dierentiate a poor appetite would then be one level medicine-cup o 25 ml.
Fail
A child that does not take at least the “moderate” amount o RUTF ails the test - the
health provider will examine the child and probably reer him/her to the IPF.
Even i the child is not taking the RUTF because s/he does not like the taste or is rightened,
the child does not pass the appetite test.
4.2 Medical history and examination
On presentation, the health worker should have taken the anthropometry and perormed
the appetite test; the nurse now takes a clinical history and examines the child or medical
complications beore deciding whether the child should be reerred to the IPF or treated
in OTP.
Ater recording the MUAC, weight and height, look up the WHZ and test or bilateral
pitting oedema.
4.2.1 Take the history
• Ask the mother why she has brought the child to the centre – i.e. what she has noticed
wrong/changed with the child, when the complaints started and how they have progressed.
• Ask the systematic questions:
o Size at birth (small, normal, large), prematurity
o Able to drink or breasteed
o Food and fuids taken in past ew days
o Usual diet beore current episode o illness
o Lethargic or unconscious
o Vomiting everything
o Has cough
o Had convulsions
27
o Has recent and requent diarrhoea; type o diarrhoea (watery/bloody)
o Recent change in appearance o ace (sinking o eyes)
o Mother’s perception o appetite
o Has any other reported problem
o Immunization history
o Illness or contact with TB, HIV, measles (in amily)
o Family circumstances, (e.g. death o siblings, absent or illness o parents, poverty
assessment, etc.)
4.2.2 Examine the child
• Ater the anthropometry, appetite test and history have been taken, observe the child
or movements, alertness, cry, body tone and general demeanour. I the child appears
critically ill, look or critical signs, then move directly to the emergency triage, assessment
and treatment plus admission (ETAT+) protocol.
• Emergency and priority signs:
o Lethargic or unconscious
o Cold hands
o Slow capillary rell (>3 seconds)
o Weak (low volume) or rapid pulse
o Convulsion.
• Respiration: rapid or shallow, other diculty in breathing (e.g. wheeze, stridor). NB the
respiration rate in SAM children with pneumonia is usually about 5 breaths/minute lower
than in normal children – the cut-o points are given in Table 3 below:
Table 3: Cut-off points for respiration rate in SAM children
Age Normal respiration rate Respiratory distress
(breaths per minute) (breaths per minute)
<2 months 30 to 60 >60
2-12 months 30 to 50 >50
1-5 years 24 to 40 >40
Over 5 years 18 to 30 >30
Adolescent 12 to 16 >20
All ages - ANY CHEST INDRAWING
• Temperature:
o Hypothermia: axillary temperature <35.0 °C or rectal temperature <35.5 °C
o Fever (temperature ≥38.5 °C axillary or 39 °C rectal).
• Anaemia: assess palmar pallor (i hands not cold), otherwise observe mucus membranes/
conjunctiva.
• Eyes: signs o vitamin A deciency or eye inection.
• Skin: open skin sores or inection, rash (measles etc.)
28
• Signs o abnormality o the ears, mouth and look or mastoiditis.
• Tap spine or early signs o Pott’s disease.
I the child has SAM, has no complications and has a reasonable appetite s/he should
be treated as an outpatient.
I the child ails the appetite test or has any major medical complication, the child should
be reerred or inpatient management. I the mother reuses to go to the hospital, because
o amily circumstances or example, then the mother should be counselled realistically.
I she decides not to go to the hospital, the sta can arrange to treat the child as an
outpatient and give the child RUTF and the standard drugs, but this child should be seen
daily or every other day until there is improvement. The mother must be told that she is
“not bad” but she can change her mind at any time and the sta will respect her choice.
4.3 Decision from triage criteria on whether to treat as an in- or outpatient
Based on the assessments o appetite, history and examination described, children
should be allocated to in- or outpatient care, taking the mother’s choice into consideration
and reerred accordingly. The same parameters are used to monitor children during
treatment and to make decisions on the need or transer reerral.
I ANY o these indicate that the patient needs inpatient treatment, the child should be
reerred to the IPF with the agreement o the caretaker. See Table 4 below.
Table 4. Classication o cases or initial reerral to inpatient or outpatient care
Factor Inpatient care Outpatient care
Mother’s choice Mother is actually the primary healthcare worker or her own child.
She knows the child and her home circumstances. The mother’s
choice must be respected. I not she will deault, will not return
and will not bring any other children in case the sta are angry
with her or humiliate her. Legally she has the right to decide and
we are her proessional advisors.
Appetite Failed or equivocal appetite test Passes appetite test
Bilateral oedema Bilateral pitting oedema Grade 2 Bilateral pitting oedema Grade
(++) & 3 (+++) 1 (+) and W/H> -3Z
Both marasmus and kwashiorkor
(W/H < -3Z-score and bilateral
oedema)
Skin Open skin lesions No open skin lesions
Medical Any severe illness, using the Alert with no medical
IMCI
Complications Criteria – respiratory tract inec- Complications
tion, severe anaemia, clinical vi-
tamin-A deciency, dehydration,
ever, lethargy, measles rash etc.
29
Candidiasis Presence o severe candidiasis Presence o severe candidi-
or other signs o severe im- asis or other signs o severe
mune-incompetence immune-incompetence
Caretaker No suitable or willing caretaker. Reasonable home circum-
stances and a willing caretaker
4.4 Classication o nutritional oedema
Oedema caused by acute malnutrition presents with two special characteristics:
• It is bilateral (occurs equally on both let and right sides o the body).
• It is pitting (leaves an impression ater pressure is applied).
Grades o oedema are classied according to the criteria shown in Table 5.
Table 5. Grades of oedema
GRADE DEFINITION BILATERAL PITTING OEDEMA FOUND:
Absent No bilateral pitting oedema
+ Mild bilateral pitting oedema In the eet
++ Moderate bilateral pitting oedema In the eet, lower legs, hands or lower arms
+++ Severe bilateral pitting oedema Generally, including in the eet, hands, arms andace
Figure 1: Summary of triage decision-making for IPF or OTP
2 nd TRIAGE: SAM - IPF : OTP TRIAGE
SAM
Bilateral oedema ++ Test appetite and Check for
and +++ clinical complications (IMCI)
or Marasmus- include oedema +
Kwashiorkor
Caretaker choice, Caretaker choice,
Poor appetite Mod./Good appetite
or complication No complication
In- patient facility Out- patient treatment
4.5 Transport of sick patients
Very ill malnourished children may be brought to an OTP distribution site or health centre
and the protocol requires them to be “transerred” to an IPF.
30
However, it is commonly ound that malnourished children who are relatively well beore
transport, deteriorate and die soon ater arrival ater a long or dicult journey. This is
“transport trauma”.
Public transport is not recommended. Rather use an ambulance, as or other very ill
patients.
It is recommended that, where possible, sick patients be stabilised at the OTP or nearest
health centre beore transport. The provisions in this protocol or the management o
severe malnutrition or inpatients and its complications should be ollowed as ar as
easible in the health centre. 10
4.5.1 IPF
The IPF should be contacted by telephone so that it can take responsibility or and “cover”
the nurse in the eld. The IPF reassures the nurse that it is the correct course o action not
to transport the child and gives advice and support or the management o the patient.
The telephone call, advice given and the name o the doctor and IPF contacted should
be recorded on the patient’s chart.
4.5.2 OTP
The nurse must explain to the caretaker that the patient is critically ill and may die, but
that the danger o transporting the patient to the hospital is greater than trying to stabilise
him/her at the health centre. Again the mother’s choice should be ollowed.
4.5.3 District Hospital Nutrition Ocer (ocal point) and Emergency Department
Mobilise the community about the problem o transport o sick patients rom one centre
to another.
Explore solutions: 1) use a national or international NGO; 2) establish a community
und; 3) have an ambulance; 4) establish a phone consultation to treat patients without
transport; 5) establish a local IPF to manage/stabilise complicated malnutrition cases
close to an epicentre o malnutrition.
Organise the transport o the critically ill transer-patients:
o Organise payment or transport (lend money, subsidise the cost, provide ree
transport or poorest cases or pay or transport).
o Train sta about care during the transport:
The vehicle must drive slowly.
It must not be crowded.
10Transport trauma is one o the main reasons why IPFs should be established as close to the patient’s village as
possible. Many o the advantages o having OTPs close to the patient’s home apply equally to IPFs.
31
It should stop or 5 minutes every 20-30 minutes during the drive to lessen the eects
o motion sickness on the sick patient.
Water must be available.
Children should be nursed by their mother.
Do not give drugs to sedate or prevent motion sickness (vomiting) to malnourished
patients (this is particularly important).
Anticipate vehicle breakdown, seasonally impassable roads (fooding, etc. during the
rainy season).
Pre-position stocks i seasonally impassable roads are anticipated (stocks o RUTF,
train village volunteers i team cannot travel).
Consider having an “emergency kit” or IPF-style stabilisation o children prior to
transport, i transport dicult/impossible or i mother reuses to travel.
Regularly evaluate the outcome o patients that have been transported under dicult
circumstances. Detailed analysis o death during and or 48 hours ater transport should
be undertaken by the District Nutrition Ocer and actions taken (such as opening a
satellite IPF). The time o leaving and the time o arrival at the destination acility should
be noted on the transer orm and analysed periodically to determine i this is a major
problem within the district.
Establish regular meetings between the IPF doctors and the OTP sta in order to
acilitate communication between the dierent teams and give condence to the IPF
about the judgement o the OTP/community sta.
Monthly reports should be checked and updated or deaths occurring during transport.
Transer times reported on the transer orm should be examined and i they are excessive,
ways o resolving the problem should then be explored.
32
5. OUTPATIENT MANAGEMENT OF SAM IN CHILDREN
AGED OVER 6 MONTHS
Outpatient care is suitable or children aged 6 months and above with SAM without
complications and a good appetite: the vast majority o cases have these characteristics. It
should also be used or nearly all children transerred ater successul initial management
in an IPF.
Children admitted de novo or outpatient management o SAM should receive medical
and therapeutic eeding treatment according to their weight, and a weekly medical
examination to monitor their progress. I they are not gaining weight rapidly they should
have their appetite tests repeated. Box 3 gives an overview o OTP management.
Box 3. Overview of activities in outpatient management of SAM
• Observe or critical illness: emergency signs and prompt treatment ollowed by reerral to
IPF (see ETAT)
• Welcome children to the centre and oer them sugar-water to drink
Full assessment (repeated as necessary)
• History and examination
• Dierential diagnoses (decision: treatment as inpatient or outpatient)
Treatment
• Prevention o hypoglycaemia
• Management o non-critical inections and other medical conditions
• Commencement o nutritional rehabilitation
Weekly care
• Anthropometric measurements (MUAC and weight). Height is only measured on admission,
when the “target” weight or discharge is determined.
• Repeat appetite test i not gaining weight appropriately.
• Monitoring or signs o improvement, complications, ailure to respond to treatment. Regular
education sessions including: hygiene promotion, inant and young child eeding (IYCF), emo-
tional and sensory stimulation o a child, amily planning, HIV prevention, etc.
• Psychosocial support o mother or caretaker.
• Health and nutrition counselling o mother or caretaker.
• Preparation or discharge (nal vaccination, arrangement o ollow-up).
End of active treatment
• Follow up, home visits, etc.
5.1 Tools for OTP
• MUAC tapes (115mm)
• Scale, length board, WHZ tables (WHO 2006)
• Registration book, patient charts (OTP charts)
• RUTF, sugar, sae drinking water, medical measuring cup or scale (5 g precision)
• Water and soap to wash hands
33
• Thermometer
• Examination tools (stethoscope, otoscope etc.)
• Transer orms
• Drugs
5.2 Initial assessment
When children and caretakers attend a health acility, they have oten travelled or many
hours. Transport can lead to serious deterioration o sick or malnourished children. There
must be a comortable place or patients to wait, in the shade, with water reely available;
the children should be immediately given a drink o sugar-water (approximately 10%
sugar in water i.e. approximately 10 g or 2 small sugar spoons in 100 ml o boiled water):
this will prevent hypoglycaemia. However the children who are so ill that they cannot take
the drink should be reerred to IPF immediately without waiting.
During triage (see previous chapter), the child’s anthropometry has been taken, oedema
assessed and the presence o SAM conrmed. The appetite test will have been perormed
and the history and examination taken.
5.3 Ensure decision-making for outpatient or inpatient care was
appropriate during triage
I during the assessment there is a medical complication or a poor appetite or oedema
(grade ++ or +++) or i the child has a combination o SAM anthropometric criteria and
oedema (e.g. oedema and WHZ < -3Z = “marasmic-kwashiorkor”), reer him/her or
inpatient treatment with the mother’s consent. I the mother does not consent then see the
chapters on IPF management and complications, and attempt to ollow the procedures
outlined there.
I the child has a reasonable appetite and no complications, retain in OTP as described
in this section o the guidelines.
5.3.1 First priorities
1. Record on the OTP chart the administrative and baseline inormation, anthropometry
history, clinical examination and appetite test.
2. Register the patient in the acility registration book and assign both an admission
number and ID number (e.g. insurance number) in order to be able to ollow the
patient i he/she is transerred to another acility (e.g. IPF or another OTP closer to
home).
3. Explain to the caretaker the severity o the child’s condition and that s/he can be
treated as an outpatient.
4. Outline the management: s/he must come back each week or ollow-up and to
obtain resh supplies o the special ood (RUTF) used as a medicine to treat the
child; explain the child’s expected progress and when s/he will be judged ully
recovered, and that treatment is likely to take about two months (less or oedema
(only +) cases).
5. Prescribe the routine medicine and any other treatment the child may need. Teach
the caretaker how to give the drug(s) and observe the rst dose being given.
34
6. Check the child’s vaccination schedule and vaccinate i not already ully immunized;
this is not a priority and can be given at week 4 beore discharge (when the patient
is nutritionally improved and their immune unction is better).
7. Explain the signs o deterioration to the caretaker and ensure that she or he knows
they must come back to the health acility at any time i the child’s condition
deteriorates, even i they do not have an appointment.
8. Give one week’s supply o RUTF. Observe the caretaker eeding the child with
RUTF. Ensure she or he understands how to give the RUTF at home.
9. Go over the key messages with the caretaker.
10. Make an appointment or the next visit.
11. At subsequent visits give health and nutrition counselling (e.g. or appropriate
inant and young child eeding practices) and education sessions.
5.4 Medical management
5.4.1 Treatment to be given in the clinic
On admission, routine medicines should be given to all SAM children as shown in Table
6.
Table 6 Medication for newly admitted OTP patients: omit for patients transferred from IPF.
MEDICATION WHEN GIVEN
Amoxicillin On admission or all new patients – 5 days
Antimalaria drugs: lumeantrine-artemether At any time i clinical signs indicative and
(according to national protocol) paracheck/ microscopy conrm
Mebendazol/albendazol Single dose on second week: 400 mg or chil-
dren aged over 2 years, 200 mg or children
aged 1-2 years.
Vitamin A (i RUTF not available) I diet does not contain vitamin A (stock-out
RUTF), to be given on admission unless al-
ready given in last 3–4 months.
Do not given to children with oedema on
admission; instead give a single dose on
discharge.
Measles vaccination One dose in week 4
The risk o nosocomial inections in OTP is
low except i there is an outbreak o measles,
when all children should be given vaccine.
Note: Children who have been transerred rom hospital-based management o SAM
should not receive routine medications that have already been administered during their
hospital stay (e.g. antibiotics). However, i any treatments received during inpatient care
are incomplete (e.g. or clinical vitamin A deciency), this inormation should be included
on reerral documents and the doses required to complete that treatment given during
outpatient ollow-up care.
•Antibiotics
A course o oral antibiotic such as amoxicillin should be given to all children to treat any
underlying inections. (Never give chloramphenicol to children less than 5 kg as they are
35
in danger o the “grey baby syndrome”.)
The rst dose o amoxicillin should be taken during the admission process, under the
supervision o the healthcare provider. An explanation should be given to the caretaker
on how to complete the treatment at home. The recommended dosage or amoxicillin is
25 mg/kg twice a day or 5 days.
•Worm treatment
A single dose o albendazol/mebendazol should be given on the second or ourth visit or
outpatient treatment; the dose required is shown in Table 7. Albendazol is preerred but
where albendazol is not available, mebendazol should be given.
Table 7. Mebendazol/albendazol drug dosage
AGE (WEIGHT) OF THE MEBENDAZOL (single dose ALBENDAZOL (single dose
CHILD before food) before food)
1 year or below None None
1–2 years (or <10 kg) 500 mg 200 mg
≥ 2 years (or ≥ 10 kg) 500 mg 400 mg
When treating inants, the tablets should be crushed into small pieces beore administration.
• Vitamin A
Children with SAM do not require a high dose o vitamin A as a supplement i they are
receiving RUTF that complies with WHO specications (and thereore already contains
sucient vitamin A), or vitamin A is part o other daily supplements. THE CHILD WILL
RECEIVE THE DOSE OF vitamin A at 4th week beore discharge (i the child did not
receive routine Vitamin A)
Vitamin A deciency
Children with eye signs o vitamin A deciency (e.g. corneal ulceration, xerophthalmia,
corneal xerosis, cloudiness, keratomalacia) should be transerred to IPF immediately,
as the condition o the eyes can deteriorate rapidly and there is a high risk o blindness.
Check careully at each visit during an outbreak o measles.
I eye signs o vitamin A deciency have been identied, the rst high dose o vitamin A
should be given to the child beore transer to the IPF. The dose MUST be recorded on
the reerral slip.
Table 8. First dose vitamin A before transfer to IPF
AGE OF THE CHILD VITAMIN A
6–12 months 100,000 IU
> 12 months 200,000 IU
I the mother declines to go to the IPF then treat or vitamin A deciency as per the
schedule in Chapter 6 (on the management o complications).
36
• Other medical treatments
The less serious medical conditions that aect the child with SAM without medical
complications should be treated using the IMCI protocols.
Anaemia
Iron supplementation may be harmul during the acute phases o SAM, because it can
promote inections, increase the severity o malaria and cause oxidative stress to damage
the tissues. Thereore, i the child does not need specic treatment, RUTF contains 10.6
mg iron plus 193 µg o olic acid per 500 kcal (92 g packet). Any patient with severe
anaemia (severe palmo/plantar or conjunctiva pallor AND/OR Hb < 6 g/dl where easible)
should be reerred to IPF, where laboratory testing can be done and the anaemia treated
accordingly.
Diarrhoea
Diarrhoea is oten a precipitating cause leading to SAM. However, the use o standard
WHO oral rehydration therapy is not recommended or children with SAM.
In the case o diarrhoea, a recent onset o requent watery diarrhoea (> 3 watery stools
per day), vomiting and sinking o the eyes SINCE THE START o the diarrhoea show that
the child is dehydrated and needs oral rehydration with a special fuid called ReSoMal
(rehydration solution or malnutrition). I there are any other signs o deterioration, such
as lethargy or weight loss then an immediate transer to IPF is important, provided that
transport is available. Children with SAM already have some sinking o their eyes due to
loss o at rom the orbit, and the “skin-pinch” is unreliable because o loss o at rom
the subcutaneous tissues. I the eyes also have a “staring” rightened appearance due
to retraction o the eyelids, this is also a sign o dehydration. In the case o recent and
requent watery stools, i ReSoMal is not available the child should receive a rst dose o
diluted oral rehydration therapy beore reerral to hospital.
The eect o diarrhoea without severe dehydration on the nutrition status o children can
be minimized by continued eeding, breasteeding and administration o RUTF, since the
paste provides a daily supplement o zinc. And also i the child has not lost weight but
only has small requent stools it can be managed with observation in the health centre.
Children with long-standing (persistent) diarrhoea are not dehydrated unless they have
an acute exacerbation. Children with oedema are not dehydrated. It is never dangerous
to give sugar-water, and this should always be available and given during transport.
5.5 Dietary treatment in outpatient care
Children with SAM need sae, palatable, nutrient-dense ood. It must have a high energy
content and increased amounts o ALL the vitamins and minerals needed or growth11
(see specications in Annex 18). RUTFs are sot or crushable oods that can be consumed
easily by children rom 6 months o age without adding water.
11 Transport trauma is one o the main reasons why IPFs should be established as close to the patient’s village as
possible. Many o the advantages o having OTPs close to the patient’s home apply equally to IPFs.
37
When there are no medical complications, a malnourished child with appetite, i aged
6 months or more, is given a standard dose o RUTF adjusted to their weight. This is
consumed at home, directly rom a container or the packet, at any time o the day or
night. Because RUTF does not contain water, children MUST be oered sae drinking
water at the same time. Any opened package that is not consumed may be saely kept
to eat later, but must be covered to prevent insects and rodents rom contaminating the
ood.
The dietary management in outpatient care is based on supplying 100% o nutritional
needs with RUTF. As RUTF contains all the nutrients that are needed to recover in
adequate amounts, other oods are not necessary or ull recovery. However, the child
oten wishes to take ood with the rest o the amily; this is perectly acceptable but the
additional local oods should be nutrient-dense. Many local oods contain anti-nutrients
which can impair the absorption o the nutrients rom the RUTF and reduce the appetite;
the RUTF should be taken 2 hours beore or ater a amily meal – and i possible during
the night. Beore any meal, including RUTF, children less than 2 years should be oered
breast milk.
RUTF is given at 170 kcal/kg per day and can be presented in the orm o a paste or a
special therapeutic biscuit (e.g. BP100 – not the biscuits used as supplementary eed
or moderate malnutrition or prevention). I therapeutic biscuits are used or younger
children, aged 6–24 months, the biscuits can be mixed with sae water to make porridge.
Table 9 gives the recommended dosage based on the weight o the child.
Table 9. Recommended dosage of RUTF according to the weight of the child
WEIGHT RUTF PASTE RUTF SACHETS (92 G) BISCUIT (BP100)®
CATEGORY GRAMMES GRAMMES SACHET SACHET BARS BARS
(KG) PER PER PER PER PER PER
DAY WEEK DAY WEEK DAY WEEK
3.0 – 3.4 105 750 1¼ 8 2 14
3.5 – 4.9 130 900 1½ 10 2½ 17½
5.0 – 6.9 200 1400 2 15 4 28
7.0 – 9.9 260 1800 3 20 5 35
>10.0 400 2800 4 30 7 49
Note: The package size is commonly 92 g/500 kcal. Locally manuactured therapeutic
pastes can be supplied in dierent quantities per packet or pot; i so, ration tables should
be adapted.
The average weight gain o OTP patients is much less than IPF where the diet is given
under supervision; this is due to sharing o the diet and the amount o amily ood that
is taken. The amount o kcal per day can be decreased by a third without changing the
rate o weight gain. This avoids wasting resources and can decrease sharing at home.
The appetite at the beginning o the treatment is not very good and it takes some time
or the appetite to improve. Excess RUTF given initially can encourage sharing rom the
start o treatment. For this reason, the amount can be increased more gradually, but
this complicates the instructions and is not generally recommended. IF the centre is
acing a stock-out then a reduced amount o RUTF should be given to all the children (a
38
supplementary table to ace this contingency is given in Annex 9).
To ensure proper use o therapeutic oods at home, it is important to provide detailed,
clear inormation to the caretaker, and check that it has been understood. Box 4 presents
messages or the caretaker.
Box 4. Treating with RUTF at home: messages for the caretaker
• The RUTF is a ood and a medicine or the very thin or swollen child only.
• The RUTF is the ood the child needs in order to recover. The child should complete his
or her daily ration o RUTF beore being given other ood. The child should continue to
be breasted on demand. Sick children oten don’t like to eat. Give small regular meals o
therapeutic paste and encourage the child to eat oten.
• Always oer breast milk beore and plenty o clean water during/ater s/he is eating the
RUTF. Children need to drink more than normal when taking the diet.
• For inants and children aged less than 2 years, continue to put the child to the breast
regularly. Oer breast milk BEFORE every eed.
• Wash children’s hands and ace with soap and water beore eeding, i possible.
• Keep ood clean and protected rom insects, rodents and pets.
• Sick children get cold quickly. Always keep the child covered and warm.
• The RUTF is a ood and a medicine or the very thin or swollen child only.
• The RUTF is the ood the child needs in order to recover. The child should complete his
or her daily ration o RUTF beore being given other ood. The child should continue to
be breasted on demand. Sick children oten don’t like to eat. Give small regular meals o
therapeutic paste and encourage the child to eat oten.
• Always oer breast milk beore and plenty o clean water during/ater s/he is eating the
RUTF. Children need to drink more than normal when taking the diet.
• For inants and children aged less than 2 years, continue to put the child to the breast
regularly. Oer breast milk BEFORE every eed.
• Wash children’s hands and ace with soap and water beore eeding, i possible.
• Keep ood clean and protected rom insects, rodents and pets.
• Sick children get cold quickly. Always keep the child covered and warm.
Note: There is always some degree o sharing, even i this is denied by the amily –
calculations o the rate o weight gain against the amount “supposed” to be taken by the
child is used to calculate the maximum that the child has taken and shows that this is
always the case. The amily must not be orced to tell lies or eel guilty by the sta i they
insist that there has to be no sharing at all.
5.6 Monitoring and follow-up treatment as an outpatient
During weekly visits, the child is again weighed and MUAC measured, assessed or
danger signs, given RUTF and, i weight gain is not satisactory, is given a repeat appetite
test. I there is weight loss or i medical complications are identied, a ull assessment is
made and transer to the IPF is considered. The inormation recorded on the chart during
admission provides baseline data or comparison during ollow-up and the course o
treatment.
The child is monitored weekly, but the caretaker must understand that i s/he is concerned
about the child at any time, s/he should return to the centre.
In certain circumstances, once the child is recovering, ortnightly ollow-up may be
39
considered, but ONLY IF the distance to the health acility is excessive. Remarks: this
should exceptional, as 15 days is a long time or a SAM child. A home visit needs then
to be organized. I this is common then an OTP should be established closer to the
children’s home, possibly with a mobile team (oering all health services including OTP,
vaccination, IMCI etc.).
Education sessions and health & nutrition counselling ocusing on appropriate inant and
young child eeding practices should be given during OTP visits.
Table 10 summarises the activities carried out during the weekly OTP sessions.
Table 10. Activities required at follow-up visits
ACTIVITY FREQUENCY
Weight Each week
MUAC Each week
Check or oedema Each week
Height/length Once only
Medical history Each week
Physical examination (including temperature and respiratory rate) Each week
Appetite test Where indicated
Medical treatment Where indicated
Home visit Where indicated
Vaccinations Where indicated
Evaluation o health and nutrition status progress and eed-back o and to Each week
caretaker
Education sessions, individual counselling, emotional stimulation or child, Each week
support or caretaker
Provision o take-home RUTF and, where indicated, medicine Each week
The possible outcomes o each visit are: child is making good progress; a home visit is
needed; more counselling is indicated; reerral to IPF. Table 11 indicates the criteria the
health worker will use to decide on the outcomes.
I the child is making good progress, has good appetite, is gaining weight, MUAC is
increasing, oedema is absent or decreasing, there are no severe medical complications,
and the child is regularly attending weekly ollow-up visits, then he or she can continue in
outpatient care until he or she reaches the criteria or discharge.
40
Table 11. Action table for follow-up visits: on follow-up visits, the danger signs should be
reassessed
SIGNS TRANSFER TO INPATIENT CARE HOME VISIT
General condition Deteriorating Child is absent,
Bilateral pitting oedema Grade ++ deaulting, not gain-
ing weight or losing
Any grade o bilateral pitting oe-
weight on two consec-
dema with severe wasting (maras-
utive visits.
mus-kwashiorkor)
Increase in bilateral pitting oedema
Bilateral pitting oedema not reducing
by week 3
Anorexia Poor appetite or unable to eat – ailed
appetite test
SIGNS TRANSFER TO INPATIENT CARE HOME VISIT
Vomiting Intractable vomiting Follow-up home visits
Convulsions Ask mother i the child has had con- are essential i the
vulsions since the previous visit caretaker reuses
Lethargy or not alert Child is dicult to wake transer to inpatient
care.
Unconcious Child does not respond to painul
stimuli
Hypoglycaemia A clinical sign in a child with SAM is
eyelid retraction: child sleeps with
eyes slightly open
Dehydration Dehydration based primarily on re-
cent history o diarrhoea and recent
appearance o clinical signs o de-
hydration as reported by the mother/
caretaker
High fever Axillary temperature ≥ 38.5 °C, rectal
temperature ≥ 39 °C
Hypothermia Axillary temperature < 35 °C, rectal
temperature < 35.5 °C
Respiration rate ≥ 60 respirations/min or children
aged under 2 months
≥ 50 respirations/min or children
aged 2–12 months
≥ 40 respirations/min or children
aged 1–5 years
≥ 30 respirations/min or children
aged over 5 years
Any chest indrawing
Anaemia Palmar pallor or unusual paleness o
the mucosa
Skin lesions or infections Broken skin, ssures, faking o skin
or any inection requiring intramuscu-
lar (IM) antibiotics
41
Weight changes not ex- Weight loss o 5% o body Follow-up home visits are
plained by a home visit to weight at any visit essential i the
identify social causes Weight loss or two consecu- caretaker reuses transer to
tive visits inpatient care.
Static weight or three con-
secutive visits
Remarks: these are ailure
to respond to treatment and
need to be investigated rst
at household level and then
decision should be taken.
The cause may be nutritional,
social or medical.
Request by caretaker for Mother/caretaker requests
inpatient care treatment o child in inpatient
care or social reasons (de-
cided by supervisor)
Not responding to treatment A child that is not responding
to treatment is reerred to IPF
i a home visit does not nd a
social cause.
Home visits should be done by the CHW or patients who are absent or, deaulting, dead
or non-responding etc. The procedure is described in Chapter 3.
The health worker should check any patient or HIV testing and TB screening: i positive,
reer the child or appropriate treatment.
5.7 Failure to respond to treatment as an outpatient
Children with SAM may be slow to respond, or may not respond to treatment. It is important
to nd out the reason and take appropriate action.
The criteria or ailure to respond are given in Table 12. Children ullling any o these
criteria must be diagnosed as ailure-to-respond and the ailure-to-respond procedures
ollowed.
Table 12. Failure to respond criteria 12
CRITERIA FOR FAILURE TO RESPOND TIME AFTER ADMISSION
Failure to gain any weight (non-oedematous 21 days
children)
Weight loss since admission to programme 14 days
(non-oedematous children)
Failure to start to lose oedema 14 days
Oedema still present 21 days
Failure o appetite test At any visit
Weight loss o 5% o body weight (non-oe- At any visit
dematous children)
12 See Annex 10: Weight loss 5% table
42
Weight loss or two successive visits At any visit
Failure to start to gain weight satisactorily a- At any visit
ter loss o oedema (kwashiorkor) or rom day
14 (marasmus) onwards.
Do NOT simply monitor a failing child and carry on with routine treatment.
Discharging the child at the end of 12 weeks as a failure is not ethical: do not
abandon such children – instead take actions earlier during follow up (refer to IPF,
home visits etc.).
Many causes o non-response are attributable to the unctioning and the perormance o
the service where the child is receiving the treatment; most o the others are related to
the socioeconomic circumstances o the child; some are related to underlying medical
problems. There is no point in reerring a child to the IPF or social problems; i many
children ail to respond, the most likely reason is the quality o the service.
Box 5. Causes of failure to respond to treatment as an outpatient
Causes related to the quality of programme
• Breaks in the supply o RUTF (common and brings the whole programme into disrepute with
the community, undermines eorts at community mobilisation)
• Initial triage assessment was inadequate and has missed a reason that the child is not
suitable or direct admission to OTP
• Poor or non-observed assessment o appetite on admission and ollow-up visits
• Inadequate counselling given to caretakers
• Routine drugs are not available
• Excessive time between distributions and ollow-up visits
• Mother reused to go to the IPF when the child had a poor appetite or medical complication
(reasons vary, but oten relate to sta attitudes, cost and distance).
Causes related to the child’s socioeconomic situation
• Excessive sharing o therapeutic paste at household level e.g. lack o ood in the household
leading to most o the RUTF being shared among amily members; no (or low) income,
leading to sale o RUTF.
• Discrimination against the mother or amily or social reasons
• Absence o a social network to help in times o stress
• Poor eeding or caring practices, owing to lack o time or the caretaker or daily pressures,
or poor knowledge about appropriate inant and young child eeding practices
• Poor health, depression, trauma, absence or death o the caretaker or amily provider.
Causes related to the health status of the child
• TB or HIV inection
• Vitamin or mineral deciency
• Unrecognized inection, persistent diarrhoea, dysentery, otitis, pneumonia, urinary tract
inection, malaria, helminthiasis, hepatitis
• Other serious underlying disease, such as congenital abnormalities, neurological damage,
inborn errors o metabolism
• Psychological trauma etc.
43
5.8 End of outpatient care treatment
5.8.1 Criteria for the end of treatment
The criteria shown in Box 6 are used to determine when the child can be discharged
to ollow-up. The same criteria can be used or monitoring and reporting. It should be
recognized that early discharge results in increased relapse rates.
A child admitted on a specic measurement should be identied as cured on the same
measurement.
Box 6. Criteria for admission and discharge from outpatient treatment (children
aged 6–59 mo.)
CRITERIA FOR DISCHARGE TO FOLLOW-UP
Cured Discharged with MUAC: and clinically well
MUAC ≥ 125 mma
Discharged with weight-or-
height/length: weight-or-
height ≥ –1.5 Z-scoreb
Admitted with oedema:
no oedema or 2 consecutive
weeks and either MUAC ≥
125 mm or
weight-or-height/length ≥
–1.5 Z-score
Conrmed deault Absent or three consecutive Deaulters during 3 weeks
visits o absence can die and it is
important or our inormation
to know i he/she is an uncon-
rmed or conrmed deaulter
Unconrmed deault Absent or three consecutive Absent or 3 weeks, without a
visits home visit to determine i the
child died
Died Died during treatment in OTP This should be conrmed with
a home visit: otherwise sever-
al deaths will be inappropri-
ately classied as deaulting
Non-recovereda Did not meet the discharge RARE: action should be taken
criteria ater our months in long beore this stage.
treatment
a
Note that a child or person whose condition is not responding to treatment should have
a home visit and investigation o social or medical conditions and underlying pathologies,
or reerred to IPF or closer monitoring. Movements between inpatient and outpatient
treatment are transers rather than discharges and should be recorded as such.
b
WHO recommends > –2 Z-score, but most programmes have a higher relapse rate
unless the criterion is set at –1.5 Z-score. The old WHO recommendation o > –1 Z-score
led to unrealistically long patient treatment. HOWEVER it can be reduced to > -2 Z-score
44
where ollow up is good and the community is engaged and motivated.
In addition to anthropometric criteria, the ollowing services should be in place beore
discharge:
• Eorts to re-initiate and/or encourage exclusive breasteeding
• Counselling to caretakers on appropriate inant and child eeding practices has
been provided
• Stimulation o emotional and physical development has been initiated and taught
to the mother or continued practice at home and into the uture (see Chapter 9)
• The mother or caretaker has been provided with psychosocial support (see
Chapter 11).
5.8.2 Procedures for the end of treatment
When a child ulls the criteria or the end o treatment, the healthcare worker will:
1. Complete the patient’s chart with the required discharge inormation.
2. Check that all drugs and vaccines have been given beore discharge.
3. Give a nal ration o RUTF or the ensuing 7 days to take home.
4. Give the caretaker support or appropriate complementary eeding or child eeding
and improved amily oods. This may be done through individual counselling
or, where possible, linking to ongoing nutrition support programmes. These
can include health and nutrition education sessions, counselling on inant and
young child eeding practices (reer to maternal, inant and young child (MIYCN)
counselling cards).
5. In emergency settings where access to ood is disrupted, all children discharged
rom OTP should be reerred to a supplementary eeding programme, regardless
o their anthropometric measurements, or 3 months’ ollow-up in that programme.
6. Ensure that the caretaker knows how to recognise the signs o deterioration o the
child and tell her that, i this occurs, the child should be brought back to the health
acility to be assessed.
7. Complete the acility register book.
8. At the end o the month, complete the monthly report orm with the discharge
details o all children leaving the OTP during that month, with any corrections rom
previous months.
45
6. MANAGEMENT OF COMPLICATIONS OF SEVERE
ACUTE MALNUTRITION IN CHILDREN OVER 6 MONTHS
OF AGE
As children with SAM usually have complications, these need to be addressed when the
child is rst admitted. This section o the protocol should be read in conjunction with the
routine management o children in IPF.
When a patient develops a complication, always transer him/her to acute-phase or
treatment (inpatients are transerred back to acute-phase i they are in transition phase;
outpatients are reerred to the IPF i suitable transport is available and the inpatient acility
is within a reasonable distance o the OTP site, otherwise where easible, attempts to start
phase 1 and treat the complications should be started beore transport in consultation by
phone with the IPF).
Stabilization o critically ill children with SAM is crucial. Where the child is not in immediate
risk o death, ull assessment, routine and specic treatment, and daily quality care are
considered.
6.1 Emergency Triage Assessment and Treatment in hospital settings
Health workers who are involved in ETAT+ o ill children presenting at the hospital should
assess the children’s nutritional status as early as possible, because the principles and
procedures o ETAT+ dier or children with SAM compared to well-nourished children.
6.1.1 Principles of ETAT+
When rst seen, every child with SAM must be examined or emergency critical signs
and, i present, treated beore any other action is initiated.
Box 7. Summary of steps in Emergency Triage Assessment and Treatment (ETAT)
First, check or emergency signs in three steps.
• Step 1: I there is any airway or breathing problem manage the airway and give oxy-
gen.
• Step 2: I the child is in shock due to diarrhoea with very severe dehydration start intra-
venous (IV) fuid resuscitation and give oxygen.
• Step 3: I the child is unconscious or convulsing, give IV glucose or hypoglycaemia.
Give an anticonvulsant or convulsions.
I emergency signs are ound:
• Call or help, but do not delay starting treatment.
• Carry out emergency investigations (blood glucose, blood smear, haemoglobin). Send
blood or typing and cross-matching i the child is in shock, appears to be severely
anaemic or is bleeding signicantly.
• Ater stabilization proceed to assessing, diagnosing and treating the underlying prob-
lem.
46
ETAT procedures in children with SAM
In order o emergency, assess and treat the ABCD:
Airway and breathing, “A” and “B”:
• Does the child’s airway appear obstructed? Look and listen to determine whether
there is poor air movement during breathing.
• Does the child have severe respiratory distress? (Head nodding, grunting, central
cyanosis, ast breathing, retractions, not able to eed.)
See Section 6.1.6 for treatment of severe pneumonia.
Circulation “C”
• Check the radial pulse, capillary rell time, and coldness o extremities. I you cannot
eel a radial pulse o an inant (less than 1 year o age), eel the central pulse. I the room
is very cold, rely on the emoral/carotid pulse to determine whether the child is in shock.
See Section 6.1.2 on management of shock
Disability “D”
Level of consciousness: Is the child lethargic or in coma (unconscious)? Check the level
o consciousness on the “AVPU” scale (A alert, V responds to voice, P responds to pain, U
unconscious).
Convulsions: Is the child convulsing?
See Section 6.1.9 on treatment of convulsions.
Hypoglycaemia
• Does the child sleep with eyelids open? Does the child have a low body temperature
(< 36.5 °C), limpness and diminution in the level consciousness?
See Section 6.1.10 for treatment of hypoglycaemia
Hypothermia – hyperthermia
• Does the child have a low body temperature (< 35.0 °C axillary or < 35.5 °C rectal).
Low body temperature is a sign o hypoglycaemia and sepsis. Warming the child is an
emergency treatment.
• Does the child have a very high body temperature (≥ 38.5 °C axillary or ≥ 38°C rectal)?
Cooling the child with tepid sponging in used.
Note: A child with SAM has disturbances o body temperature regulation and tends to take the
temperature o the environment. Keeping the child warm is a routine treatment.
See Section 6.1.11 on the management of hypothermia and hyperthermia
47
Severe anaemia
• Does the child show severe pallor?
See Section 6.1.8 on treatment o very severe anaemia.
Severe dehydration without shock
• Does the child have diarrhoea with recent sunken eyes? Ask the mother/carer whether
the child has had recent and requent watery diarrhoea or vomiting and i the ace has
changed in appearance.
See Section 6.1.3 on treatment of dehydration without shock.
6.1.2 Shock
• Diagnosis
Signs o shock are cold hands, capillary rell time longer than 3 seconds, and weak and
ast pulse, or a very slow pulse.
The common causes o shock in SAM are septicaemia, severe dehydration, cardiogenic,
toxicity rom traditional medicines or therapeutic drugs (e.g. excess metronidazole),
hepatic ailure and severe hypernatraemia. Frequently, several o these causes appear
simultaneously in SAM children (e.g. septicaemia leading to compromised heart and
hepatic unction). Children with SAM do not usually have haemorrhagic shock or
anaphylaxis.
• Treatment of hypovolemic shock
• Start a critical care chart and record the respiratory rate, pulse rate, capillary rell
time, level o consciousness, liver size (mark on the skin with a marker pen) and
weight.
• Give oxygen through nasal prongs or a nasal catheter, with a fow o 1–2 L/min.
• Insert an IV line and draw blood or emergency laboratory investigations.
• Give 10% glucose solution, 5 ml/kg IV, ollowed by 50 ml o 10% glucose or sucrose
by nasogastric tube, to prevent/ treat hypoglycaemia.
• Keep the child warm to prevent or treat hypothermia.
• Give IV cetriaxone 100 mg/kg per day divided 12 hourly or IV ceotaxime 150
mg/kg per day divided 8 hourly and IV ciprofoxacin 20 mg/kg per day divided 12
hourly.
• Initiate and careully monitor specic IV fuid: give 15 ml/kg over 1 hour.
Do not handle the child any more than is essential or treatment.
•Intravenous uid management
IV fuid used is Ringer’s lactate solution with 5% dextrose.
I Ringer’s lactate is not available, use hal-normal saline with 5% dextrose. Add 10%
sterile potassium chloride solution 20 mmol/L when using Ringer’s lactate solution, with
5% dextrose or hal-normal saline with 5% dextrose or IV fuid management, i it can be
made saely.
48
Table 13. Amounts o IV fuid or children with SAM and shock due to severe dehydration to
give in the rst hour (do not give an initial bolus to SAM children)
WEIGHT OF CHILD VOLUME IV FLUID WEIGHT OF CHILD VOLUME IV FLUID
(KG) TO GIVE OVER 1 (KG) TO GIVE OVER 1
HOUR (15 ML/KG) HOUR (15 ML/KG)
4 60 ml 12 180 ml
6 90 ml 14 210 ml
8 120 ml 16 240 ml
10 150 ml 18 270 ml
During an initial IV inusion DO NOT give any ReSoMal or other fuid by nasogastric tube
to a child in shock; urther management must be based upon the response o the child
to the inusion.
Monitor signs o fuid overload such as increasing pulse rate (≥ 15 beats/min), increasing
respiratory rate (≥ 5 breaths/min), liver enlargement, ne crackles throughout lung elds,
raised jugular venous pressure, development o galloping heart rhythm, puy eyelids
and increasing oedema. Stop the inusion immediately i any o these signs appear.
NOTE: for children who are truly dehydrated, the response to treatment is remarkable
and obvious with a gain in weight towards the target “rehydrated weight”. If a prompt
response is not observed then the diagnosis of shock due to dehydration was incorrect
and an alternative diagnosis should be considered.
•Reassess the child after 1 hour:
I the child shows signs o improvement (alling pulse and respiratory rates), then:
• I still unconscious: repeat the same amount o IV fuid (15 mg/kg) or another hour
without giving any fuid by mouth or nasogastric tube at this stage. Weigh to check
fuid balance – i there is gain in weight and improvement is maintained then the
diagnosis o dehydration as the cause o the shock is conrmed.
• I conscious: switch to oral or nasogastric rehydration with ReSoMal at 10 ml/kg
per hour.
o I the weight o the child remains steady, increase the volume given orally
by steps o 5 ml/kg per day until there is steady weight gain and continued
improvement.
o Stop all rehydration fuid when the child reaches his/her rehydrated “target
weight”.
• When rehydrated and conscious, start therapeutic eeding with F75: the amounts
to be given and requency are detailed in the table or routine care (see table 14).
• I the child vomits, give the diet by nasogastric tube. I the child continues to vomit
repeatedly, give the diet more slowly. I the problem does not resolve, stop eeding
the child and give maintenance IV fuids at a rate o 4 ml/kg per hour.
I the child ails to improve ater the rst hour with the 15 ml/kg IV fuid treatment, then the
diagnosis was incorrect and needs revision to a second dierent diagnostic.
49
• Treatment o septic shock
• Start a critical care chart and record the respiratory rate, pulse rate, capillary rell
time, level o consciousness, liver size (mark liver edge on the skin) and weight.
• Give oxygen through nasal prongs or a nasal catheter, with a fow o 1–2 L/min.
• Insert and IV line and draw blood or emergency laboratory investigations.
• Give 10% glucose solution, 5 ml/kg IV, ollowed by 50 ml o 10% glucose or sucrose
by nasogastric (NG) tube, to prevent/ treat hypoglycaemia.
• Keep the child warm to prevent or treat hypothermia.
• Give IV cetriaxone 100 mg/kg per day divided 12 hourly or IV ceotaxime 150 mg/
kg per day divided 8 hourly and IV ciprofoxacin 20 mg/kg per day divided 12 hourly.
• Give maintenance IV fuid, 4 ml/kg per hour (do not exceed this volume) while
waiting or the blood:
o When blood is available, stop all IV fuids and transuse packed red blood
cells (PRBC), this can be done by giving 5 ml/kg over 3-4 hours, then waiting
or about 8 hours and repeating the inusion o a second 5 ml/kg. I this is
not possible then give 10 ml/kg very slowly over a minimum o 4 hours and
monitor closely.
o During the blood transusion, stop all other intake o ood or fuid – nothing
by mouth or nasogastric tube or IV. This minimizes the risk o precipitation o
heart ailure.
o Blood transusions should only be given to children with SAM within the rst
24 hours o admission. This is because, as the F75 starts to heal the cells,
a large amount o sodium efuxes rom the cells and potassium enters the
cells. This sodium expands the plasma volume, enlarges the liver and drops
the haemoglobin concentration. This physiological readjustment o body
electrolytes makes the child very vulnerable to volume overload, so any blood
transusion must be given beore F75 starts to heal the body.
o Ater the transusion do not give anything orally or at least 3 hours to allow
time or the circulation to adjust to the new blood volume; ater a minimum o
3 hours wait start re-eeding with F75 by nasogastric tube or orally.
• I there are signs o liver ailure (e.g. purpura, jaundice, enlarged tender liver), give
vitamin K1, 1 mg IV single dose
Note: the treatment with IV fuids o children with SAM with shock diers rom that or a
well-nourished child. This is because shocks arising from dehydration, sepsis and the
other causes oten coexist and are very dicult to dierentiate on clinical grounds. SAM
patients are particularly susceptible to rapid changes in blood volume and readily go into
heart ailure rom fuid overload.
6.1.3 Dehydration but no shock
• Diagnosis
Dehydration tends to be over-diagnosed and its severity overestimated in children with
SAM. This is because it is dicult to estimate dehydration status accurately in a child with
SAM using clinical signs alone. Assume that children with requent and recent watery
diarrhoea may have some dehydration. Low blood volume is common in children with
oedema – this is not due to dehydration, even i the child has diarrhoea; it is due to
50
vascular dilatation rom excess production o the physiological vaso-dilator, nitric oxide,
in kwashiorkor children and does not require specic treatment.
Signs o dehydration in children who have SAM with diarrhoea are recent sunken eyes
with the eyes having a staring appearance (eyelid retraction). Thereore, the mother or
carer should be asked whether the eyes only became sunken ater the diarrhoea started.
• Treatment of dehydration without shock
I dehydration is conrmed and there are no signs o shock, do not insert an IV line but
proceed to ull assessment and treatment.
Treatment consists o giving oral rehydration, starting antibiotic treatment, continuing
breasteeding, initiating therapeutic eeding, and keeping the child warm. Use oral
rehydration solution or malnutrition (ReSoMal).
Box 8. Rehydration solution for malnutrition (ReSoMal)
Because children with SAM are decient in potassium and have abnormally high levels o
sodium in their body (whether or not plasma sodium is normal or low), the recommended oral
rehydration solution or malnutrition (ReSoMal) contains less sodium and more potassium than
the standard WHO low-osmolarity oral rehydration solution. Magnesium, selenium, zinc and
copper have been added in ormulation o ReSoMal to start correction o these deciencies.
(Note: even children SAM with hyponatraemia always have abnormally high levels o sodium
in their body because o the high intracellular sodium level, and their renal unction is impaired
so that they do not excrete excess sodium rapidly even when the extracellular volume is ex-
panded; this makes them particularly vulnerable to fuid overload).
• Rehydration
• Weigh the child to monitor fuid balance and the progress o rehydration.
• Record the respiratory rate, pulse and liver edge on the critical care chart.
• Give ReSoMal orally or by nasogastric over a maximum o 12 hours:
o Starting with: ReSoMal 10 ml/kg per hour or the rst 2 hours orally.
o Re-weigh the child to determine i the child is gaining or losing weight:
- I the child is gaining weight AND clinically improving, continue.
- I the child’s weight is steady (the same), increase the ReSoMal to 15 ml/kg/h.
- I the child is losing weight, increase the ReSoMal to 20 ml/kg/h.
I the child is gaining weight, but clinically deteriorating STOP ALL ATTEMPTS at
rehydration – the child is not dehydrated.
I there is continued weight loss with 20 ml/kg per hour (2% o body weight) then the
rate o fuid loss is excessive, start rehydration with either standard WHO oral rehydration
solution (ORS) or start an IV inusion o Ringer’s-lactate at 20 ml/kg per hour and continue
to monitor, as this is now cholera-like fuid-loss and the composition o ReSoMal is not
appropriate or cholera-like diarrhoea.
51
The target weight for “rehydration” is less than in a normal child because o the
diculties o assessing the degree o dehydration. I the diarrhoea has started ater
admission, use the pre-diarrhoeal weight as the target weight. For conscious children
on admission assume that it is 3% o the admission body weight, or unconscious
children use a gure o 5% o body weight. Do not give fuids to increase the body
weight above this target weight.
• Give the required amount o fuids as sips by cup or spoon every ew minutes.
Malnourished children are weak and quickly become exhausted. I the child does not
continue to take enough fuid voluntarily, give the solution by nasogastric tube at the
same rate. Use an nasogastric tube in all weak or exhausted children and in those
who vomit or have ast breathing or painul mouth lesions.
• Monitor the progress o rehydration hal-hourly or 2 hours, then hourly or the next
4–10 hours. Check respiratory rate, pulse rate, urine requency, requency o stools
and vomit. Be alert or signs o over-hydration (respiratory distress, acial oedema,
hyper hepatomegaly), which is very dangerous and may lead to heart ailure.
• Stop ReSoMal immediately i signs o over-hydration appear.
• Rehydration is completed and ReSoMal should be stopped when the target weight
is reached – or i the child is no longer thirsty, urine is passed and any other signs o
dehydration have disappeared.
• I diarrhoea continues give children 20–30 ml o ReSoMal ater each loose stool; do
not give more than this.
NOTE: I the child develops diarrhoea ater admission and has not lost weight, the child
is NOT dehydrated and should NOT be treated with ReSoMal or any other sodium-
containing fuids. Recovering children usually develop some loose stools with a change
o diet and do not need to be treated.
• Children with oedema have already an excess o sodium and water in the extracellular
fuid as well as inside their cells. They are already overhydrated and cannot also
be dehydrated, although they are requently hypovolemic with the fuid in the wrong
place. Do not give ReSoMal or ORS to oedematous children.
• The treatment o symptomatic hypovolemia in kwashiorkor is the same as the treatment
or septic shock.
• Zinc supplementation is not needed in children with SAM (even or those with
diarrhoea and dehydration) who are receiving therapeutic oods that comply with
WHO specications, as the zinc is already incorporated in the fuids and diet.
52
Treatment of dehydration
ONLY Rehydrate until
the weight decit
(measured or estimated)
is corrected and then
Conscious STOP - DO not give Unconscious
extra uid “prevent
recurrence”
IV uid
Resomal
10ml/kg/hr first 2hrs 1/2 saline & 5% glucose
then reassess using weight change or Ringer lactate & 5% dextrose
and clinical change
at 15ml/kg the first hr & reassess
- If improving, 15ml/kg 2nd hr;
-If conscious, NGT: ReSomal
- If not improving assume other
cause - toxic/septic shock,
cardiogenic shock, liver failure,
cerebral malaria, grug
intoxication, acidos is, etc.
Rehydration
Monitor Weight
Gain Stable Loss
Clinically Clinically
Improved not
improved
continue - STOP ALL - Increase - Increase
rehydration fluid ReSoMal by: ReSoMal by:
Target -Give F75 5ml/kg/hr 10ml/kg/hr
weight - Re-diagnose & - Reassess
assess
-Reassess
every hr
F75 every hr
6.1.4 Hypernatræmic dehydration
Hypernatraemic dehydration is common in areas with a dry atmosphere, particularly i
the air temperature is also high.
It is most likely to occur in children who have been carried or long distances to the
53
IPF/OTP in the sun, without the mother stopping to rest or give the child something to
drink. It is important that those arriving at clinics, OTP etc. are given water/sugar-water
to drink on arrival and, i they have to wait to be seen, are oered a shady place to sit.
Hypernatraemic dehydration also occurs when eeds are over-concentrated. Note that
F100 is a concentrated diet that has a high renal-solute load – it should never be given in
phase 1 to very sick children, and never to inants less than 3 kg as it will cause hyper-
osmolar syndrome unless diluted with plain water.
Although hypernatraemia is dicult to treat saely, it is easy to prevent saely. Malnourished
children, particularly those in dry and hot environments, should be given continuous
access to sucient plain water.
• Diagnosis
• The rst sign to appear is a change in the texture and eel o the skin.
• The skin develops plasticity similar to the eel o dough (four and water mixed or
bread making).
• The eyes can sink somewhat.
• The abdomen requently then becomes fat and may progress to become
progressively sunken and wrinkled (so called “scaphoid abdomen” or “prune belly”).
• The child may develop ever.
• The child becomes progressively drowsy and then unconscious.
• Convulsions ollow and, i treatment or hypernatraemia is not instituted, this
leads to death. The convulsions are not responsive to the normal anti-convulsants
(phenobarbitone, diazepam etc.).
• Failure to control convulsions with anti-convulsants may be the rst indication o
the underlying diagnosis.
The diagnosis can be conrmed by nding an elevated serum sodium. Normally
hypernatraemia is diagnosed when the serum sodium is more than 150 mmol/L.
• Treatment
For incipient (starting) hypernatraemic dehydration – an alert child who is only showing
changes in the texture and eel o the skin:
• Breasteed the child or give breast milk. This can be supplemented with up to
about 10 ml/kg per hour o 10% sugar-water in sips (little by little) over several hours
until the child’s thirst is satised. At this early stage treatment is relatively sae.
• Give water but the child should not drink large amounts rapidly – take several
hours to correct the mild hypernatraemic dehydration.
For developed hypernatraemic dehydration, treatment must be slow.
I it is possible, measure serum sodium:
• The aim is to reduce the serum sodium concentration by about 12 mmol/L over a
24-hour period. The rapid correct o hypernatraemia can cause death rom cerebral
oedema.
I it is not possible to measure the serum sodium:
54
• The aim is to take at least 48 hours to correct hypernatraemic dehydration. The
treatment should start slowly and, as the serum sodium approaches normality, the
rate o repletion can be increased.
Progress is assessed by serial weighing of the child:
• First, put the child in a relatively humid, thermo-neutral (28-32 ˚C) environment
(mist or spray water into the air i necessary) – this is the most important step and
must not be omitted.
• Weigh the child on an accurate balance and record the weight.
The objective o treatment is to put the child into positive water balance o about 60 ml/kg
per day over the course o treatment (assessed by weight gain), which is equivalent to a
net gain o 2.5 ml/kg per hour o plain water. This amount should not be exceeded until
the child is awake and alert.
If the child is conscious or semi-conscious and there is no diarrhoea:
Put down an nasogastric tube and start 2.5 ml/kg per hour o 10% sugar water or breast
milk. Do not give F75 at this stage. Never give F100 or inant ormula. Expressed breast
milk is the best “rehydrating” fuid available.
• Reweigh the child every 2 hours:
o I the weight is static or there is continuing weight loss, recheck the
immediate environment to try to prevent on-going water losses. Then increase
the amount o sugar-water intake to compensate or the on-going weight loss
(calculated as g/hour and increase the intake by this amount).
o I the weight is increasing, continue treatment until the child is awake and
alert.
If there is accompanying diarrhoea:
•Give one th normal saline in 5% dextrose orally or by nasogastric tube.
If the child is unconscious:
• Then the same volumes o fuid (5% dextrose i there is no diarrhoea and one th
normal saline in 5% dextrose i there is diarrhoea) can be given by IV inusion. There
should be a peristaltic pump or accurate paediatric burette in order to ensure that
that the correct rate o administration o fuid is not exceeded during treatment.
When the child is awake and alert and the skin quality returns to normal (or, if there are
facilities to measure sodium, the serum sodium is normal):
• Then recommence eeding with F75.
55
6.1.5 Respiratory distress
When a child with SAM presents with respiratory distress, it is important dierentiate
between pneumonia and heart ailure.
Note: on admission the most likely diagnosis is pneumonia. Heart ailure (or inhalation
pneumonia) is more likely i the child has developed respiratory distress whilst in the
ward ater starting F75 (day 2-5), or ater an IV inusion, transusion or ReSoMal or ORS.
6.1.6 Severe pneumonia
•Diagnosis
Children with SAM may have very severe pneumonia i they have a cough or dicult
breathing plus at least one o the ollowing: central cyanosis, severe respiratory distress,
chest wall indrawing. However those signs may also occur with pulmonary oedema or
heart ailure.
In SAM, the absence o ast breathing does not exclude severe pneumonia because
when muscle wasting is severe there may not be an increase in respiratory rate at all.
Chest auscultation signs o pneumonia may also be absent.
The swallowing refex in SAM children is compromised and oesophageal peristalsis is
slow. Inhalation o eeds into the lungs, particularly solid or peanut-containing oods, is
particularly dangerous and a common cause o sudden death in children who seem to be
recovering well. The children must never be orce-ed by mouth and the correct eeding
technique must be taught to the mothers.
•Treatment
Follow the Rwanda National protocol or the management o very severe pneumonia.
I the child does not show signs o prompt improvement (maximum delay 48 hours)
on recommended therapy and staphylococcal pneumonia is suspected (chest X-ray
is particularly useul or this condition, as pulmonary abscesses may occur), switch to
gentamicin 7.5 mg/kg IM or IV once a day and cloxacillin 50 mg/kg IM or IV every 6 hours.
6.1.7 Congestive heart ailure
This is usually a complication o over-hydration (especially when an IV inusion or
standard oral rehydration solution has been given), very severe anaemia, blood or
plasma transusion, or giving a diet with a high sodium content. It commonly occurs ater
the rst day or so o admission, as the F75 repairs the cells and the high intracellular
sodium reverses by export to the plasma. This causes the plasma volume to increase,
the haemoglobin concentration to drop and the liver to enlarge. This does not need any
treatment and is normal, but it makes the child particularly vulnerable at this time to a high
salt intake. Frequently, the new diet causes some loose stools because some o the diet
is mal-absorbed; i this is mistaken or diarrhoea likely to lead to dehydration and treated
with ReSoMal then the child can go into heart ailure, either congestive heart ailure or
occasionally sudden death. I there has been no signicant weight loss since the onset
o diarrhoea, no matter what the amount and requency o deecation, the child is not
dehydrated and must not be treated as i s/he is dehydrated.
56
• Diagnosis
Congestive heart ailure or cardiogenic shock occurs when the heart is unable to provide
sucient pump action to distribute the blood fow to meet the needs o the body. Heart
ailure can cause a number o symptoms, but in SAM the rst sign o heart ailure is ast
breathing (increase in respiratory rate o ≥ 5 breaths/minute). Later signs are rapid pulse
(increase in pulse rate o ≥ 15 beats/minute), distension o the jugular veins, enlarged
liver, cold hands and eet and cyanosis o the ngertips and under the tongue.
Heart ailure must be dierentiated rom respiratory inection and septic shock, but this
dierentiation is extremely dicult, and they may occur together to a greater or lesser
extent, in which case treating one may lead to worsening o the other. The key to successul
management is requent reassessment.
Pneumonia is usually associated with weight loss. I, ater admission, there is WEIGHT
GAIN WITH RESPIRATORY SYMPTOMS then the diagnosis is heart ailure until proved
otherwise.
• Treatment
The objective o treatment is to get the child to lose weight again (negative fuid balance):
• Weigh the child (we expect the child to lose weight during improvement).
• Start a critical care chart.
• Stop all intake o ood.
• Stop all IV fuids. Do not give any fuid until the heart ailure has improved, even i
this takes 24–48 hours.
• Never transuse a SAM child in heart ailure (unless there are acilities or exchange
transusion).
• Give a diuretic IV. The most appropriate is urosemide, 1 mg/kg. Reassess the
child ater giving urosemide. It is not as eective in the SAM child as in normal
children and may not cause a natriuresis.
• Oxygen can be given i the child has a respiratory rate ≥ 70/min, shows signs o
respiratory distress, or has central cyanosis or a low oxygen saturation.
• Try to nd i there is a source o sodium intake that has not been accounted or
– typical sources are tap-water, carer’s ood shared with the child, drugs that are
ormulated as the sodium salts (most antibiotics and antacids).
57
Respiratory distress
Examine daily weights
Weight Increase Weight decrease
Weight stable
Fluid overload Pneumonia
Heart failure (Aspiration)
6.1.8 Anaemia
Nearly all children with SAM have anaemia, which is oten associated with bacteraemia,
requent bouts o malaria, hookworm inection, HIV inection and micronutrient deciencies.
But studies show that the children have increased body stores o iron – iron deciency is
rare in SAM children.
• Severe anaemia
Diagnosis
Children with SAM that have very severe anaemia require a blood transusion i their
haemoglobin is < 4 g/dl – this MUST be accomplished soon ater admission (beore F75
has started to cause sodium to come out o the cells and potassium to go in) to expand
the circulation. Ater the rst 24–48 hours o F75 eeding, any transusion o blood or
PRBC (unless there has been an exchange transusion) can result in sudden death. This
injunction lasts or about 14 days by which time cell sodium has returned to normal.
The haemoglobin level nearly always alls during initial treatment with F75 – this is dilutional
anaemia and is a sign o an expanding blood volume and impending fuid overload. I the
all in haemoglobin is excessive then stop eeding, treat or volume overload and restart
eeding at a reduced intake o F75 when the haemoglobin/haematocrit stabilises.
Treatment
Transusion in a child with SAM must be much slower and o smaller volume than or a
well-nourished child. They are unable to cope physiologically with sudden large changes
in blood volume, particularly i this is already expanded during initial treatment with F75
.
Stop all oral intake o ood and liquid, and stop any IV fuids or several hours beore
starting the transusion.
Mark the edge o the liver, weigh the child, document the respiratory and pulse rates
on the critical care chart and examine careully or any possible signs o congestive
heart ailure (such as ast breathing, respiratory distress, rapid pulse, engorgement o
the jugular vein, cold hands and eet, cyanosis o the nger tips and under the tongue).
Listen with a stethoscope careully to the heart sounds and the lungs or any sign o
58
gallop rhythm or crepitation. Feel the apex beat and ensure that it is not displaced.
Transusion: i there are no signs o heart ailure, give PRBC 5 ml/kg over 3 hours by drip
or preerably inusion pump. Wait or 6–8 hours to allow adjustment to the new blood
volume and then repeat the same amount (5 ml/kg over 3 hours) ater the end o the
waiting period and the rst transusion. I an inusion pump is not available and a drip
cannot be properly controlled then give PRBC 10 ml/kg over a minimum o 4 hours with
close monitoring.
Monitor the pulse and breathing rates every 15 minutes during the transusion. I breathing
increases by 5 breaths/min or the pulse increases by 15 beats/min or signs o heart ailure
develop, STOP the transusion (transusing more slowly is not an adequate response).
I the haemoglobin is still below 4 g/dl immediately ater the transusion, do not repeat the
transusion or 14 days.
I the haemoglobin is 2 g/dl or less then this is an emergency that requires specialised
treatment – transer the child to a acility where exchange transusion can be perormed
(e.g. a neonatal unit).
Note: IV furosemide can be given prophylactically 1 mg/kg IV (10 mg/ml), but is not
usually necessary and may exacerbate the electrolyte derangements that are nearly
always present.
Only measure haemoglobin (Hb) on admission. In every child, the haemoglobin alls
during the rst week o treatment; this is normal and is caused by the plasma expansion
during electrolyte re-distribution. A large all in haemoglobin is another sign o actual or
impending heart ailure through excess plasma expansion and must never be used as a
reason or transusion ater 24–48 hours o treatment.
Iron is never given during the rst phase o treatment (F75 is deliberately very low in iron
and sodium). RUTF contain iron in sucient amounts to allow or blood expansion during
catch-up weight gain.
DIAGNOSIS AND TREATMENT OF ANAEMIA
Check Hb at admission if any
clinical suspicion of anaemia
- Hb < 4g/100ml or - Hb < 4g/100ml or
- Packed cell vol < 12% - Packed cell vol < 12%
- Or between 2 and 14
ONLY during the first
days after admission 48hrs after admission:
Give 10ml/kg whole or
No acute treatment
packed cells 4hrs - No
37
food for 3 to 5 hrs after
59
• Non-severe anaemia
I a child has a good appetite and is gaining weight rapidly to consume the excess body
stores by incorporation into the new body tissue, he/she may become iron-decient. So
i he/she is on F100 in the rehabilitation phase, iron can be given at low dose (2-3 mg/kg
per day).
There is sucient iron in RUTF so additional iron is NOT needed in any child who is
ollowing this protocol.
The other haematinics are all in plentiul supply in F75, F100 and RUTF. It is not necessary
to give any additional nutrients.
6.1.9 Convulsions
• Treatment
Convulsions are not common in SAM children, even those with a high ever. One common
cause is hypernatraemic dehydration, which must always be considered in any SAM
child who has convulsions – the serum sodium concentration should be measured in all
SAM children that have had a convulsion. Some traditional medicines cause convulsions.
Convulsions are treated similarly in children with or without SAM. BUT, as drugs aecting
the brain are all lipid-soluble, in children with low body-at, the concentration that will
occur in the brain with standard doses can be excessive and may even aect vital centres
such as the respiratory centre. Nevertheless it is critical to stop the convulsions and to
determine the underlying cause.
Turn the child into the le lateral position and manage the airway and breathing.
Gain circulatory access.
If there is hypoglycaemia, give 10% glucose solution 5 ml/kg IV. If it is not possible to mea-
sure blood glucose, give empirical treatment with glucose.
If the convulsion does not stop in 2 min give diazepam, 0.2 mg/kg IV or 0.5 mg/kg rectally.
If convulsion continues aer 5 min, give a second dose of diazepam IV or rectally.
If convulsion continues aer another 5 min, give phenobarbital, 15 mg/kg IV.
If the child has a high fever, sponge with tepid (lukewarm) water to reduce the fever.
Do not give oral medication until the convulsion has been controlled, because of the danger
of aspiration. If there is hypocalcaemia, symptoms may settle if the child is given 2 ml/kg of
10% calcium gluconate as a slow IV infusion.
Rule out central nervous system infection (e.g. TB meningitis) and cerebral malaria. Treat if
present.
6.1.10 Hypoglycaemia
All severely malnourished children are at risk o developing hypoglycaemia (blood
glucose < 3 mmol/L or < 54 mg/dl) i they have not had carbohydrate to eat in the past
10 hours and have an inection. It can easily be prevented by giving ALL children who
arrive in the clinic a drink o sugar-water on arrival (volume not critical – about 100 ml is
typical). To prevent hypoglycaemia, sick children should be ed every 3 hours night and
day with F75. As they start to recover, night eeding is not necessary i they have taken
60
all their F75, F100 or RUTF during the daytime.
• Diagnosis
Measure blood glucose i there is any suspicion o hypoglycaemia and where blood
glucose results can be obtained quickly (e.g. with dextrostix). Hypoglycaemia is
present when the blood glucose is < 3 mmol/L or 54 mg/dl. I blood glucose cannot
be measured, assume that all non-alert children with SAM, who have not already had
sugar-water during admission, have hypoglycaemia. Signs o hypoglycaemia include low
body temperature (< 36.5 °C), lethargy, limpness and loss o consciousness, a staring/
rightened expression due to eyelid retraction and sleeping with the eyes open. Sweating
and pallor do not usually occur in malnourished children with hypoglycaemia.
• Treatment
I hypoglycaemia is suspected, give treatment immediately without laboratory conrmation;
it can do no harm, even i the diagnosis is incorrect.
I the patient is unconscious give 10% glucose IV 5 ml/kg. I only 50% glucose solution
is available DO NOT GIVE UNDILUTED AS IT WILL CAUSE SCLEROSIS OF THE VEIN:
dilute one part with our parts o sterile water.
I the patient is conscious or can be roused and is able to drink, give 50 ml o 10%
glucose or sucrose, or give F75 diet (whichever is available most quickly).
Stay with the child until he or she is fully alert. If the symptoms are truly due to hypogly-
caemia the child will become alert within a few minutes. If this does not occur then there
is another reason for the signs and symptoms and it must be found and corrected. Keep the
child warm.
Start on appropriate IV or IM antibiotics.
Proceed to complete treatment of other emergency signs of full assessment.
6.1.11 Hypothermia
Hypothermia is usually due to a cool environment – a SAM child is unable to maintain
his/her body temperature i the environment is less than 24 °C. Inants aged less than 12
months, children with marasmus and oedematous children with large areas o damaged
skin or serious inections are highly likely to develop hypothermia.
• Diagnosis
The body temperature is below 35.5 °C rectal temperature, or below 35.0 °C axillary
temperature.
• Treatment
• Warm the child, preerably using the “kangaroo” technique, by placing the child
on the mother’s bare chest or abdomen (skin-to-skin) and covering both o them
or clothing the child well (including the head), covering with a warmed blanket and
placing an incandescent lamp near the mother and child. Fluorescent lamps are
61
o no use and hot water bottles are dangerous.
• Give oral treatment or hypoglycaemia.
• Examine careully or all emergency signs (ull assessment).
• Monitor the body temperature every 2 hours until it rises to more than 36.5 °C. Be
very careul with rapid heating as these children also rapidly become hyperthermic.
The axillary temperature is not a reliable guide to body temperature during re-
warming (use rectal temperature).
• Ensure that the child is covered at all times, especially at night. Keep the head
covered, preerably with a warm bonnet, to reduce heat loss.
• Give appropriate IV or IM antibiotics.
• Do not wash children early in the morning and never wash a hypothermic child.
6.1.12 Eye signs o vitamin A deciency
• Diagnosis
Take great care while examining the eyes, as they easily rupture in children with vitamin
A deciency. Children with vitamin A decient eye disease are usually photophobic,
so do NOT orce the eyes open. Examine them gently in a low light, with a torch at an
angle across the eyes or corneal lesions that are indicative o vitamin A deciency:
xerophthalmia, corneal xerosis and ulceration, cloudiness and keratomalacia.
The earliest sign o vitamin A deciency is blurring o the “mirror” o the eye. In a normal
eye you can easily see the refection o the room behind you; it should be clear and sharp.
I it is slightly blurred then the cells on the surace o the cornea are becoming misaligned
and i not corrected this will progress to major corneal pathology. At this early stage the
vitamin A in the therapeutic diets should be sucient to correct the abnormality.
• Treatment
Give emergency treatment to prevent blindness:
• Instil 1% tetracycline eye drops or apply ointment, every 6 hours until all signs o
infammation or ulceration resolve.
• Apply 0.1% atropine eye drops, 1 drop every 8 hours or 3–5 days, to relax the
lens.
• Protect eyes showing ocular infammation or ulceration with sot cotton pads
soaked in 0.9% saline, and bandaged over the aected eye(s). Scratching with a
nger can cause rupture o an ulcerated cornea.
• With developed major eye signs give a ull therapeutic dose o vitamin A (50,000
IU or inants aged less than 6 months, 100,000 IU or inants aged 6–12 months
and 200,000 IU or children aged more than 1 year) on days 1 and 2, and a third
dose on day 14 (or at least 2 weeks later), irrespective o the therapeutic ood the
child is receiving.
6.1.13 Candidiasis
Children with SAM are severely immune-compromised, even when HIV negative, and
candidiasis is common. Oral candidiasis causes creamy-white lesions in the mouth
62
and may be painul, making eeding dicult. The diagnosis o supercial (oral, skin)
candidiasis is conrmed by the presence o typical yeast orms on Gram staining o
scrapings rom the lesion.
• Give 100,000 units/ml o nystatin suspension, 1–2 ml orally every 6 hours or 7
days.
• Apply 2% miconidazole gel each 12 hours to the perineum whilst there are open
sores.
• In case o oesophageal, gastric, colonic, rectal and dermal (groin, perineum,
axillae) respiratory tract and systemic candidiasis, give:
• Fluconazole, 3–6 mg/kg per day orally once a day or 7 days.
• Note: Never give amphotericin B to SAM children. It is very toxic and always
compromises renal unction; any drug that aects renal unction should be avoided
in these particular patients.
6.1.14 Parasitic infections
• Dysentery
Dysentery is diarrhoea presenting with loose, requent stools containing blood. Most
episodes o dysentery are due to Shigella. Treatment is with an oral antibiotic to which
most local strains o Shigella are sensitive.
Amoebiasis can cause dysentery, liver abscess and other systemic complications but is
rare in children aged less than 5 years. (Note: nding amoebic cysts in the stools is not
sucient or a diagnosis o amoebiasis).
• For Shigella: ciprofoxacin, 10–20 mg/kg per day orally every 12 hours or 5 days.
• I there is no improvement and the diagnosis is conrmed as due to Shigella, ater
2 days give cetriaxone: 80 mg/kg per day IV once a day over 30 min or 3 days.
• For amoebiasis: metronidazole, 10 mg/kg per day every 12 hours orally or 7 days.
Note: do NOT give the standard dose of metronidazole given to normal children. It
becomes cumulative and causes severe hepatic damage with cholestasis – white stools
is a sign of severe metronidazole toxicity.
• Giardiasis
Intestinal inection with Giardia is common.
• Give metronidazole, 10 mg/kg per day every 12 hours orally until the diarrhoea
ceases and then stop.
6.1.15 Helminthiasis
Ascariasis, hookworm and trichuriasis inections are treated with the standard protocol.
Inection with Strongyloides stercoralis is uncommon. The diagnosis is dicult as it
requires special laboratory techniques o larval culture. I suspected, repeat the standard
doses o albendazol or 3 days instead o giving a single dose (Note: mebendazol is not
63
effective as it is not absorbed).
Note: Tiabendazole is dangerous for malnourished children because it causes severe
anorexia. Ivermectin should not be used in patients with bilateral pitting oedema, as they
are likely to have a compromised blood–brain barrier.
6.1.16 Persistent diarrhoea
Persistent diarrhoea is dened as three or more loose stools a day or at least 14 days.
Weight loss is common with persistent diarrhoea. Possible causes o persistent diarrhoea
in children with SAM include causes that give rise to malabsorption (osmotic diarrhoea).
The most common cause is nutritional deciency itsel (particularly zinc deciency)
aecting the intestine’s absorptive ability rather than an enteric inection. However
Cryptosporidium, Giardia, Shigella or Salmonella can also cause persistent diarrhoea.
Management o persistent diarrhoea in children with SAM involves therapeutic eeding
with oods rich in essential nutrients, particularly zinc; and restricting disaccharides.
• Persistent diarrhoea is nearly always cured by the standard treatment given to
SAM children. Do not give additional drugs or nutrients unless a specic inective
cause is identied.
• NEVER give rehydration therapy or persistent diarrhoea in SAM children – they
have adapted over the weeks/months with persistent diarrhoea and do not become
dehydrated unless there is also acute watery diarrhoea. Attempts at rehydration
can be dangerous.
6.1.17 Osmotic diarrhoea caused by carbohydrate intolerance (re-eeding
diarrhoea)
Carbohydrate intolerance is usually the result o intestinal damage (villous atrophy) and
small-bowel bacterial overgrowth, which are common in children with SAM. Osmotic
diarrhoea caused by carbohydrate intolerance may be suspected i diarrhoea worsens
substantially with home-made F75 because it is hyperosmolar. Diarrhoea is rarely a
result o lactose intolerance. Treat children or lactose intolerance only i the continuing
diarrhoea is associated with weight loss. F75 is a low-lactose eed.
• Ensure that the commercial preparation o F75 is used.
• In exceptional cases, substitute milk eeds with ermented milk such as yoghurt, or
with a lactose-ree inant ormula.
• Most malnourished children also have pancreatic deciency, especially those
with kwashiorkor. I available, commercial pancreatic enzyme supplements can
be given.
6.1.18 Cholera or very severe watery diarrhoea
In children with SAM who have prouse watery diarrhoea or suspected or conrmed
cholera, sodium losses are usually above 90 mOsm/L and ReSoMal is not adapted to
replace the sodium loss. Standard low-osmolarity oral rehydration solutions should be
used or oral rehydration.
64
• Reer urgently to hospital or specialized cholera care sites.
• Treat dehydration with standard low-osmolarity ORS instead o ReSoMal – but
ollow the protocol or rehydration in SAM children by ollowing weight changes.
Ensure that sucient ORS is given to stop and reverse continuing weight loss.
• Give erythromycin, 12.5 mg/kg/dose orally every 6 hours or 3 days as the rst-
line antibiotic o choice to speed recovery as soon as vomiting stops. Or give
an oral antibiotic to which strains o Vibrio cholera in the area are known to be
sensitive. For urther details o microbial treatment or children with cholera see
WHO Cholera guidelines.
7.2
6.1.19 Eye infections
I a child with SAM has sticky eyes and mild conjunctivitis, and no other complications:
• Wash the eyes and apply 1% tetracycline eye ointment, every 6 hours or 5 days.
• Show the mother how to wash the eyes with water and to put eye ointment in the
eyes. Advise the mother to wash her hands beore and ater doing this.
• Review or improvement 48 hours ater treatment.
• These children may have underlying vitamin A deciency: check requently and i
unsure treat as per protocol or vitamin A deciency.
6.1.20 HIV
Children who are HIV-positive commonly present with moderate malnutrition or SAM.
HIV-positive children with SAM have a three times higher risk o dying than those who
are HIV-negative i their CD4 count is low; those with a normal CD4 count have the same
prognosis as HIV-negative children. In some countries, up to hal o the children with
SAM are HIV-positive. Testing children who have SAM or their HIV status is important
to determine whether they need cotrimoxazole (prophylactic dose) and antiretroviral
therapy (ART).
• Routinely test all inants and children with SAM or HIV.
The management o HIV in children with SAM should ollow the national guidelines.
However, the start o ART in children with SAM is delayed in IPF patients because o
the toxicity o these drugs. They are started as soon as possible ater phase 1 when
metabolic complications and sepsis are resolved. I there is no improvement in the
medical complications ater 7 days o standard SAM treatment, then ART should be
started.
6.1.21 Tuberculosis
The development o TB depends on the competence o the immune system to resist
multiplication o the M. tuberculosis inection. In children with SAM, TB can develop more
easily.
Do not immediately transer to a TB centre i they have little experience/ are untrained
in treating SAM: the treatment o the SAM takes precedence in view o the respective
mortality rates. Treatment or TB can also be delayed or at least two weeks, except in
the cases o miliary TB, TB meningitis and Pott’s disease, when treatment should start
65
immediately despite the danger o drug toxicity.
For patients with miliary TB, Pott’s disease and TB meningitis the treatment should be
started immediately.
Reer to the Rwanda national protocol or tuberculosis diagnosis and management, but
remember that the diagnosis o TB in children is dicult, especially in those with SAM.
6.1.22 Malaria
• Screen all children with SAM in IPF or malaria, regardless o body temperature.
• Use insecticide-impregnated bed-nets in the IPF in malaria-prone districts.
• Reer to the national protocol or treatment o malaria
- DO NOT use quinine in the SAM child because it is toxic.
- Avoid coartem and riampicin i the patients have SAM and are on ARVs.
6.1.23 Measles
Measles is a highly contagious viral disease with serious complications and high mortality.
Because children with severe malnutrition may not present with classical clinical signs o
measles, diagnosis may be dicult. As a preventive measure, always:
Give measles vaccine to all children with SAM who are aged 4.5 months13 14, and older
who are not vaccinated this is particularly important in areas where HIV is prevalent.1516 ,
• Give a second dose o measles vaccine at the end o treatment or week 4 in OTP.
• Complete the child’s immunization ollowing the national immunization schedule
beore discharge.
• HIV-positive children should have 3 doses o live measles vaccine.
•
There is no specic treatment or measles – the management is symptomatic. Treat any
associated inection.
6.1.24 Meningitis
Suspect meningitis in children with signs o serious bacterial inection (drowsiness,
lethargy, unconsciousness, sti neck, anorexia, irritability, a high-pitched cry, petechial
or purpuric rash and, in young inants, apnoeic episodes, convulsions or a bulging
ontanelle). When meningitis is suspected, and where possible, do a lumbar puncture to
conrm inection. All children with meningitis are treated in hospital according to national
or WHO guidelines.
13 Aaby, P. et al. ‘Non-Specic Eects o Standard Measles Vaccine at 4.5 and 9 Months o Age on Childhood Mor-
tality: Randomised Controlled Trial’. BMJ 2010 341 c6495.
14 Rasmussen, S.M. et al. ‘The Eect o Early Measles Vaccination at 4.5 Months o Age on Growth at 9 and 24
Months o Age in a Randomized Trial in Guinea-Bissau’. BMC Pediatrics 2016 16 199.
15 Measles vaccines: WHO position paper. Wkly Epidemiol Rec 2004; 79:130h a
16 Tejiokem. M.C. et al. HIV-Inected Children Living in Central Arica Have Low Persistence o Antibodies to Vac-
cines Used in the Expanded Program on Immunization. PloS One 2007 2 e1260
66
6.1.25 Otitis media
Otitis media occurs requently in children, oten in connection with hospital-acquired
upper-respiratory inection. There are no specic clinical signs except when the eardrum
has ruptured, causing drainage rom the ear. Typical signs o infammation may not be
present. Give the routine antibiotic treatment or SAM
In case o signs o mastoiditis – ear pain, pus draining rom ear, and tender swelling
behind the ear – the child needs immediate reerral and treatment in hospital. Start
antibiotic beore reerral.
6.1.26 Skin infections
• Bacterial skin infections
Bacterial skin inections include pustules, impetigo, inected ssures (especially behind
the ears) and indolent ulcers.
• Wash the aected area with soap and water and gently remove debris and crusts
by soaking in warm saline or clean warm water. Dry the child careully.
• Apply 10% polyvidone iodine ointment or 5% chlorhexidine lotion to the aected
area.
• Widespread supercial and deep-seated inections could be a sign o
osteomyelitis that needs to be conrmed by X-ray. Treatment may require an anti-
staphylococcal antibiotic: cloxacillin (250 mg capsule), 15 mg/kg orally every 6
hours (or fucloxacillin or oxacillin) as Staphylococcus aureus is a common cause
of skin infection.
• Drain any abscesses surgically.
• Scabies
Scabies is caused by a mite that burrows supercially into the skin and causes intense
itching. The scratched lesions oten become secondarily inected.
• Make sure that the child’s nails are cut and smooth to prevent skin damage due
to scratching.
• Apply permethrin cream 5% or lotion 1% on the whole body or 12 hours and wash
with soap. Do not apply on ace or mucus membrane.
• Alternative: 0.3% lindane lotion to the aected areas, once daily or 2 days.
• Change and boil all clothes.
• Treat amily members to prevent inestation or re-inestation.
• Kwashiorkor dermatosis
In kwashiorkor there are oten open skin lesions where the epidermis has stripped away
to leave raw weeping wounds that resemble burns. The lesions can be treated in the
same way as burns. Serum may be lost through the lesions. There is also an increased
loss o heat by evaporation – hypothermia is common and must be prevented. The
lesions usually become overgrown with bacteria and Candida under usual IPF conditions.
67
Normally these patients have not an infammatory reaction, pus ormation or ever due
to their decient infammatory and immune unction; an infammatory reaction can occur
during treatment as the nutritional status o the patient improves.
Treatment
• Put the patient onto second- or third-line systemic antibiotics, including fuconazole.
• Monitor body temperature; do not wash the child unless the environmental
temperature is high.
• I possible expose the lesions directly to the atmosphere during the heat o the day
so that they dry (orm a crust); do not cover with occlusive dressings.
• I available dress with silver suladiazine impregnated tulle or cream (1%) once
per day; i this is unavailable dress with zinc oxide ointment (10%).
• At night and in cold conditions dress the lesions, preerably with sterile paran
gauze.
• Gently massage oil (e.g. mustard or soya oil) into the areas o unaected skin to
prevent urther breakdown o the skin.
• I the patient has candidiasis, apply miconazole cream to the skin lesions until they
are dry.
• Perineal excoriation
This is normally a chemical dermatitis caused by bacterial decomposition o urine to
ammonia. It is very common where plastic pants or bags are used by the mother to
cover the perineal area to prevent soiling o her clothes, sheets etc. With exposure to
the atmosphere the child’s bottom will dry and bacteria and yeasts will not fourish –
they thrive in warm damp conditions such as under plastic or occlusive dressings; any
ammonia generated will escape to the atmosphere and the mother can observe when the
child is dirty and needs to be cleaned.
Prevention
• Ban the use o plastic pants/ polythene etc. to cover the child’s bottom.
• Get the mothers to make or give them waterproo aprons to wear to protect their
clothing when they are eeding/ nursing/ changing/ playing with the child.
• Leave young children naked as much as possible during the day.
• Regularly massage all the children’s skin with oil (use whatever local custom
dictates – mustard oil appears to be particularly eective).
• About 20 minutes ater nishing a eed, put all the children onto the potty; the
mother can support the child on her eet, acing her legs.
Treatment
• The most important measure is to wash and then expose the child’s bottom to the
atmosphere.
• I severe it can be treated in the same way as kwashiorkor dermatosis.
• Otherwise, continue with second-line antibiotics, give nystatin orally.
• Apply miconazole 2% nitrate cream/ointment until the lesions are dry.
• Fungal infections of the skin
68
Ringworm, intertrigo (ungal inections o groins, axillae and other “sweaty places”),
athlete’s oot and other local skin inections are common in many areas.
• Local ungal inections o the skin or nails are all treated with miconazole nitrate
cream/ointment (2%).
• Apply cream directly to the lesions twice daily.
• Continue or at least 10 days ater the lesion has resolved.
6.1.27 Infection after admission
Children with SAM are susceptible to inection, particularly when exposed to other
people with transmissible inections. Such children, especially when treated in IPF, have
a high incidence o nosocomial inections. However, as the nutritional treatment starts to
reconstitute the immune and infammatory systems, inections that were present but not
clinically recognizable start to cause ever, and other classical signs. This is common
and usually misinterpreted as a nosocomial inection (in particular, latent tuberculosis). It
is common or patients with latent TB to have rapid progress during rehabilitation.
However, or children that deteriorate during rehabilitation there must be a high index o
suspicion o tuberculosis
• Put into place a high level o inection control, including hand-washing or health
workers, mothers, carers and children, and hygiene measures or bedding and
the environment.
• Careully consider the use o antibiotics that rapidly induce antimicrobial resistance
o clinical importance.
• Ensure TB screening or children deteriorating during rehabilitation.
6.1.28 Re-eeding syndrome
“Re-eeding syndrome” reers to malnourished patients (and those who have been asting
or more than one week) who develop any o the ollowing shortly ater they have a rapid,
large increase in their ood intake: acute weakness, “foppiness”, lethargy, delirium,
neurological symptoms, acidosis, muscle necrosis, liver and pancreatic ailure, cardiac
ailure or sudden unexpected death. The syndrome is due to rapid consumption o key
nutrients during anabolism or metabolism particularly i the diet is unbalanced. There is
requently a large reduction in plasma phosphorus, potassium and magnesium.
Other separate problems during early re-eeding include re-eeding oedema and re-
eeding diarrhoea (see Section 6.1.17).
• Prevention
It is necessary at the start o treatment not to have a sudden jump in the adapted
malnourished state to a very high intake – this is the purpose o transition phase. On
admission, malnourished patients should never be orce-ed in excess o amounts
prescribed in the protocol; particular care needs to be taken with those who are being
ed by nasogastric tube.
69
• Treatment
• Stop eeding or 1 day.
• Restart with 50% recommended intake o F75 until all signs and symptoms
disappear and then gradually increase.
6.2 Routine inpatient management of SAM in children aged over 6
months of age
This section covers the routine inpatient management o SAM patients with a poor appetite
or medical complications. Management o acutely ill children who have complications on
admission, and o children whose complications arise during routine treatment is given
in the preceding section. When no critical emergency conditions are present, ater their
treatment has started successully and or children without critical complications routine
management is started.
6.2.1 Full assessment
Children receive a ull assessment.
This is the same as the admission assessment o children in the health clinic. The same
history and examinations are perormed (see Chapter 4 “Triage at the health acility”).
The standard recording orm o the IPF usually needs to be adapted or, preerably, a
specic chart used or SAM children (see Annex 12).
A specic pro-orma chart can also be used to record the history and examination (see
Annex 16). This is useul as it is clear i any important inormation is missing rom a
narrative history and examination record, and critical inormation on the baseline signs
and symptoms can later be retrieved rapidly i any complication arises.
6.2.2 Laboratory and other investigations
Where acilities are present, some o the tests given in Annex 24 can be perormed
to diagnose specic medical problems and guide treatment. However, the start o
initial treatment should not be delayed unless a conrmed diagnosis is required. The
interpretation o test results is requently altered by SAM, and may need to be repeated
later. The most important guide to treatment remains requent careul clinical assessment
o the child and monitoring the progress o treatment.
NOTE: On F75, a marasmic child should NOT gain or lose weight, whereas a child with
kwashiorkor should lose weight. During this stage s/he is repairing tissues, re-synthesising
enzymes and organ function is improving. Weight gain (anabolism) at this stage is an
added stress and must not be imposed upon the child’s metabolism. Weight gain is
expected only in the transition and rehabilitation phases.
70
6.2.3 Systematic treatment
• Prevention of hypoglycaemia
On presentation the children should be given sugar-water routinely.
The sick child is at risk o hypoglycaemia and should be given the treatment outlined in
the ETAT section (Section 6.1). Ater a child recovers s/he needs to be ed every 3 hours
during the night and day i s/he has not taken the ull amount o the F75 during the day. I
the child is taking the diet during the day there is no need to give a night-time eed; this
simplies the protocol, allows the mother and child to sleep and relieves night sta to
give more attention to critically ill children.
An early sign o impending hypoglycaemia is the child sleeping with their eyes open. The
mother should be told i she sees this to awaken the child and ask the nurse or a eed o
F75 – or give the child a drink o sugar-water i F75 is not readily available.
6.2.4 Prevention of hypothermia
Children with SAM have diculty controlling their body temperature and must be kept
warm and ed requently. Keeping them warm also conserves their energy.
• The ward must be kept warm (room temperature at 28–32 °C to prevent temperature
swings). I it is comortable or the sta it is oten too cold or the child – close
windows at night.
• Keep the child covered with a blanket and have a hat on the child, as most heat is
lost through the head.
• Apply the “kangaroo” technique: put the child and mother skin-to-skin and wrap
them together with a blanket. Oer warm drinks and ood to the mother.
• Change wet nappies, clothes and bedding to keep the child and the bed dry.
• Do NOT wash children early in the morning. Wash them at midday when it is warm.
• Provide adult beds, do not use baby cots or these children, and ensure that the
child sleeps with the mother or carer or warmth. (A mattress on the foor is saer
than a baby cot.)
6.2.5 Management o inections and other medical conditions
• Presumptive treatment of bacterial infections
Nearly all children with SAM have bacterial inections. Many have several inections
caused by dierent organisms. Although signs o inection should be careully looked or
when the child is evaluated, they are dicult to detect or absent. Unlike well-nourished
children, who respond to inection with ever and infammation, malnourished children
with serious inections may only become apathetic or drowsy.
Evidence has shown that early presumptive treatment o bacterial inections with eective
antimicrobials improves the nutritional response to eeding, prevents septic shock and
reduces mortality. All children with SAM should thereore systematically receive broad-
spectrum antimicrobial treatment when rst admitted or care.
71
Antimicrobials are divided into those used or rst-line treatment, which are given routinely
to all children with SAM, and those used or second- or third-line treatment, which are
given when a child is very seriously ill or is not improving or when a specic inection
is diagnosed. Although local resistance patterns o important bacterial pathogens and
the availability and cost o antimicrobials will determine the exact policy, a suggested
scheme is given below.
• Routine rst-line antibiotic treatment
• Treat all children with SAM without medical complications and no apparent
signs o inection systematically with:
o Amoxicillin, 25 mg/kg/dose orally every 12 hours or 5 days.
• Treat all children with SAM with any medical complications or anorexia or who
are lethargic systematically with:
o Benzylpenicillin (50,000 U/kg/dose) IM or IV every 6 hours or ampicillin, 50
mg/kg/dose IV (or IM) every 6 hours or 2 days, ollowed by amoxicillin, 25
mg/kg/dose orally every 12 hour or 5 days.
o Gentamicin: 5 mg/kg IV (or IM) daily single dose or 7 days.
•Second-line antibiotic treatment
• I the child has a serious condition such as hypoglycaemia, hypothermia, skin
inections, pneumonia OR I the child ails to improve within 48 hours OR i there
is resistance to amoxicillin and ampicillin, add a second-line broad-spectrum
antibiotic:
o Cetriaxone, 80 mg/kg per day (or 50 mg/kg per day i inant < 2 kg) IV
daily, single dose given over 30 min.
o Oral ciprofoxacin (5–15 mg/ kg/dose twice per day)
• In all cases o severe sepsis or septic shock:
o IM ceotaxime (or children /inants beyond 1 month: 50 mg / kg/dose every
8 hours)
PLUS
o Oral ciprofoxacin (5–15 mg/ kg twice per day).
• •I there are suspected staphylococcal inections:
o Add IV cloxacillin (12.5–50 mg/kg/dose our times a day, depending on the
severity o the inection).
• The duration o treatment depends on the response and nutritional status o the
child. Continue antimicrobials or at least 5 days. I anorexia persists ater 5 days
o treatment, give the child another 5-day course. I anorexia persists ater 10 days
o treatment, reassess the child ully.
72
•Third-line antibiotic treatment
Third-line or other additional antibiotic treatment should be guided by clinical examination,
chest X-ray, urine dipstick, lumbar puncture, blood, urine or cerebrospinal fuid (CSF)
cultures, or other available investigations. I a lung ocus is suspected, then specic
management or staphylococcal inection, pleural eusion or TB may be appropriate.
I the gut or urinary tract is suspected, or i there is no ocus o inection, then consider:
Ciprofoxacin, 10 mg/kg/dose IV every 12 hours (i ciprofoxacin IV is not available, then
use Ciprofoxacin, 15 mg/kg/dose orally every 12 hours) or 5 days.
• Routine prevention of infections
Immunization schedule update
All children over 4.5 months o age17 who are sick enough to be admitted to the IPT
should be given a measles inoculation on admission or shortly thereater. This will be
repeated during the 4th week o OTP rehabilitation.
Malaria prevention in endemic areas
The use o impregnated bed-nets should be used in all IPFs in areas where malaria is
endemic.
6.2.6 Electrolyte management and micronutrient supplementation
• Folic acid supplementation
Children with SAM in inpatient care on F75, F100 or RUTF do not need supplementary
olic acid, as it is in the diet in adequate amounts.
• Iron supplementation if on F100
Ater stabilization, or children being rehabilitated in the IPF to ull recovery on F100 are
given iron supplements (errous umarate, 3 mg/kg per day). Iron supplementation should
not be given during stabilization or in rehabilitation when on RUTF, as RUTF contains
sucient iron or daily supplementation.
• Preventive dose of vitamin A supplementation in children with SAM (without clinical eye
signs o vitamin A deciency)
All the recommended diets used to treat SAM have sucient vitamin A in the diet.
• Fluid and electrolyte imbalance, and other micronutrient supplementations
Children on therapeutic oods that comply with WHO specications, in amounts prescribed
according to their body weight, receive all the necessary fuids, electrolytes, minerals
and vitamins to re-establish their metabolism.
17 Aaby, P. ‘Non-Specic Eects o Standard Measles Vaccine at 4.5 and 9 Months o Age on Childhood Mortality:
Randomised Controlled Trial’. BMJ 2010 341 c6495.
73
6.2.7 Initial re-eeding
Almost all children with SAM have inections, impaired liver and intestinal unction, and
problems related to imbalance o electrolytes, when admitted to hospital. The potassium
decit, present in all malnourished children, adversely aects cardiac unction and
gastric emptying. Magnesium is essential or potassium to enter cells and be retained.
Because o these problems, children with SAM cannot tolerate the usual amounts o
dietary protein, at and sodium. It is thereore important to begin eeding these children
with a diet that is low in protein, at and sodium and high in carbohydrate with a ull and
balanced complement o all minerals and vitamins: the diets prescribed or the dierent
phases are all ormulated to meet these specic requirements. NO additional nutrients
need to be given to children taking the recommended diets. In particular, additional zinc
is not given post-diarrhoea, and extra potassium and magnesium or vitamins are not
required.
Children should also continue to be breasted BEFORE giving any therapeutic oods.
The therapeutic ood F75 is used or the initial phase o treatment o severely malnourished
children (75 kcal/ml). Add either one large packet o F75 (410g) to 2 L o water or one
small packet o F75 (102.5g) to 500 ml o water. Where small numbers o children are
being treated as inpatients, do not order the large packets o F75 These are or use in
emergency settings with large numbers o SAM patients. The provision o F75 in tins with
a WHITE scoop is being introduced to replace the sachets; ollow the instructions on the
tin – one white scoop to 25 ml o clean water (do NOT use the old red scoop or any other
scoop). This is a special diet or the initial treatment o SAM children, it must NEVER be
used or normal children; it is NOT a breast-milk substitute and is insucient to support
growth.
• Amounts to give
Give the amounts in the table below to each patient in phase 1.
Table 14. ‘Look up’ table or the Initial Phase (Phase 1)
CLASS OF WEIGHT 8 FEEDS PER DAY 6 FEEDS PER DAY 5 FEEDS PER DAY
(KG ML FOR EACH FEED ML FOR EACH FEED ML FOR EACH FEED
2.0 – 2.1 kg 40 ml per eed 50 ml per eed 65 ml per eed
2.2 – 2.4 45 60 70
2.5 – 2.7 50 65 75
2.8 – 2.9 55 70 80
3.0 – 3.4 60 75 85
3.5 – 3.9 65 80 95
4.0 – 4.4 70 85 110
4.5 – 4.9 80 95 120
5.0 – 5.4 90 110 130
5.5 – 5.9 100 120 150
6.0 – 6.9 110 140 175
7.0 – 7.9 125 160 200
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8.0 – 8.9 140 180 225
9.0 – 9.9 155 190 250
10 – 10.9 170 200 275
11 – 11.9 190 230 275
12 – 12.9 205 250 300
13 – 13.9 230 275 350
14 – 14.9 250 290 375
15 – 19.9 260 300 400
20 – 24.9 290 320 450
25 – 29.9 300 350 450
30 – 39.9 320 370 500
40 – 60 350 400 500
• • Give F75, 130 ml/kg per day, providing 100 kcal/kg per day during
stabilization.
• Do not reduce the amount o the diet or children with oedema (this was an old
recommendation based upon aulty data o the usual proportion o oedema18 ).
• Give F75 requently and in small amounts to avoid overloading the intestine’s ability
to absorb the diet. Give F75 every 3 or 4 hours, day and night, or use the 5 eeds
per day regime (i.e. miss out a night eed) i the children do not get re-eeding
osmotic diarrhoea (this allows the mothers and children to sleep during the early
hours o the morning).
• Continue and/or support breasteeding beore each eed.
• Feed by nasogastric tube only these children who do not consume at least 75% o
the prescribed amount.
• I vomiting occurs, reduce both the amount given at each eed and the interval
between eeds.
• Use the body weight on admission (or body weight ater rehydration in case o
dehydration) throughout the initial phase o treatment, to determine the daily
amount o the F75 diet.
• Discard any therapeutic milk not taken by the child and never reuse it or the next
eed or keep it or later eeding.
• Give the child at least 80 kcal/kg per day, but no more than 100 kcal/kg per day.
I the child is given less than 80 kcal/kg per day, the tissues will continue to be
broken down and the child will deteriorate. I given more than 100 kcal/kg per day,
a serious metabolic imbalance may develop and cause re-eeding syndrome (see
Chapter 6 on complications).
• Feed children rom a cup; eeding bottles should never be used, even or very
young inants, as they are an important source o inection. Children who are very
weak should be ed by nasogastric tube. While being ed, children should always
be held securely in a sitting position on the attendant’s or mother’s or carer’s lap.
The carers should wash her or his hands beore eeding the child. Children should
never be let alone in bed to eed themselves.
18 Golden, M.H. ‘The Clinical Assessment o Oedema: Implications or Feeding the Malnourished Child’. Eur J Clin
Nutr 1989 43 581-2.
75
• Nasogastric feeding
Despite coaxing and patience, some children will not take sucient diet by mouth during
the rst ew days o treatment. Such children should be ed using an nasogastric tube but
this should be used or as short a time as possible.
The criteria or nasogastric eeding are:
• Anorexia, taking less than 75% o prescribed daily need.
• Being too weak to drink.
• Painul mouth or throat, stomatitis or physical disability.
• Lethargy or unconsciousness
At each eed, oer the child the diet orally. Ater the child has taken as much as he or she
wants, give the remainder by nasogastric tube. Remove the tube when the child is taking
three quarters o the day’s diet orally or two consecutive eeds ully by mouth. I, over the
next 24 hours, the child ails to take 80 kcal, reinsert the tube.
Always aspirate the nasogastric tube beore administering fuids. Experienced sta
should carry out the nasogastric eeding and ensure the tube is xed properly so that it is
not in the lungs. A child who is still being ed by nasogastric tube is not considered ready
to start transition.
• Milk or lactose intolerance
Clinically signicant milk or lactose intolerance is unusual in children with SAM. Intolerance
should be diagnosed only i children have copious watery diarrhoea promptly ater milk-
based eeds are begun and the diarrhoea clearly improves when milk intake is reduced
or stopped and recurs when milk is given again. Other signs o milk or lactose intolerance
include acidic aeces (pH 5.0) and the presence o increased levels o reducing substances
in the aeces. In such cases, partially or totally replace the milk with ermented milk or
yoghurt or a commercial lactose-ree ormula. Beore the child is discharged, give milk-
based eeds again to determine whether the intolerance has resolved.
• Recording 24-hour therapeutic food intake
Ater each eed, record the F75 eed taken on the patient’s SAM chart. I the child vomits,
estimate the amount lost in relation to the size o the eed (e.g. a whole eed, hal a eed)
and indicate this on the chart.
Box 9. Summary of the routine treatment during phase 1
1. Antimicrobial treatment or systemic bacterial inections.
2. Antihelminth treatment or suspected helminthiasis (this should be delayed until the child
is improving).
3. Measles vaccination, plus immunization schedule update.
4. Therapeutic eeding complying with WHO specications.
5. Treatment or other medical conditions based on diagnosis.
An integral part o care during stabilization is to promote, provide and/or support hygiene
76
(o sta and carers, child, ood and the environment), psychosocial support to the mother
or carer and child, health and nutrition counselling, and emotional stimulation o child and
early childhood development (see the relevant chapters o this guideline).
• Daily care during stabilization
Monitoring
Each day the nurse records:
• Weight (and graphs the weight to examine gain or loss)
• Oedema
• Respiratory rate
• Presence or absence o cough
• Pulse rate
• Temperature (a.m. and p.m.)
• Stools passed
• Diarrhoea
• Vomit
• Feeding plan
• Antibiotics and other medication prescribed and given
• Nasogastric tube in place, inusions and transusions and ReSoMail given
• Other abnormalities or specic children that require daily monitoring e.g. liver
edge, Candida, skin lesions, etc.
• Improvement during stabilization includes:
• Medical complications start resolving
• Oedema starts reducing
• Appetite returns
• The child is awake and increasingly alert.
Children should not gain weight in phase 1 and children with oedema should start losing
weight as their oedema decreases. Weight and weight gain or loss are critical key signs
in the initial treatment and should be closely monitored and recorded.
I the child’s appetite improves, then the treatment has been successul and the child is
ready to change diet and start recovering lost weight. The stabilization phase ends when
the child becomes hungry. This indicates that inections are coming under control, the
liver is able to metabolize the diet, and oedema and other metabolic abnormalities are
improving.
6.2.8 Transition phase
Transition reers to the introduction o high-protein, high-energy therapeutic ood or
catch-up growth. It prepares the child or rehabilitation as either an inpatient or outpatient.
Children usually regain appetite 2–7 days ater initiating treatment. Some children may
take longer, whereas others are hungry rom the start and can transition aster. The child’s
appetite, reduction o oedema (i present) and general condition determine the phase o
treatment, not the length o time since admission.
77
• Feeding during transition
In inpatient settings where RUTF is available:
The recommended energy intake during this period is between 100 and 135 kcal/kg per
day.
Give the child the prescribed amount o RUTF or the transition phase. Let the child drink
water reely. I he or she does not take at least hal the prescribed amount o RUTF in the
rst 12 hours, then stop giving the RUTF and give F75 again. Retry the same approach
ater another 1–2 days until the child takes the appropriate amount o RUTF to meet his
or her energy needs.
The amount o RUTF to give daily during transition phase is given in the table below.
Table 15: ‘Look up’ table or eeds in Transition Phase
WEIGHT CATEGORY PASTE PASTE TOTAL
(KG)
IN GRAMS SACHETS KCAL
3.0 – 3.4 90 1.00 500
3.5 – 3.9 100 1.00 550
4.0 – 4.9 110 1.25 600
5.0 – 5.9 130 1.50 700
6.0 – 6.9 150 1.75 800
7.0 – 7.9 180 2.00 1,000
8.0 – 8.9 200 2.00 1100
9.0 – 9.9 220 2.50 1200
10 – 11.9 250 3.00 1350
12 – 14.9 300 3.50 1600
> 15 370 4.00 2000
In inpatient settings where F100 is provided as the therapeutic ood in the transition
phase
For children entering transition phase using F100, exactly the same amount o F100 is
give as F75 was given in phase 1. Because the F100 is more energy-dense (but also
has a completely dierent composition) the same volume gives about 30% more energy
to the child and allows or weight gain up to about 6g/kg per day. Ater taking the F100
eeding the children should be oered plain water to drink.
Children who have been admitted with complicated SAM and are achieving rapid weight
gain on F100 should be changed to RUTF and observed beore transer to the OTP.
Monitoring progress during transition
The monitoring and recording o clinical signs continue exactly as in phase 1.
78
• Criteria to move back from transition phase to the acute phase
Move the child back to acute phase (on F75) i:
• I there is a rapid increase in the size o the liver.
• I any other signs o fuid overload develop (e.g. increased respiratory rate).
• I tense abdominal distension develops (indicates abnormal peristalsis, small
bowel overgrowth and perhaps excess carbohydrate intake).
• I the patient gets signicant re-eeding diarrhoea so that there is weight loss.
• I a complication arises that necessitates an intravenous inusion.
• I there is any deterioration in the child’s condition.
• I there is increasing oedema (look or unexpected sodium intake, particularly rom
mother’s diet or drugs – i an extraneous source i sodium is ound then it should be
eliminated and children with good appetites can remain in transition-phase).
• I a child who does not have oedema develops oedema.
• It is common or the children to get some change in stool requency when they
change diet. This does not need to be treated unless the children lose weight. Several
loose stools without weight loss is not a criterion to move back to acute-phase.
• Criteria to progress from transition phase to OTP
Transer the patient to the OTP:
• I s/he has a good appetite - this means taking at least 90% o the ood prescribed
or the transition phase.
• For oedematous patients, i there is a denite and steady reduction in oedema
accompanied by a loss o weight.
• I there is a capable caretaker.
• I the caretaker agrees to OTP.
• I there are reasonable home social circumstances.
• I there is a sustained supply o RUTF in the OTP.
• I an OTP programme is in operation in the area close to the patient’s home.
A patient transerring rom one to another phase o treatment, one as an inpatient and the
other as an outpatient, is still under the care o the programme or this episode o severe
malnutrition; this is not a “discharge” rom the IPF but an internal transer. The IPF records
this as “successul treatment” in their report orms.
6.2.9 Rehabilitation in the IPF
Rehabilitation in hospital is only necessary i no RUTF or outpatient services are available,
or i there are other concerns related to the child’s or mother’s or carer’s condition. The
treatment given is then identical to that described under OTP management. Hospitals
should also run an OTP with weekly attendance or patients living within the catchment
area o the hospital i the health centres are not closer to the patient’s home.
Catch-up growth with daily quality care and monitoring o progress and signs o
complications should continue. The child and mother or carer will be gradually prepared
or discharge rom hospital and the end o treatment, and or the child’s return to the
community with a minimal risk o relapse.
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6.3 Failure to respond to treatment in the IPF
The criteria or ailure to respond to treatment in the IPF are given in the table below
Table 16 Criteria for failure to respond to treatment
CRITERION TIME AFTER ADMISSION
Primary failure to respond
Failure to gain consciousness
Failure to start resolving medical complication
Failure to regain appetite Day 4
Failure to start to resolve oedema Day 4
Oedema still present Day 10
Failure to regain appetite Day 10
Secondary failure to respond
Failure to gain at least 5 g/kg o body weight per day During rehabilitation or 3
successive days
Reappearance o danger signs At any time
When a child ails to respond to treatment, it is essential to review all practices in the
treatment unit careully and to re-evaluate the child thoroughly. The objective is to identiy
the cause o ailure to respond and to correct the problem by making specic changes
to care practices or to the child’s treatment. The child should undergo a complete and
thorough new clinical assessment, to identiy newly developed or missed conditions or
underlying disease.
The box below lists the most requent causes o ailure to respond.
80
Box 10. Frequent causes of failure to respond to treatment in inpatient care
Problems with care practices
• Poor environment or malnourished children, including hygiene (e.g. hand-washing by
sta and carers, body hygiene o child, bed and ward hygiene)
• Insucient or inadequately trained sta
• Insucient junior or trainee sta at night
• Inaccurate anthropometric equipment (such as weighing scales)
• Insucient essential supplies
• Inadequate detection o medical complications, inections and serious underlying dis-
eases
• Lack o compliance with specic and routine treatment protocols
• Incorrect preparation or provision o therapeutic ood
• Insucient emotional and physical stimulation o the child
• Inadequate counselling and psychosocial support to the mother or carer, or the mother
or carer is not engaged in the rationale or the treatments being given
• Inadequate individual case-monitoring, quality-improvement and quality-perormance
monitoring
Problems with the treatment of the child
• Feeding: insucient therapeutic ood and/or fuid taken
• Insucient vitamin or mineral supplementation
• Malabsorption o nutrients
• Rumination
• Undetected or untreated inections or serious underlying disease
• Psychological trauma
The child should undergo a ull and thorough assessment to identiy newly developed
or missed conditions, or underlying disease, and receive prompt treatment based on
diagnosis.
6.3.1 Problems with care practices in inpatient care
• Problems with the treatment facility
Environment
Failure to respond is more likely when a malnourished child is treated in a general
paediatric ward than in a special nutrition unit. This is because the sta tend to ignore
malnourished children AND the children themselves do not demand attention, cry or
complain. General ward sta are less likely to have the essential skills and attitudes or
management o malnourished children.
Wherever possible, severely malnourished children with no appetite or with medical
complications should be managed in a special nutrition unit. I this is not possible, they
should be treated in a specially designated area o a paediatric ward, by sta who are
specically trained in the treatment o severe malnutrition. Strict observance o hand-
washing by sta and carers must be respected.
81
The special nutrition unit must be well organized. I essential therapeutic ood supplies or
medications are not available, weighing scales do not work properly, diagnostic acilities
or administrative procedures are inadequate, or sta are insuciently trained, treatment
ailure and mortality will be high. An eective management system should ensure careul
monitoring o each child and proper training o nurses and auxiliary sta, use o the most
experienced sta as supervisors, reliable supplies o drugs and ood supplements, and
reliable record-keeping.
Staff
Experienced sta (including junior sta) who understand the needs o malnourished
children and are amiliar with important details o their management are essential or
a well-unctioning treatment acility. It is important to avoid loss o experienced sta
wherever possible. For this reason, sta o the treatment unit should not take part in the
routine rotation o sta that is practised in many hospitals. I sta must be changed, this
should be done one person at a time, to minimize disruption o routines in the unit and
allow the new sta to learn and be mentored.
Night duty is the most common problem. There are oten plenty o trained nurses and doctors
during the day – at night there may be just one junior nurse to manage on her own. She has
many children to look ater: some are very sick and require constant monitoring; others also
require the nurse to monitor record, treat, manage IV lines, give drugs and eed.
She may be tired hersel. It is dark. It is not possible or her to give adequate care, but she
will be criticised i she does not complete her work, so she alsies records to avoid censure
and being disciplined. Falsied records are then used to make critical decisions aecting the
patients’ risk o death/recovery, eeds that are thought to be ully taken are in act only hal
what has been prescribed, drugs may not have been given, IV lines are “rushed through” just
beore the day sta arrive – etc. Senior doctors should do a ward visit at 2 a.m. to see how
the ward really works. Every eort has to be made to reduce night work, so the nurse can
concentrate on those critical patients that must have close treatment. Everything the doctor
or protocol requires means sta time and eort to comply – do not ask or anything that is not
essential (such as all children getting night eeds) to the recovery o all the children. Protocols
need to be simplied as ar as possible and, particularly night sta, protected.
Sta attitudes can determine whether treatment o the child will succeed or ail. I sta
believe that a child is beyond help and that mothers are neglectul, they give less attention
to the child. Such children oten ail to respond to treatment, which seems to conrm the
opinion o the sta. This “clinical prejudice” may be dicult to correct, especially when it
refects the views o the most experienced sta. It is essential to remind sta requently
that each child’s well being depends on their eorts and that every child must be given
their ull attention.
Where there is a shortage o doctors and nurses, assistants can play a key role in
supporting activities such as taking measurements, eeding, monitoring and calling a
doctor or a nurse in case o danger signs. When planning, aim or one assistant or 10
inpatients.
Equipment and supplies
Essential therapeutic equipment and supplies need to be secured or inpatient and
82
outpatient care. Any dysunction or interruption o supply will compromise the quality o
care and adherence to medical and dietary treatment protocols.
MUAC tapes, a scale with 10 g precision, a UNISCALE and a length/height board must
be available.
Machines used or weighing children must be calibrated so they do not give misleading
inormation on the progress o children in the acility. Inant weighing scales must measure
weight accurately to within 20 g, preerably 10 g. All weighing machines must be checked
and adjusted ollowing a standard procedure. Records o daily checks should be kept.
Height boards must be accurate. Weighing machines used or preparing therapeutic ood
or or measuring the ingredients o the electrolyte and mineral mix should be checked
and adjusted weekly.
Medical complications, inections and serious underlying disease
Any ailure to diagnose and immediately treat lie-threatening and other medical
complications, inections or serious underlying diseases can adversely aect treatment
outcome, by causing development o a more serious condition, delay in response, non-
response, relapse or death.
Adherence to treatment protocols
Treatment acilities should comply with medical treatment and fuid-management
protocols in managing medical complications in children with SAM.
6.3.2 Problems with the treatment of the child in inpatient care
•Feeding (preparing or giving therapeutic ood and home diet)
The treatment acility kitchen should use standard hygiene practices when storing,
preparing and handling therapeutic ood. Sta should wash their hands with soap and
water ater being with each patient, ater using the toilet and beore handling ood. Any
prepared solid ood that will be stored or more than 2 hours should be rerigerated (ater
allowing it to cool to room temperature) and reheated until it is thoroughly hot, and then
allowed to cool beore serving. People with inections on their hands should not handle
any ood.
All people involved in preparing therapeutic or solid ood should be checked to ensure
that they are ollowing the correct procedures or weighing, measuring, mixing, cooking
and storing the ood. They should be observed making the eeds, and recipes should be
checked to ensure they are correct and all ingredients are added.
Sucient time must be allocated to eed each child, and adequate sta (both day and
night) should be allocated or this task. Feeding a malnourished child takes more time
and patience than eeding a normal child. I it takes about 15 minutes to eed each child
and i ood is given every 3 hours, one person is needed, day and night, to eed 12
children.
83
• Problems with feeding individual children
Is enough ood being given?
Recalculate the ood requirement or the child. Ensure that the correct amount is being
oered at the required times, and that the amount taken by the child is measured and
recorded accurately. Observe the measuring and giving o ood.
Is the child ruminating?
Rumination is a condition that occurs in up to 10% o severely malnourished, emotionally
impaired children. It should be suspected when a child eats well, but ails to gain weight.
Children with this condition regurgitate ood rom the stomach into the mouth, and then
vomit part o it and swallow the rest. This usually happens when they are ignored, so it may
not be observed. Such children are usually thought to have vomiting without diarrhoea
because they oten smell o vomit, and may have vomit-stained clothes or bedding. They
are oten unusually alert and suspicious, may make stereotyped chewing movements,
and do not appear distressed by vomiting.
Rumination is best treated by sta members who have experience with this problem and
can give special attention to the child. They need to show disapproval whenever the
child begins to ruminate, without being intimidating, and to encourage other less harmul
behaviours.
Infection
Unrecognized inections are a requent cause o ailure to respond. Those most oten
overlooked include pneumonia, urinary tract inection, otitis media and TB. Others include
malaria, dengue and viral hepatitis.
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7A. MANAGEMENT OF SAM IN INFANTS AGED LESS THAN
6 MONTHS
Through various health services and initiatives, community-based inant and young child
eeding/ nutrition and healthcare support should promote, protect and support exclusive
breasteeding in inants aged less than 6 months. The development o SAM in inants
aged less than 6 months refects diculties with breasteeding: this is oten related to
low birth-weight, recurring inections, persistent diarrhoea, disability or social problems.
Risk actors or increased morbidity and mortality include recent weight loss, ailure to
gain weight, ailure to eed eectively, the presence o bilateral oedema and loss o the
mother.
Some exclusively breasted premature and small-or-gestational-age babies gain
weight at a satisactory rate – such inants are thriving and do not need admission to
the programme. The best way to distinguish inants who are thriving rom those who are
becoming malnourished is to weigh them repeatedly over time; this is the value o the
growth-monitoring programme.
For infants who are thriving despite being low birth-weight or have a low weight-
for-age, follow the documents on Maternal and Infant and Young Child Feeding
(MIYCF).
The young inant’s organs are relatively immature, so the problems o their unctional
capacity and the diculties o diagnosis are similar to those ound in older children with
SAM who have reductive adaptation. The objective o treatment, however, is dierent.
Young inants need to be returned to exclusive breasteeding wherever possible. I the
treatment or older children is given to young inants they normally wean rom the breast
and the mother’s milk production ceases: this is a disastrous outcome as it deprives the
inant o all the advantages o breast-eeding ater discharge.
Although many mothers correctly say that they do not produce sucient milk or their
baby, all mothers can produce more than enough milk i adequately stimulated. It should
be emphasised that the amount o milk produced is a result o the degree o stimulation
given to the mother by the inant (i.e. the inant demands and the mother supplies – the
amount is controlled physiologically by the inant and not the mother). Malnourished and
eeble inants usually do not adequately stimulate milk production. I the inant does not
cry and is not suckling suciently strongly there will be insucient breast milk produced
or normal development – the objective o treatment is to get the inant to be strong and
hungry so that s/he can properly stimulate an adequate supply o breast milk.
Thus, the objective o treatment o these patients is to return them to ull exclusive
breasteeding. This is achieved by simultaneously breasteeding and supplementing the
inant until s/he becomes strong enough to stimulate sucient breast milk production to
allow her/him to catch-up, grow and develop properly without any supplementation.
This is achieved by the supplemental suckling (SS) technique. The SS milk serves to
strengthen the inant, cure any nutrient deciency and make her/him hungry to increase
the orce with which s/he suckles; simultaneously putting the inant to the breast then
provides the stimulation needed to increase breast milk production. It is important to put
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the child to the breast as oten as possible. The SS technique is time-consuming and
requires skill, but is the only technique that works in practice.
7A.1 Structure and organisation
These inants should always be treated in IPF and not in OTP. RUTF is NOT suitable or
young inants and milk-based eeds should not be given or home treatment.
There should be a special service/programme to assist mothers who have diculty
breasteeding. The aim o such a service would be concentrate on all breasteeding
problems, including or the malnourished, to re-establish exclusive breasteeding and
achieve condence in the mother’s ability to produce sucient milk or her baby to thrive.
Its outpatient arm would counsel and provide one-to-one support or all mothers
who have diculty with breasteeding ollowing MIYCF guidelines.
The inpatient arm would be or mothers whose children are not “thriving” and
become malnourished.
It is inappropriate to admit young inants to most general paediatric or nutrition wards. I
such a service does not exist then the programme should be part o the neonatal service;
otherwise there should be a specic section o the IPF devoted to the management o the
malnourished young inant.
In most cultures, the ward/room where these inants are managed should be adequately
screened and private. Unannounced arrival o males in the section should be orbidden.
The mothers must be condent that they will not be disturbed or surprised by men arriving
in the ward whilst they are uncovered. There should be a separate visiting room where
mothers can meet with their husbands without them being admitted to the service.
The sta should be emale and have proessional training in breasteeding support and
counselling as well as skills in care o the neonate and the malnourished child. This is a
separate cadre o sta that has to be exclusively engaged with the young inant without
other duties.
7A.2 Assessment at health-facility level
When inants with their mother or carer are reerred to or sel-present at the healthcare
acility or at the hospital, they are assessed according to the IMCI or inants aged 1–6
months, and to the integrated management o pregnancy and childbirth (IMPAC) or
neonates (< 1 month).
Inants with any emergency signs should be reerred to the IPF or treatment according
to the IMCI/IMPAC protocols.
7A.3 Activities and tools
7A.3.1 Activities
Admit the baby: take the anthropometric measurements and examine the baby,
check the criteria o admission, register in the registration book and the chart.
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Explain to the mother the aim o the management.
Manage the inants using the supplemental suckling (SS) technique.
Prepare the milks, teach and demonstrate the techniques, conduct surveillance
and ollow the baby and the mother.
Discharge the baby and the mother.
7A.3.2 Tools
o Registration book.
o Inant SS chart (Annex 18).
o Material or SS technique: nasogastric tubes size 6 to 8, cups, material to clean the
tube, measuring jug (never use a eeding bottle).
o Scale with a precision o 10 g.
o Diet expressed breast milk, generic inant ormula or F100 dilute; meals or the
mother.
o Drugs or systematic treatment and ood/nutrients or the mother.
o Others: posters to encourage breast-eeding, fip charts to show technique,
reerence table or the eeds.
7A.4 Admission criteria for SAM/ lactation failure in infants aged less
than 6 months
The criteria or admission o young inants are NOT the same as or older children (see
Table 17 below).
Table 17: Criteria of admission of young infant with a caretaker
AGE ADMISSION CRITERIA
INFANT LESS THAN 6 The inant is too weak or eeble to suckle eectively
MONTHS (irrespective o his/her weight-or-length (W/L), weight-or-age (W/A)
or other anthropometry)
OR or
The inant is not gaining weight at home (by serial measurement
INFANT < 3 KG o weight during growth monitoring, i.e. change in weight-or-age)
WITH A FEMALE or
CARER CAPABLE OF W/L (weight-or-length) less than < -3 Z-score
BREASTFEEDING or
Weight-or-age < -3 Z-score
or
Presence o bilateral oedema
Each o these criteria objectively shows a ailure o satisactory breasteeding so that the
child is not gaining weight and developing normally.
Height is very dicult to take in these inants so it is more appropriate to use weight-or-
age as an admission criterion or SAM in the < 6 moth old. For inants with a length < 45
cm, the weight-or-length has not been established. Thus, rom birth to 6 months o age,
weight-or-age < -3 Z-score is the most appropriate measure to assess nutritional status.
At this age, ailure to gain weight can be dened as acute malnutrition.
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7A.5 History and examination
This is similar to that or older children using IMCI criteria (or inants < 6 months) with the
addition o:
Detailed breasteeding assessment
Psychosocial, health and nutrition assessment o the mother and/or carer
The inant’s weight is re-ordered with a scale o 10 g precision
Examine the mother’s breasts.
7A.6 Supplemental feeding technique
7A.6.1 At the beginning o the SS technique
Use a tube the same size as no. 6 to 8 nasogastric tube (no. 5 tube can be used
and is better or the inant, but the milk should not contain any small particles that
block the tube).
Put the appropriate amount o SS-milk in a cup and hold it.
Put the end o the tube in the cup.
Put the tip o the tube on the breast at the nipple.
Note: At the beginning the mothers nd it better to attach the tube to the breast with some
tape, later as she gets experience this is not normally necessary.
Tell the mother to oer the breast in the normal way so that the inant latches on
properly.
When the inant suckles on the breast, with the tube in his mouth, the milk rom the
cup is sucked up through the tube and taken by the inant. It is like taking a drink
through a straw.
Help the mother at rst by holding the cup and the tube in place.
Encourage the mother condently.
Place the cup at rst about 5–10 cm below the level o the nipple so the SS-milk
can be taken with little eort by a weak inant.
NEVER place the cup above the level o the nipple, or it will fow quickly into the
inant’s mouth by siphonage with a major risk o inhalation.
Tell the mother to relax. Excessive or ocious instructions about the correct
positioning or attachment positions oten inhibit the mothers and make her think the
technique is much more dicult than it is. Any way in which the mother is comortable
and nds that the technique works is satisactory.
It may take one or two days or the inant to get used o the tube and the taste o the
mixture o milks, but it is important to persevere.
7A.6.2 Later, as the inant becomes stronger
Lower the cup progressively to about 30 cm below the breast.
Later, when the mothers are more condent, ask i they want to manage to hold the
cup and tube without assistance. The mother, instead o the assistant, can hold the
tube at the breast with one hand and the other holds the inant and the cup. In this
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way she can perorm SS eeding without assistance.
Use another mother who is using the technique successully to help.
Try to have the mothers together at the same time using the SS technique. Once
one mother is using the SS technique successully the other mothers are greatly
encouraged and nd it relatively easy to copy her.
I the SS-milk ormula is changed suddenly then the inant normally takes a ew
days to become used to the new taste. It is preerable to continue with the same
supplementary diet throughout the treatment.
The gure shows an inant being supported during SS eeding
Figure 2. Supplementary suckling technique
This inant is suckling the breast and also
getting the SS-milk (135 ml/kg per day) by the
supplemental suckling technique. Raising or
lowering the cup determines the ease with which
the inant gets the supplement: or very weak
inants it can be at the level o the inant’s mouth.
I it is above this level, the eed can go into the
child by siphonage when there is a danger o
aspiration.
Ater eeding is completed, the tube is fushed through with clean water using a syringe.
It is then spun (twirled) rapidly to remove the water in the lumen o the tube by centriugal
orce. I convenient, the tube is then let exposed to direct sunlight.
7A.6.3 Diet and amounts to give
Inants with SAM without oedema should be supplemented with expressed breast milk,
generic inant ormula or F100 diluted. Do not use F75 unless the child has oedema.
Young inants with oedema should be supplemented with expressed breast milk or, i this
not possible, F75 or a generic inant ormula, until the oedema has resolved.
Undiluted F100 should never be given to inants aged less than 6 months with SAM
because o the high renal solute load and risk o hypernatraemic dehydration.
• Preparation
For inant ormula:
Dilute according to the supplier’s instructions.
For F100 dilute:
Put one small packet o F100 into 670 ml o water (instead o 500 ml).
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OR use 100ml o F100 already prepared and add 35 ml o water, then you will get
135 ml o F100 diluted. Discard any excess waste.
Don’t make smaller quantities.
• Amounts to give by SS technique
Table 18. Amounts of SS-milk for infants during SS feeding
CLASS OF ML PER FEED 50% OF THE REQUIRED 75% OF THE REQUIRED
w
WEIGHT (KG) (FOR 8 FEEDS / DAY) QUANTITY QUANTITY
(100%)
F100-dilute
< =1,2kg 25 ml per feed 12,5 18 ml
1,3 - 1,5 30 15 24 ml
1,6 - 1,7 35 18 27 ml
1,8 - 2,1 40 20 30
2,2 - 2,4 45 23 35
2,5 - 2,7 50 25 40
2,8 - 2,9 55 28 45
3,0 - 3,4 60 30 45
3,5 - 3,9 65 33 50
4,0 - 4,4 70 35 55
7A.6.4 Procedure
• The inant should be weighed daily with a scale graduated to within 10–20 g.
• Breasteed on demand or oer breast milk at least every 3 hours or at least 20
min.
• Between 30 and 60 minutes ater the normal breasteed, give maintenance
amounts o SS milk supplement according to the table above (i.e. 135 ml/kg per
day, distributed across eight eeds per day, providing 100 kcal/kg per day).
• The quantity o milk supplementation is not increased during the stay.
o I the inant starts gaining weight at 20 g per day, decrease the SS supplement
up to 50% o the maintenance intake, so that the inant is stimulated to take
more breast milk.
o I the weight gain is maintained at 10 g per day, stop the milk supplement.
o I the weight gain is not maintained, increase the amount o milk supplement
to 75% o the maintenance amount, then decrease the amount again to 50%
as the inant gains weight at 10 g per day.
o I weight gain is maintained at 20 g per day, stop the SS supplement and
ensure that the inant is gaining weight at 10 g per day on exclusive breast
milk.
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• Encourage the mother when the inant is gaining weight and tell her that “the
recovery is due to her own breast milk”.
• As soon as the baby is gaining weight on breast milk alone with no SS supply, the
baby and mother are ready or discharge rom hospital (see below).
7A.7 Routine treatment
Systematic treatment is similar to that or children aged 6 months or older.
7A.7.1 Antibiotics
• I there are no medical complications, give amoxicillin 25 mg/kg orally every 12
hours or 5 days, as routine rst-line antibiotic.
• I there are medical complications, give benzylpenicillin (50,000 units/kg IV every
6 hours or 5 days) or ampicillin 50 mg/kg IV (or IM) every 6 hours or 2 days, then
switch to amoxicillin 25 mg/kg orally twice a day or 5 days, and then gentamicin 3
mg/kg IV (or IM) once a day or 7 days.
• Do not give anthelmintics; measles vaccination can be given rom age 4.5 months.
7A.8 Care for the mothers
As the aim is to increase breast milk, the mother’s health and nutritional status are critical
or the nutritional repletion o the inant.
Check mother’s MUAC and the presence o oedema.
Explain to the mother what the aim o treatment is and what is expected o her.
Do not make the mother eel guilty or the state o her child or blame her or giving
other oods.
Introduce her to the other mothers in the centre and introduce her to the sta
personally. Make her eel “at home” in a riendly and relaxing atmosphere.
Agree with her that she may not have enough milk at present – but strongly reassure
the mother that the technique works and that enough milk will “come into” her breasts
as her baby recovers. She will then be able, with her own milk, to make her baby
better.
Tell her and encourage her to drink at least 3 litres per day.
Make the necessary arrangement or the mother so she can eat about 2,500 kcal/
day o a high quality diet.
Give to the mother vitamin A: 1) I the child is below 2 months or the mother is
menstruating: 200,000 UI (there should be no risk o pregnancy); 2) I the child is
above 2 months: 25,000 UI once a week.
Give ull micronutrient supplements.
Note: breast milk from malnourished mothers may have inadequate amounts of type I
nutrients – the mother MUST be given multivitamin and mineral supplements during SS
treatment and counselled about adequate and diverse dietary intake following discharge.
Decrease as much as possible the length o stay in the acility.
I needed, give drugs which help with lactation (e.g. metoclopramide 10 mg 8
hourly).
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Other drugs that increase milk fow (e.g. chlorpromazine) are less eective, cross into
breast milk and will potentially aect the mother and child adversely; in some cultures,
there are local spices that stimulate breast milk output (e.g. enugreek) but their saety
has not been established.
7A.9 Preparing for discharge from hospital
7A.9.1 Health and nutrition counselling
• Provide health and nutrition counselling and education o the mother, paying
special concern to support and counselling on breasteeding or replacement
eeding.
• In situations with no prospect o breasteeding, mothers or carers should receive
support to enable the sae preparation and use o generic inant ormula at home.
Mothers or carers who are expected to give ormula milk to their inants ater they
are discharged rom inpatient care need clear guidance on the sae preparation
and use o such replacement eeds.
I the mother or carer cannot aord generic inant ormula, she or he should be taught
how to prepare a sae and appropriate replacement milk during the treatment period.
7A.9.2 Psychological support to the mother or carer, plus health and
nutrition support
• Provide psychological support, health and nutrition counselling and education o
the mother or carer.
• Provide health and nutrition support according to the health and nutrition condition.
7A.9.3 Criteria or reerral to outpatient inant and young child eeding/
nutrition support
Inants aged less than 6 months can be transerred to outpatient care or inant and young
child eeding/ nutrition support, when there is all o the ollowing:
• All clinical complications including oedema are resolved.
• The inant has good appetite and is clinically well and alert.
• Weight and weight gain on either exclusive breasteeding or replacement eeding
is satisactory (above the median o the WHO weight velocity standards or > 5 g/kg
per day) or at least 3 successive days.
• Immunization schedule and other routine interventions are completed.
• Mothers or carers are linked with community-based ollow-up and support.
Inants and their mothers or carers should continue community inant and young child
nutrition support initiatives and link with community health workers or home visits.
7A.10 Discharge
Decide when to discharge the inant according to the discharge criteria and write in the
registration book, the inant SS chart, and on the health card (passport) o the child.
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Table 19: Criteria of discharge for infants less than 6 months with a caretaker
AGE DISCHARGE CRITERIA
Inant less than 6 months It is clear that s/he is gaining weight on breast milk alone ater
or less than 3 kg being the supplemented suckling technique has been used.
breasted There is no medical problem.
The mother has been adequately supplemented with vitamins
and minerals, so that she has accumulated body stores o type 1
nutrients.
The mother has been appropriately counselled.
NOTE: there are no anthropometric criteria or discharge o the ully breasted inant who
is gaining weight.
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7B. NUTRITIONAL SUPPORT TO INFANTS WITH NO
PROSPECT OF BREASTFEEDING
I there is no realistic prospect o being breasted, inants with SAM should be given
appropriate replacement eeding. Inants with SAM without oedema can be ed with sae
expressed breast milk, a generic inant ormula, or F100 diluted. Inants with oedema
should be ed with expressed breast milk, a generic inant ormula, or F75 until the oedema
has resolved, ater which they should switch to generic inant ormula or F100 diluted.
The protocol is the same as or older children EXCEPT that the diets are NOT the same.
7B.1 Feeding during stabilization
• Give expressed breast milk, generic inant ormula milk, or F100 diluted or F75 (in
case o oedema only) at 130 ml/kg per day, distributed across eight eeds per day
(3-hourly eeding), providing 100 kcal/kg per day.
Once there is a return o appetite and oedema starts resolving, the inant can enter a
transition phase.
7B.2 Feeding during transition
• Give expressed breast milk, inant ormula milk or F100 diluted provided at 150–170
ml/kg per day, or increased by one third over the amount given in the stabilization
phase, providing 110–130 kcal/kg per day.
The criteria to progress rom the transition period to the rehabilitation phase are:
• A good appetite: taking at least 90% o the inant ormula milk or F100 diluted
prescribed or the transition phase; and
• Complete loss o bilateral pitting oedema; or
• Minimum stay o 2 days in the transition phase; and
• No other medical problem.
7B.3 Feeding during rehabilitation
• Give expressed breast milk, inant ormula milk or F100 diluted provided at 200 ml/
kg per day, or twice the volume given in the stabilization phase, providing 150 kcal/
kg per day.
• When the inant is gaining weight satisactorily on generic inant ormula and there are
no outstanding medical problems, the inant is ready or discharge.
Generic inant ormula milk can be provided saely in some inpatient settings.
Whenever ormula milk is provided as part o management o SAM in inants, it should
not conuse or compromise the wider public health message concerning exclusive
breasteeding or inants aged less than 6 months.
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8. MANAGEMENT OF SAM IN OLDER CHILDREN,
ADOLESCENTS AND ADULTS
Severe acute malnutrition occurs as a primary disorder in older children (5–9 years),
adolescents (10–18 years) and adults (over 18 years) in conditions o ood insecurity.
It also occurs in situations o dependency, or example in the elderly, those with
mental illnesses and emotional problems, and prisoners. Malnutrition in this age group
is commonly associated with other illnesses, such as chronic inections, intestinal
malabsorption, alcohol and drug dependence, liver disease, endocrine and autoimmune
diseases, cancer, HIV and TB. In such cases, both the malnutrition and the underlying
illness must be treated.
8.1 Principles of management
The physiological changes and principles o management o older children, adolescents
and adults with SAM are the same as those or children over 6 months and, in general, the
same guidelines should be ollowed. There are, however, dierences in the classication
o acute malnutrition, the amount o ood required and the drug dosages. Except in
amine conditions, adolescents and adults rarely associate wasting or oedema with their
diet. As a consequence, they do not believe that altering their diet will help them. Even in
amine conditions, they are oten very reluctant to eat anything except traditional oods,
which they view as perectly satisactory. Moreover, the oods they are allowed are oten
restricted by cultural and religious belies. They are oten reluctant to take therapeutic
oods unless they can be persuaded that such eeds are a orm o medicine. This problem
is one o the most dicult aspects o treating adolescents and adults.
8.2 Assessment and classication o malnutrition
8.2.1 School-aged children (5–9 years)
SAM in older children (5–9 years) is dened by the presence o nutritional oedema, and/
or severe muscle wasting. The degree o thinness is assessed by weight-or-height using
the tables in Annex 3.
8.2.2 Adolescents (10–18 years)
SAM in adolescents is also dened by the presence o nutritional oedema and/or severe
muscle wasting, and recent weight loss in the past 4 weeks. The degree o thinness is
assessed using the weight-or-height given in Annex 4.
8.2.3 Adults (over 18 years)
Severe acute malnutrition in adults is dened by the presence o nutritional oedema and/
or severe thinness, and recent weight loss in the past 4 weeks. The degree o thinness
is assessed using a BMI given in Annex 5: anyone with a BMI below 16.0 (pregnant
women excluded) is regarded as severely thin. The causes o oedema in adults include
pre-eclampsia (in pregnant women), severe proteinuria (nephrotic syndrome), nephritis,
acute lariasis (the limb is hot, painul and does not pit on pressure), heart ailure and
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wet beriberi. Non-nutritional causes o oedema can readily be identied by the history,
physical examination and urine analysis. Adults with SAM with medical complications or
poor appetite (appetite test ailed), or underlying illness that needs treatment in inpatient
care should be admitted to hospital.
When an adult is too ill to stand, that is a reason on its own or admission to hospital and
carries the highest mortality rate. To assess BMI, the hal arm span can be measured.
This is the distance rom the middle o the sternal notch to the tip o the middle nger
with the arm held out horizontally to the side. Both sides should be measured. I there is
a discrepancy, measurements should be repeated and the longest one taken. The height
(in metres) can then be calculated as ollows: Height = (0.73 × (2 × hal arm span)) +
0.43.
The BMI is then assessed rom the table or computed using weight/(height*height)
Table 20. Classication o thinness in adults by body mass index
Body mass index Nutritional status
≥ 18.5 Normal
17.0–18.49 Mild thinness
16.0–16.99 Moderate thinness
< 16.0 Severe thinness
8.3 History and physical examination
A thorough examination should be conducted to exclude conditions that give rise to
secondary malnutrition. A careul dietary history should be taken. Blood sugar should be
tested to exclude diabetes mellitus.
8.4 Initial management
I possible, older children, adolescents and adults should be given the same therapeutic
oods and ollow the same protocol as children over 6 months. The initial goal o treatment
is to prevent urther loss o tissue. The amount o RUTF or ormula eed given per kg o body
weight is much less than or children aged up to 5 years, and decreases with increasing
age, refecting the lower energy requirements o adults. Recommended amounts or
dierent ages are given in the tables or children in Chapter 7. These amounts will
meet all nutrient requirements o children rom 5 years o age onwards, adolescents and
adults. I older children, adolescents and adults with SAM are anorexic, the ormula eed
is given by nasogastric tube during the rst ew days. As soon as appetite returns, RUTF
will be oered and amily ood will be gradually introduced. Adults and adolescents are
also susceptible to hypoglycaemia and hypothermia. The latter condition is managed as
described or children. Aected individuals should also be given immediate systemic
antibiotics and anthelmintics ater 1 week o treatment.
8.5 Failure to respond to treatment
Failure to respond to treatment in adolescents and adults is usually due to an unrecognized
96
underlying illness, a nutrient deciency, or reusal to ollow the treatment regimen. Follow
the procedures or children.
8.6 Preparation for discharge from hospital and end of treatment
An improving appetite indicates the beginning o rehabilitation. During rehabilitation, it
is usual or adolescents and adults to become very hungry, oten reusing the ormula
eed and demanding enormous amounts o solid ood. When this happens, RUTF will
be introduced (i not done earlier), supplemented with a diet based on traditional oods,
but with added oil, mineral and vitamin mix. As soon as a variety o oods are tolerated,
prepare the patient or discharge. Allow the patients to eat as much as they want.
8.7 Criteria for discharge from inpatient care, and end of treatment
Children aged 5–9 years can be discharged rom inpatient care when they are eating well
and gaining weight. They should continue to receive a supplemented diet as outpatients
until their WHZ is ≥ –2 Z-score. Adolescents and adults can be discharged rom inpatient
care when they are eating well and gaining weight, they have a reliable source o nutritious
ood outside the hospital, and any other health problems have been diagnosed and
treatment begun. Adults should continue to receive a supplemented diet as outpatients
until their BMI is ≥ 18.5; or adolescents, their diets should be supplemented until their
W/H is ≥ 85% o the median NCHS reerence value. Experience has shown that the return
o sexual unction indicates recovery.
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9.EMOTIONALANDPHYSICALSTIMULATIONOFCHILDREN
Children with SAM have delayed mental and behavioural development which, i not treated,
can become a serious long-term result o malnutrition. Emotional and physical stimulation
through play activities that start once the child is alert can substantially reduce the risk o
permanent mental and emotional impairment. This stimulation needs to be sustained or
a prolonged period, so the most important aspect is to teach the mother/caretaker/ amily
that it is by play and exploration that the child learns and that they should continue this
throughout the child’s upbringing.
Combined psychosocial care and nutritional programming is critical in order to address
the physical, social, emotional and intellectual developmental needs o the child and
to enhance maternal well being. Opportunities should thereore be made in routine
nutritional care to incorporate early childhood development activities. This is particularly
emphasized in situations o ood shortage and emergency, to help increase and sustain
the impact on a young child’s health and nutritional status.
Psychosocial assessment and treatment also needs to be provided or the mother, ather
or carer, to assist with childcare, sustained breasteeding or addressing other problems.
Child participation should be encouraged whenever possible. Carers should be
encouraged to listen and consult with their inants and children on their engagement in
any activities. Creative mediums o art and play might be used as a way or very young
children to express their views. Children with HIV or mental and physical disabilities
are at higher risk o being neglected, o lacking play opportunities, or o not receiving
appropriate nutrition. Every eort should be made to ensure participation o children who
are rom vulnerable groups.
Singing, use o large pictorial cards and other interactive methods can be used.
Inexpensive toys made rom cardboard boxes, plastic bottles, tin cans and similar locally
available materials are best, because mothers can copy them. Examples o suitable toys
are described in Figure 3.
9.1 Outpatient care
Simple early stimulation, learning and play activities can be introduced when mothers
come to health acilities or ollow-up visits. One-to-one counselling or the mother can
be given while weighing or assessing the child or distributing therapeutic ood. Ideally,
all nutrition and associated volunteer sta who have direct contact with mothers can be
trained to provide simple health messages in addition to routine education. For example,
messages on the importance o breasteeding can be combined with messages on how it
provides the opportunity to show warmth and love and the advantages o communicating
through singing, touch and acial expression.
9.1.1 Child-riendly spaces
Creating sae, clean, baby-riendly spaces within health acilities (or using separate
“baby tents” i there is no space and in emergency contexts) is advantageous or both
the mother or carer and inant or child. Tents can be equipped with special kits and toys
made by parents, and provide space or breasteeding in private, counselling and play.
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The baby tent also provides a sae space or babies to interact with their carers and to
be watched; they learn rom each other, and this allows or babies to interact and play
with one another.
9.1.2 Mother/carer and baby groups
Mother/carer and baby groups can be established on the same day that mothers return
to receive ollow-up care. This aspect o providing direct and continuing social support
is probably one o the key elements in improving maternal mood and ostering resilience.
9.2 Inpatient care
During inpatient care, care must be taken to avoid sensory deprivation. Practices that
involve wrapping or tying an undernourished child to prevent movement, or covering the
child’s ace, should be discouraged by explaining that they limit needed contact and
thereore limit psychosocial stimulation. The child must be able to see and hear what
is happening around him or her and have unrestricted movement. 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 carer’s condence and role are
not undermined. Where appropriate, education about this issue should be given to all
members o the amily, including the extended amily.
It is essential that the mother or carer is present with her or his child in the hospital or
nutrition rehabilitation centre, and that she or he is encouraged to eed, hold, comort and
play with the child as much as possible. The number o other adults who interact with
the child should be as ew as possible. Each adult should talk, smile and show aection
towards the child. Medical procedures, such as venepuncture, should be done by the
most skilled person available, preerably out o earshot and sight o the other children.
Immediately ater any unpleasant procedure, the child should be held and comorted.
9.2.1 The environment
The austerity o a traditional hospital should be avoided when possible in the treatment o
malnourished children. Rooms should be as stimulating as possible, with bright colours,
decorations and colourul mobiles that interest children. Brightly coloured aprons or use
o more inormal clothing is encouraged. A radio can provide background music. The
atmosphere in the ward should be relaxed, cheerul and welcoming.
Toys should always be available in the child’s bed and room, as well as in the play
area, and should be sae, washable and appropriate or the child’s age and level o
development.
9.2.2 Play activities
Malnourished children need interaction with other children during rehabilitation and
inormal play. Ater the initial phase o treatment, the child should spend prolonged
periods with other children on large play mats, and with the mother or carer or a member
o sta who guides the play session. The child can also be ed in the play area. These
activities do not increase the risk o cross-inection appreciably and the benet or the
child is substantial.
99
One person, usually a nurse or volunteer, should be responsible or developing
a curriculum o play activities and or leading the play sessions. Activities should be
selected to develop both motor and language skills, and new activities and materials
should be introduced regularly. One aim should be to play with each child, individually,
or 15–30 minutes each day, in addition to inormal group play. A sample curriculum o
play items, arranged by level o development, see gure 3. Mothers can be trained to
supervise play sessions.
Learning through play should be un or children. A child’s eorts to perorm a task
should always be praised and never criticised. When a child is taught a skill, the nurse
or volunteer should demonstrate the skill rst, then help the child do it, and nally let the
child do it alone. This sequence should be repeated until the child has mastered the skill.
9.2.3 Physical activities
Physical activities promote the development o essential motor skills and may also
enhance growth during rehabilitation. For those children who are unable to move, passive
limb movements and splashing in a warm bath are helpul. For other children, play should
include such activities as rolling on a mattress, running ater and tossing a ball, climbing
stairs and walking. The duration and intensity o physical activities should increase as
the child’s nutritional status and general condition improve. I there is sucient space, an
outdoor playground should be developed.
100
Figure 3: Home-made play items (diagram supplied by Professor S. Grantham-
McGregor)
101
10. COUNSELLING ON GROWTH AND FEEDING
It is common or the mothers to know what to do but be unable to ollow the advice
because they are orced to obey their husbands and mother-in-law. For all education,
community health workers should actively seek the whole amily or consultation about
child growth, development, eeding, nutrition etc.
It is also important to have MALE community health workers who can talk to the husbands
and persuade them to ensure that their wives ollow the guidance given. It is oten o
limited use to involve only the mother or carer o the child in education sessions, IYCF
counselling and early child development guidance.
Sta must be riendly and treat the mothers, athers and carers as partners in the care
o the children. A carer should never be scolded, blamed or her or his child’s problems,
humiliated, reprimanded or made to eel unwelcome. Moreover, helping, teaching,
counselling and beriending the parent or carer are essential parts o the long-term
treatment o the child.
All parents should know how to prevent malnutrition rom recurring and understand why
their child got sick. Understanding the causes o malnutrition and how to prevent its
recurrence, including correct eeding and awareness o the danger signs and when a
child should be taken or medical care, should help the child to be treated more promptly.
Some mothers can require additional support to continue breasteeding and sta should
be aware o basic lactation skills, including attachment and positioning. Similarly, when
and how to introduce appropriate complementary oods should be covered.
The importance o hygiene and clean water should be stressed, including hand-washing,
cleaning storage containers or water and ood, and the use o latrines.
Continuing to stimulate the child’s mental and emotional development at home, through
eye contact, touch, play, provision o homemade toys, songs and games should be
conveyed to the carer.
Mothers should be aware o appropriate and aordable mixed diets that are obtainable
rom their environment and the same as those recommended or a healthy child. Animal
milk is an important source o energy and protein. Solid oods should include a well-
cooked staple cereal, to which vegetable oil should be added (5–10 ml or each 100 g
serving), to enrich its energy content. The cereal should be sot and mashed; or inants,
use a thick pap or porridge. A variety o well-cooked vegetables, including orange and
dark-green leay ones, should be given. I possible, include ruit, meat, eggs or sh. The
mother should be encouraged to give the child extra ood between meals. These oods
can be gradually introduced as the child reaches the end o rehabilitation and therapeutic
oods are reduced. Any breasteeding should be continued.
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11. COUNSELLING AND PSYCHOSOCIAL SUPPORT TO
THE MOTHER OR CARER
For children with SAM, parenting interventions promoting mother–inant interactions,
including psychosocial stimulation, should be oered to improve child-development
outcomes. Such programmes should preerably be delivered within ongoing mother and
child health programmes.
A strong maternal–inant (or carer–inant) bond provided through psychosocial stimulation
is essential or positive child development. Many carers are unavailable or unable to
provide psychosocial stimulation to their children, owing to their own poor physical or
mental health. A lack o psychosocial stimulation has adverse consequences or children’s
development (cognitive, motor, language) and mental health.
Key public mental health interventions, psychosocial support and nutritional interventions
must also be provided or mothers or carers, to acilitate carer–child relations and prevent
developmental delay and mental disorders. With appropriate intervention, these problems
are largely preventable.
Carers with physical or mental health problems may need extra support to ensure that
they are able to give care to their children. Improving maternal mental health (e.g.
reducing maternal depression) may be one o the most important interventions, especially
in situations o ood shortage, or both the mother and child. In addition to enhancing
maternal knowledge and practice o early childhood development activities, mother and
child groups increase connections between women and break down eelings o isolation.
12. FOLLOW UP AFTER THE END OF TREATMENT
SAM occurs mainly in amilies that have limited access to nutritious ood and are living
in unhygienic conditions which increase the risk o repeated inections. They oten have
limited support rom their neighbours and community.
A preventative approach is essential. Once a child is ready or discharge, thereore, it is
important to ensure that, wherever possible, they are linked into supportive services in
their communities and nearby health acilities. Health sta should be aware o the range
o health, nutrition, livelihood and social services available in the context, so that they can
inorm amilies o their options and eligibility. Where a child is suering rom a particular
chronic disease, it is essential to ensure the parent or carer is aware o and, where
possible, directly linked/reerred to any relevant ollow-up and/or support. See Box 11 or
some appropriate services.
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Box 11. Infant and young child feeding counselling and support services
• Growth monitoring and promotion clinics/sites
• Mother and child health days/weeks
• Multiple micronutrient supplementation e.g. micronutrient powders, corn-soya blend/ortied
blended ood, ready-to-use supplementary ood
• Early childhood development centres/service
• Social protection schemes or poor amilies or particular disadvantaged groups
• Support services or HIV-aected households
• Food or livelihood security support services
Note: in an emergency context there may be a wider range o programmes and
interventions that the amily can be linked to.
Although much improved at the time o discharge, the child usually remains stunted
and mental development is delayed. Managing these conditions and preventing the
recurrence o SAM requires sustained improvement in eeding o the child and in other
parenting skills. Planned ollow-up o the child at regular intervals ater discharge is
essential. This should include an ecient strategy or tracing children who ail to attend
ollow-up appointments. Such children are at increased risk o recurrence o malnutrition
or o developing other serious illnesses.
As the risk of relapse is greatest soon after discharge, the child should be seen after
1 week, 2 weeks, 1 month, 3 months and 6 months. Provided the child’s weight-or-
height is no less than –2Z-score progress is considered satisfactory. If a problem
is found, visits should be more frequent until it is resolved. After 6 months, visits
should be twice yearly until the child is at least 3 years old. Children with frequent
problems should remain under supervision for longer.
The mother or carer should know the location and regular opening hours o the nearest
health acility providing nutrition service and be encouraged to bring the child without an
appointment i he or she is ill, or a previous appointment was missed.
At each visit, the mother should be asked about the child’s recent health, eeding
practices and play activities. The child should be examined, weighed and measured,
and the results recorded.
Every eort should be made to get the community to extend the social network o the
malnourished child’s amily. A supportive neighbour can be the most important help to
such a amily.
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13. MODERATE ACUTE MALNUTRITION
This section provides practical guidelines or the identication and management o
patients with moderate acute malnutrition (MAM). Moderately malnourished individuals
may be treated as outpatients through a supplementary eeding programme (SFP). The
children are at heightened risk o death in the medium and long term but, unlike the
severely malnourished, do not need immediate emergency treatment.
There are alternatives to direct distribution o ood products which may be as successul
as (or more successul than) direct ood distribution. These alternatives include income
generation support, amily micro-credit, cash transer, home-gardening support and the
HEARTH programme and positive deviance. Note that several other programmes do not
(and are not designed to) address any orm o malnutrition in a community,19 although
they do involve ood distribution.
13.1 Objectives
• Identiy moderately malnourished children in the community.
• Treat MAM and prevent deterioration to severe acute malnutrition
• Support individuals who have recovered rom severe malnutrition and been
discharged or ollow-up to prevent relapse.
13.2 Organisation
13.2.1 Opening and closing a supplementary eeding camp or programme
(SFC/SFP)
In an emergency context, where either there are rapidly rising numbers o MAM children
or the ood security situation is predicted to deteriorate, an SFP should be established
when the numbers of children with MAM exceed the normal health and social
services’ ability to respond to their needs and there is a risk that they will deteriorate to
develop severe acute malnutrition. This test should be applied in relation to the absolute
numbers o MAM children in excess o the usual services capacity to cope and not to
the percentage o SAM or MAM assessed rom a survey20. The scale and scope o the
SFP will depend upon the numbers o anticipated children, the capacity o the health
and social services and the presence or absence o other programmes to address the
problem o malnutrition in the community. Each o these actors will vary rom one situation
to another.
In an emergency, by denition, the normal services cannot manage the large increase in
malnutrition that is caused by the emergency. In some emergencies, particularly when
there is population displacement, there is a complete absence o any “normal” services,
19 For example, “ood-or-work“ programmes distribute ood mainly to the healthy well nourished who can work – the
malnourished cannot. Food-or-work is a way o securing workers when “ood” is an available medium o currency.
Likewise, school eeding only targets those that go to school (who are generally the already better o).
20 For example, i there is 15% MAM in a camp with a population o 10,000 o which 20% are children aged 6-59
months, then there will be 300 MAM children. I there are no health services in the camp, provision should be made
to treat 300 children. I in a metropolitan area o 10 million people there is 6% MAM, again with 20% children, then
there are 120,000 MAM children within that population. It is very unlikely that the health services are able to manage
this vast number o children – yet the use o a percentage cut-o would exclude them rom receiving any assistance.
This is
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there is no capacity to respond to the needs o the population and the population has
no coping mechanism; in such circumstances urgent establishment o general relie and
an SFP is urgent and should not await a nutritional survey to decide whether to open a
programme or not.
In some populations there is marked seasonality in the prevalence o acute malnutrition.
In such situations it is proper to plan to open an SFP whenever the normal services are
overwhelmed and to close it again, in a planned way, whenever the numbers decrease
to a level with which the normal services can cope.
In some chronic emergencies, and in stable situations (i.e. in a development context or
when moving rom emergency to development) other programmes are in place to address
the nutritional needs o the most vulnerable. These include cash subsidies o various
kinds, microcredit and other income-generating amily support mechanisms, positive
deviance/ hearth programmes etc. These programmes are not mutually exclusive. I such
programmes are established and there is still sucient MAM to overwhelm the health and
social services, an SFP programme could be established within a development context.
However, this is not usually necessary.
13.2.2 Structure
The SFC should not be run (i possible) rom health centres. The sta workload in the
health structures is already burdensome with many programmes to administer, including
treatment o the severely malnourished. I the health sta also have large numbers o
children attending or supplementary eeding (note there are normally about 10 MAM
children or each SAM child), their acilities and sta become swamped so that all the
essential health programmes suer. The SFC can be run rom any convenient structure
(house, school, community acility) provided that there is a secure, ventilated and pest-
ree storage acility. Ideally there would be a health centre close by, so programme
coordination is easy, the patients are quickly and easily transerred and the sta know
each other.
It may be useul to site the SFC close to a market, in which case the SFC can operate on
market days as the beneciaries/caretakers are likely to be visiting the market to buy and
sell, and can combine one travel rom home or both purposes – in this case the length o
time the spent at the SCF should be kept to a minimum and the fow o recipients steady
and rapid.
13.2.3 Stang
There is no need to have clinically trained sta. MAM treatment can be run by nutritionists
or social workers.
• Supervisor - social worker or nutritionist
Activities
S/he manages the ood and non-ood items (distribution).
S/he prepare the monthly reports.
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S/he manages the human resources.
S/he supervises the MAM treatment.
S/he organises the health and nutrition education/counselling and cooking
demonstrations with the nutritionist.
CHW or volunteers
S/he does the anthropometric measurements: weight, MUAC measurements and
checks or oedema.
S/he nds any deaulters and encourages them to come back.
S/he helps prepare the individual ration during individual/home visit (preparing the
premix and packaging).
Nutritionist/social worker
• Trained on community IMCI.
• Trained on the measurements technique and admission and discharge criteria
or the integrated management o acute malnutrition (IMAM) programme and the MAM
treatment and, in particular the procedures to ollow or all patients who ail to respond to
treatment.
• Activities
S/he admits the child according to the criteria o admission.
S/he explains to the mother the management o MAM.
S/he checks or any medical problem, the vaccinations and reers to the OTP/
health centre.
S/he registers the child in the registration book and applies the criteria o admission,
discharge and ailure to respond to treatment.
S/he identies the deaulters and any patients who ail to respond to treatment,
and inorms the CHW/volunteers.
S/he organises and supervises the preparation o the ration.
S/he distributes the prepared ration to the child or caretakers.
S/he gives health/ nutrition education sessions.
• Materials
o Scales – length board – MUAC tapes
o Laminated posters or the admission and discharge criteria – ailure to respond
o Registration book or MAM treatment; ollow-up o SAM cure children; key
messages about the products (RUSF/porridge) in local languages
o Ration card or the mother/caretakers
o Supplemental ration supplies (with secure storage acilities)
o Buckets/basins
o Salter scale (25 kg)
o Calculator
o Measuring cup/scoop
o Soap or washing utensils at the eeding centre
o Products (CSB+, CSB++/FBF and RUSF)
o Vitamin A capsules
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o Albendazole tablets
o Mebendazole tablets
o Iron/olic acid tablets
o Sae drinking water
o Cup and glass
o Posters on nutrition and health education and material or health education
sessions.
13.3 Admission
All the children that ull any o the admission criteria in the ollowing table should be
admitted into the MAM treatment.
AGE GROUP ADMISSION CRITERIA
MORE THAN 6 MONTHS CHILDREN W/H - W/L ≥ -3 and <-2 Z-score
or
MUAC ≥ 115 mm and < 125mm
ALL SAM CURED CHILDREN NO ANTHROPOMETRIC CRITERIA
FOLLOW UP FOR 3 MONTHS
13.3.1 Type of admission
New admission is done according to several criteria:
Relapse: a cured MAM child readmitted or a second episode o MAM
Follow up o a cured SAM child
Readmission o deaulters ater less than 2 months absence
Internal transer rom another SFC.
13.3.2 Admission procedure
Take the anthropometric measurements – MUAC, weight (always using the same
scale) and height – examine or oedema.
Check the admission criteria.
Explain to the mother/caretaker how treatment will be organized and reasons or
admission to SFP.
Determine i the patient has any sign o a medical problem. I the child has any
IMCI complications, reer him/her to the health centre: “ast track” those obviously ill
to the nearest hospital; do not keep them waiting.
Systematically check or measles vaccination status, in particular or children over
6 months. I necessary reer or vaccination to immunization service.
Careully explain the expectations and way the caretaker should use the supplement
and attend the centre.
Enter all the children eligible or admission to the programme in the registration
book, give a registration number.
Enter all the inormation or admission in the programme in the card and give the
card to the caretakers.
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13.4 Diet
13.4.1 Type o supplementary eeding
• Dry or wet feeding
In general there are two types o supplementary eeding centre:
1. The wet supplementary feeding centre (SFC). The ood supplement is prepared
daily in the SFC and is eaten by the beneciary in the centre one two or three times a day.
This option is only used in exceptional circumstances, usually with mass movement of the
population or natural disasters, when they do not have stability and access to cooking
facilities, fuel etc.
2. Supplementary feeding through take-home rations. The ingredients o the ration
are mixed in the SFC prior to distribution (i this is not already pre-mixed in the product
you receive, e.g. CSB+). It is necessary to give larger amounts o ood in this ration to
compensate or intra-household sharing.
• Supplementary rations – strategies
Various types o supplementary ood are dispensed or MAM children – the optimum
strategy or ration composition has not yet been determined. Nevertheless the rations
should always adhere to the ollowing principles.
The ood should contain ALL essential nutrients in adequate amounts to allow or the
extra nutritional requirements to enable them to have accelerated weight and height gain
and ull physiological recovery.
The nutrients should be biologically available to children with the altered intestinal unction
that is associated with MAM. In particular:
Dry supplements should be distributed as a mixture rather than as separate
ingredients to avoid use or other purposes.
Mixed oods can be stored at home up to 2 weeks at a time.
The ration supplied should enrich the basic diet o the beneciary with all essential
nutrients to provide the amounts o essential nutrients recommended or the
moderately malnourished child.
Escalating strategy
For the escalating strategy, at least two dierent supplementary oods must be available
in the SFC in adequate amounts and available or distribution.
The children are started on a ortied blended ood such as CSB+ or FBF and their
progress careully monitored. Any child that ails to gain weight satisactorily must be
identied early and the ood supplement changed to a product with a higher nutrient
density, whose nutrients are more readily available and which contains lower levels o
anti-nutrients. These supplementary oods (lipid-based, ready-to-use-supplementary-
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ood, RUSF) should always be taken between meals and not mixed with the amily ood
or used to prepare “sauce” to be taken with the staple ood.
Table 21: Example of ration required per child per day – strategy 1 initial diet
Food item Daily quantity* Quantity (14 days)
(g) (kg)
FBF/Super-Cereal (CSB+) 250 3.5
*Provides 1,300 kcal/beneciary/day. 14% protein, 31% at
Prepare a premix by mixing thoroughly the appropriate quantities o ingredients together
in a big basin. The ration should be prepared beore distribution in the most hygienic way,
to minimise the risk o bacterial contamination.
Distribute a ortnightly (2-week) ration (approx. 4.2 kg) to the patients. Each ration
should be given in a clean amily container.
Conduct a cooking demonstration or new caretakers. Explain how to use the porridge.
1 volume o premix to 3 volumes o water
Ration is to last or 14 days
Ration is or the malnourished patient only.
The second strategy is to commence all children on a higher nutrient dense, ready-to-eat prod-
uct (e.g. RUSF – this is more eective, but it is also more expensive) and monitor the patients.
I the patients ail to respond on this diet then the problem is much less likely to be an unmet
nutritional deciency and may be a social or underlying medical problem. This strategy is par-
ticularly suited to the younger MAM child (aged 6–24 months). These children are more likely to
deteriorate and develop SAM, have a greater inective burden, are at higher risk o death, have
higher nutrient requirements and are much more vulnerable to developing stunting and mental
deciency than older children.
Strategy where there is no ood insecurity
Where the prevalence o MAM is quite low, there is no ood insecurity at a population level
and most amilies have access to sucient ood, then the likely cause o nutritional deciency
is poor nutritional quality o the diet. However, a higher proportion o the MAM children in this
situation will have underlying social or medical problems and will probably not respond to any
nutritional supplement or this reason.
Micronutrient powder distribution to the general population to treat anaemia and other condi-
tions associated with type 1 nutrient deciency is not a strategy or the management o MAM.
Micronutrients and are very unlikely to increase weight or height gain as they principally contain
only type 1 nutrients.
13.5 Routine medicine
13.5.1 Vitamin A supplementation
On admission, check on the heath card/passport and/or ask the mother i the child has
received vitamin A in the last six months. Give standard doses o vitamin A i this has not
been taken.
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13.5.2 Albendazole/mebendazole
On admission, check on the heath card/passport and/or ask the mother i the child has
received albendazole in the last six months. I the child is over 12 months then give worm
medicine i not previously given.
13.5.3 Iron/olic acid supplementation
Administer iron (60 mg elemental iron)/olic acid (400 ug) ortnightly, as ollows:
CHILD’S WEIGHT TABLETS EVERY 14 DAYS
<10 kg 1 tablet
>10 kg 2 tablets
13. 6 Surveillance
On admission, ensure that the there is a record in the register o 1) the target weight or dis-
charge; 2) the weight which would trigger transer to OTP or SAM; and 3) (or SAM-ollow up
patients only) the criteria to re-designate the child as having MAM.
Take the MUAC measurement at each visit and compare with the discharge criteria.
Weigh the children at each distribution and on discharge and compare with the target
weight.
Diagnose whether the child meets any o the criteria o ailure-to-respond to treatment.
Check whether the child meets the minimum weight and has now met the SAM criteria (W/H
< -3Z-score) or MAM children and i they do, immediately transer them to the OTP.
For the SAM-ollow-up children, check whether the child meets the minimum weight to
enter the criteria or MAM (W/H < -2 and > -3Z-score): the child should then be reclassied
as a new MAM admission in the same SFC. This is counted as a new MAM case.
Ask the mother/caregiver i the child is ill, and i yes reer to the health centre or medical
check-up and treatment; i any acute illness, send him/her rapidly to the health centre or
IMCI investigation.
Record results in the appropriate SFP Registration Book and on the individual ration
cards o the caretaker.
Explain the change in the nutritional status to the caregiver.
Give and record ration at each visit on the ration card o the caregivers
Table 22: Summary of the surveillance in SFC
MEASURE FREQUENCY
MUAC is taken Every 2 weeks
Weight is taken using the same scale Every 2 weeks
Height/length is measured At admission
W/H Z-score can be calculated Day o admission
12.7 13.7 Diagnosis o ailure-to-respond to treatment
It is essential to strictly apply the ailure-to-respond criteria: children must not languish in
the SFP or weeks or months without being identied and the cause o ailure investigated
and managed. It is or this reason that on admission, not only the discharge weight should
111
be calculated but also the weight at which a criterion or SAM is reached and action
needs to be taken urgently.
13.7.1 Criteria or ailure-to-respond to treatment
These are maximum time limits or labelling the patient as ailure to respond to treatment
– in most circumstances action should be taken beore these limits are reached.
1. Either no or trivial weight gain ater 5 weeks in the programme or at the 3rd visit
2. Any weight loss by the 3rd week in the programme or at the 2nd visit
3. Weight loss exceeding 5% o body weight at any time (the same scale must be used)
4. Failure to reach discharge criteria ater 3 months in the programme
5. Abandonment o the programme (deaulting)
13.7.2 Reasons for failure to respond
1. Problems with the application o the protocol: this should be addressed rst
2. Nutritional deciencies that are not being corrected by the diet supplied in the SFP
3. Home/ social circumstances o the patient
4. An underlying physical condition/ illness
5. Other causes.
13.7.3 Step-by-step procedure to address ailure to respond
• Protocol problems
Where a substantial proportion o children ail to respond to treatment (or abandon the
programme), the proper application o the protocol and the training o the sta at eld level
should be systematically reviewed, i possible by external evaluation. Any deciencies
should be corrected. Failure to treat the caretakers with due respect (rudeness etc.)
is, in most situations, the commonest cause o deaulting. I it is suspected that “short
rations” are being given or that there is diversion o ood, unannounced post-distribution
monitoring should be implemented by re-weighing the ood o recipients exiting the SFC
or visiting a random selection o beneciaries at home and examining/weighing the ood
they have recently received.
• Uncorrected nutritional deciencies
The total diet oten has low concentrations o several essential nutrients (e.g. potassium,
magnesium, available phosphorus or zinc etc.). The availability o these nutrients is very
low in some diets i there are high concentrations o anti-nutrients.
• Social problems
Where RUSF is being used and the correct instructions or its use have been given (and
the caretaker conrms that they have been ollowed), the most likely cause o ailure are
social problems within the household.
To test whether any o these are the cause, an appetite test can be conducted. I the child
112
is eating well or is hungry and yet ails to gain weight at home then a major social problem
is conrmed. This is then investigated with an in-depth interview with the head / main
decision-maker in the household (ather, mother-in-law) and a home visit is perormed
• Underlying medical conditions
I the child has no appetite then there may be an underlying medical problem. The child
should be reerred to the health centre.
13.8 Discharge procedure
Discharge the children according to the discharge criteria in the table below.
Table 23. Discharge criteria
AGE GROUP DISCHARGE CRITERIA
MORE THAN 6 MONTHS CHILDREN W/H – W/L ≥ -1.5 Z-score
And
MUAC ≥ 125 mm
ALL SAM CURED CHILDREN FOLLOW UP FOR 3 MONTHS
And
W/H – W/L ≥ -1.5 Z-score
And
MUAC ≥ 125 mm
•Procedure of discharge
As soon as the child reaches the criteria or discharge (target weight and target MUAC),
s/he can be discharged rom the programme.
Record the discharge date, the child’s weight, MUAC and the type o discharge in the
registration book and in the card, and ensure that all the necessary inormation is entered
in the card.
Check that the immunizations are updated and inorm the child that the treatment is over.
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14. PREVENTION OF MALNUTRITION
14.1 Introduction
This section provides practical guidelines or the prevention o all orms o malnutrition
in vulnerable groups among the Rwandan population, specically pregnant women and
lactating mothers, inants, young children and adolescent girls.
Generally, malnutrition is caused by lack o nutritional components. It can be prevented
by having a balanced diet and adequate care through sensitive, nutrition-specic
community interventions.
14.2 Objectives
• Improve maternal, inant and young child nutrition and hygiene behaviours
• Increase knowledge and skills o households members and community settlements
to improve ood security and resilience
• Increase access, availability and utilisation o nutritious oods
• Increase behaviour-change activities at community level
• Increase access and utilisation o health services.
14.3 Key interventions
• PROMOTING NUTRITION-SPECIFIC INTERVENTIONS
Pregnant women, lactating mothers and pregnant/lactating adolescents
• Promotion o early pregnancy test in the community
• Antenatal care (ANC) visits (minimum o our standard visits)
• Need or mothers to learn about their HIV status
• Eat extra meal and diet diversity
• Monitoring o nutritional status: MUAC/BMI as appropriate
• Micronutrients supplementation: iron and olic acid supplements
• Food supplementation to vulnerable pregnant women (CSB/FBF).
• Promotion o behaviour-change communication (nutritional education and
counselling)
• Promotion o 1,000-days activities.
Note: These services should be integrated with the obstetric protocols and not with the
nutrition protocols to prevent pregnant women having to choose whether to attend food
supplement distribution or ANC visits.
0-6 months:
• Early initiation o breasteeding (within 30 minutes ater birth)
• Exclusive breasteeding
• Growth monitoring and promotion
• Promotion o 1,000-days activities
• Prevention and early treatment o inectious diseases including diarrhoea.
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6–23months
• Initiation o complementary eeding rom six months
• Adequate complementary eeding (requency, amount, variety, hygiene)
• Continued breasteeding
• Immunization as appropriate, deworming, micronutrient supplementation
• Home ortication (micronutrient powders/ongera intungamubiri)
• Vulnerable children o ubudehe category one (FBF)
• Promotion o behaviour-change communication (nutritional education and
counselling)
• Growth monitoring and promotion
• Promotion o 1,000-days activities
• Prevention and early treatment o inectious diseases including diarrhoea
• Promotion o low-cost weaning oods.
24–59 months
• Prevention and early treatment o inectious diseases including diarrhoea
• Nutritional education and counselling
• Growth monitoring and promotion
• Promotion o pre-school and ECD eeding
5–9 years
• Nutritional education and counselling to caregivers/parents
• Promotion o school eeding
• Promotion o behaviour-change communication (nutritional education and
counselling) to caregivers/parents
• Prevention and early treatment o inectious diseases including diarrhoea
• Promotion o hand-washing practices.
9-15 years
• Include basic nutrition inormation in the school curriculum
• Promotion o school eeding
• Promotion o behaviour-change communication (nutritional education and
counselling) e.g. WASH (mostly hand-washing or this age group)
• Prevention and early treatment o inectious diseases including diarrhoea
• Prevention o early pregnancies among adolescents.
PROMOTING NUTRITION-SENSITIVE INTERVENTIONS
• Promotion o a household-based ood security and resilience to cope with shocks
• Preparedness to natural disasters (droughts, foods, war, earthquake etc.)
• Promotion o bio-ortied oods (iron-rich beans, orange sweet potatoes etc.),
kitchen gardens and small livestock
• Home ood-processing and preservation/storage
• Social protection services (health insurance)
• Promotion o general hygiene, sanitation and hand-washing and sae water
• Prevention and early treatment o inectious diseases including diarrhoea
115
• Sleep under treated bed nets
• Immunization as appropriate
• Promotion o school gardening
• Early childhood development (ECD)
• Promotion o amily planning and birth spacing
• Men’s engagement
• Women’s empowerment
• Family environment / strengthening ‘Umugoroba w’ababyeyi’ (parents’ evening
orum)
• Home economics and savings and internal lending communities
14.4 Further reading
Maternal, Inant and Young Child Nutrition package adapted to Rwanda (Ministry o
Health (MoH)
Essentials Nutrition Actions, Improving maternal, newborn, inant and young child health
and nutrition, 2013 (WHO)
National Early Childhood Development Policy Strategic Plan 2016-21 (Ministry o Gender
and Family Promotion (MIGEPROF))
116
15. MONITORING AND EVALUATION
In order to ensure that services or the management o SAM are achieving their objectives
o identiying, treating and curing SAM, the activities and outcomes must be monitored.
A well designed monitoring and reporting system can identiy gaps in implementation,
and provide inormation or ongoing quality improvement (troubleshooting, redesign and
accountability).
Monitoring a service or the management o SAM comprises two major components:
• Monitoring the eectiveness o treatment – i.e. the proportion o clients treated
eectively
• Monitoring programme coverage – i.e. the proportion o the target group being
reached with treatment and appropriateness o the programme or communities.
15.1 Monitoring the effectiveness of treatment
Provision o quality treatment is acilitated by the use o standard individual monitoring
and is supported by:
• Supportive supervision
• Regular monitoring, analysis and eedback on treatment perormance indicators.
15.1.1 Supportive supervision
Supportive supervision or inpatient and outpatient care or SAM aims to improve the
quality o care oered by:
• Identiying weaknesses in the perormance o activities, taking immediate action
and applying shared corrective solutions
• Strengthening the technical capacity o health workers and motivating sta through
the encouragement o good practices.
Supervisors and managers at both acility and district level must ensure that the service
meets quality standards. Facility-level supervision should be carried out at least once
a week or each particular acility and once a month at district level. This can be done
alongside existing supervision schedules. Supervision visits are carried out through
direct observation o the perormance at the health acilities oering management o SAM,
review o documentation, and structured discussions with health workers. A supervision
checklist can acilitate this.
During supervision, gaps and discrepancies should be identied in consultation with
the sta and, as much as possible, with representatives o the community. Immediate
eedback should be given to the sta and the communities, to allow joint discussion
on possible solutions to any problems identied. Supervisions are also essential or
improving sta capacities through the organization o ormal or inormal reresher training
and mentoring (on-the-job training) during the visits.
117
15.1.2 Perormance monitoring
Quantitative data are collected on the outcomes o individuals’ treatment and allow the
calculation o standard key indicators o perormance or children aged 6–59 months.
These key indicators can then be compared to international standards such as the
Sphere Minimum Standards.
Routine data should be collected on the numbers o:
• New admissions
• Discharges by category: cured, died, deaulted, non-recovered
• Children in treatment (beneciaries registered).
These three basic elements allow calculation o key indicators:
• Cure rate
• Death rate
• Deault rate
• Non-recovery rate.
This inormation also allows monitoring o perormance trends over time and helps to
inorm programme design and a better allocation o resources.
For the purposes o this manual, a case-atality rate o inpatients > 10% is considered
unacceptable and requires urther investigation; 5–10% is good and < 1% is excellent.
Case-atality calculations should take into consideration children treated in outpatient
care, as the more complicated cases that are more likely to die will be in inpatient care.
I there are excess deaths in OTP then the triage procedures need to be revised so that
high-risk children are not sent or home-treatment.
15.2 Monitoring programme coverage
Coverage reers to individuals who need treatment compared against those actually
receiving treatment.
Coverage can be aected by the acceptability o the programme, location and accessibility
o programme sites. Other contributory actors include the general security situation,
requency o distributions, waiting time, service quality, extent o mobilization, extent o
home visiting and screening, and alignment o screening and admission criteria.
Methodologies to measure coverage vary in the level o reliability and type o inormation
generated. The method used must be stated when reporting. Current guidance should
be consulted when deciding which method is appropriate in the given context.
Programme sites should be close to the targeted population, in order to reduce the risks
and costs associated with travelling long distances with young children and the risk o
people being displaced to reach them.
A quantitative and qualitative assessment o coverage highlighting barriers and enhancers
to access assessment should be seen as a management tool. Appropriate actions should
be taken in situations o low coverage.
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16. MANAGEMENT OF SAM IN EMERGENCY SITUATIONS
16.1 General considerations
There must be in place a contingency plan to deal with an emergency. Prior planning
and anticipation (prepositioning o supplies etc.) is the key to an adequate emergency
response. But the whole key is co-ordination so that all the participants are ully aware o
their responsibilities and the command and control structure that swings into place in the
ace o an emergency. A system o communication to all actors involved is critical. There
should be a separate written emergency response document available to be activated as
soon as an emergency is declared (reer to Strategy 6 o the National Food and Nutrition
Policy - NFNP).
Health workers in emergency situations may have to manage a large number o children
with SAM. Although the principles o management are the same as in routine situations,
increased resources and support are needed to deal with the capacity gap or managing
increased case-loads without jeopardizing the essential eatures o care. This oten
requires that temporary eld and/or mobile centres are established, or that existing
health acilities receive additional support in human resources, supply management,
supervision, training and mentoring or scaling up service delivery. In addition, support in
community involvement or early identication o cases and reerral can assist with nding
children early beore complications develop, and increasing coverage o services.
Insecurity should be considered when establishing both inpatient and outpatient services,
to avoid separating the amily or long periods while a child and carer are in inpatient care
and to avoid long travel and waiting times or outpatient care. The latter could cause a
security risk, especially to emale carers.
In the case o population displacement in temporary shelters or camps where all health
services will need to be organized, support or inant and young child nutrition should be
made available as a core service, as well as a means o monitoring the nutritional status
o the population. Management o SAM services should be part o these services i the
need has been identied.
16.2 Preparedness/contingency planning
For districts that are prone to disasters or seasonal increase o the incidence o SAM,
there should be greater preparedness. Contingency planning or recurrent emergencies
should be part o the annual action planning and budgets, or both additional personnel
and uninterrupted stocks.
Reinorcing in-service training, mentoring and task-shiting are areas that can help prepare
sta. Increasing attention is being particularly given to the use and role o a community-
based health workorce that is well trained, equipped and supported to improve access
to essential primary health care or hazard-prone communities on a routine basis, and
during all phases o an emergency. This includes eorts to promote scale-up o the
community-based workorce. Appropriately trained and supervised community health
workers, supported with appropriate supplies o medicines and equipment, can be used
to identiy and correctly treat many childhood illnesses, including screening or SAM.
119
16.3 Emergency response
16.3.1 Reinorcing health services or receiving a large infux o children
It should be a priority to provide support to existing sites and/or setting up additional and/
or mobile sites to ensure that health services remain accessible to the aected population,
and are able to manage the increased case-load without compromising service quality.
Besides making nancial resources available, the ollowing should be considered:
• Human resources support: reinorce existing essential sta or deploy teams o
health workers, supervisors, logisticians and community outreach sta; use o
volunteers can help reduce waiting times and share the work burden.
• Supply support: provide additional essential medicines, vaccines and therapeutic
oods, and provide related logistic management support, including placing orders,
transportation, storage and distribution.
• Inormation support: strengthen monitoring and reporting, and surveillance (case-
load estimations or planning), including analysis to demonstrate quality o services.
• Anticipative training o sta: specialized sta at central and decentralized levels
(including nutritionists, nurses, doctors, social workers, community health workers)
are to be trained to be skilled and able to provide appropriate responses in
emergency situations.
16.3.2 Example or strengthening outpatient care
The use o mobile teams or adding activities or managing SAM to community health
teams can help improve access to amilies and improve coverage o services, which may
contribute to avoidance o unnecessary population movement and long waiting times.
Mobile teams require trained health workers, and drug and supply kits, including RUTF.
Clear guidance should be given to the carers and community about the care package,
including monitoring o treatment progress. Additional services can be established on a
temporary basis, in displacement or reugee camps or aected areas, but care should be
taken to ensure adequate services are provided or both host and incoming populations,
and to ensure equity or all socioeconomic and age groups accessing services.
Attention is necessary to accommodate additional population movement caused by
insecurity or environmental hazards such as fooding, and to ensure there is no loss to
ollow-up. Active engagement o the community and the use o community-appointed
volunteers who know the context can be helpul.
16.3.3 Example or strengthening inpatient care
Either existing health and nutrition services can be reinorced or temporary service-
delivery sites may be established to meet need.
• Location and capacity
The inpatient care site should be in a ward or in a temporary structure in the compound o
a hospital. One site can serve up to 50 children. I there are more than 50–100 children,
a second site should be established. Each site should include a unit or intensive care
120
cases, to provide round-the-clock specialized care or initial treatment to stabilize children
with complications, and either an area or recovering cases or a strong system or reerral
to outpatient care.
•Equipment and supplies
The site should be well equipped and receive appropriate medical supplies and
therapeutic oods, based on the estimated number o inants and children with SAM.
Food should be made available or mothers or carers.
•Water supply and sanitation
A minimum o 30 L o water should be available per child per day. I less than 10 L o water
are available per child per day, the site will be unable to unction. A latrine and a bathing
area are required or every 20 persons. Hand-washing acilities or health workers and
carers are essential, to help reduce the risk o cross-inection.
•Cooking and storage facilities
A collective kitchen should be organized and a reliable supply o uel or cooking ensured.
Secure storage acilities are required or therapeutic ood and medical supplies.
•Staf
Each inpatient care site should have, as a minimum, one part-time doctor, three nurses
and ten aides, one nutritionist, one social worker and one psychologist. Mothers or carers
o the children may also provide some assistance.
16.4 Principles of management
The principles o management are the same as in a routine service setting. A qualied
health worker should evaluate each child and be trained to do emergency triage;
assessment and treatment; and diagnosis, including deciding whether treatment should
be in outpatient or inpatient care. Treatment should include routine drug and dietary
treatment with therapeutic oods that comply with WHO specications, and cover other
medical conditions that have been diagnosed, as outlined in previous sections. Reerral to
outpatient care, ater stabilization o SAM with medical complications, can be organized
in the outpatient department o the hospital and in decentralized health services.
16.5 Other considerations
Adapting admission or discharge criteria ater ull recovery may be considered at certain
times o an emergency response, depending on the availability o resources.
16.5.1 Community participation
Given the high number o cases that can arise in an emergency, emphasis on case-
nding and community mobilization can help nd children beore complications set in, and
acilitate management on an outpatient basis rather than an inpatient basis with limited
121
bed capacity. Additional support can be provided through home visits. Communities
should always be engaged in the discussing, planning, decision-making, implementation,
monitoring and evaluation o programmes and can be an important means o both alerting
about problem areas (disease outbreaks, high levels o acute malnutrition) and inorming
the community about changes in service delivery in response to the emergency.
16.5.2 Early childhood development activities
WHO now advocates combined psychosocial and nutritional programming in situations
o ood shortage, in order to address the physical, social, emotional and intellectual
developmental needs o the child and to enhance maternal well-being. During ood-
shortage emergencies, integrating simple early stimulation, learning and play activities
with nutritional support is crucially important, to increase and sustain the impact on a
young child’s health and nutritional status. The various points o emergency eeding
programmes can provide access to a large group o vulnerable children and carers.
Children’s needs should be addressed through the provision o child-riendly spaces and
early childhood development centres, which oten incorporate nutritional programmes.
Child participation is important, especially o those rom vulnerable groups, including
those who are HIV-positive or who have mental or physical disabilities. Key activities
are discussed in Chapter 9. Ideally, an emergency nutrition programme should include
an early childhood development specialist as part o the team, who is responsible or
helping train nutrition and psychosocial sta and volunteers in ECD activities.
16.5.3 Inant and young child nutrition
Impeded breasteeding practices or separation o an inant rom the mother or carer can
give rise to greater problems in the population o inants aged under 6 months. Provision
should be made to ensure adequate screening, support and management o this age
group, including establishing sae areas or inant and young child eeding support i
required. Provision o inant ormula might be required, while taking care that this does
not interere with inant eeding.
16.5.4 Expanding associated health activities
Additional attention to expanded measles immunization, distribution o micronutrients,
cholera kits and cooking kits, shelters kits and others kits, mosquito nets and hygiene
promotion might be required. In an outbreak o acute watery diarrhoea or cholera, it
is essential that clear instructions are given about where a child with both SAM and
acute watery diarrhoea should be treated, to ensure both that the child is adequately
hydrated and that there is no cross-inection with other immune-compromised children
being treated in the same acility.
122
ANNEXES
1. Anthropometric measurement techniques
2. Nutrition screening tally sheet using MUAC
3. Weight-or-height table - child
4. Weight-or-height table - adolescent
5. BMI chart or adults
6. Registration book or OTP and IPF
7. OTP chart
8. Transer orm
9. Variable/minimum RUTF in OTP
10. 5% Weight loss/gain chart
11. Weight gain over 14 days
12. IPF Multi-chart or patient and inant less than 6 months without carer
13. Critical care chart
14. How to insert nasogastric tube
15. Dangers o IV cannula
16. History and examination sheet
17. Supplementary suckling (SS) chart
18. RUTF specications
19. Drug dosages
20. SFP Registration book
21. SFP/OTP Ration card
22. Advantages and disadvantages o dry and wet eeding
23. Nutrient density used or supplementary ood or MAM
24. Laboratory test
Annex 1: Anthropometric measurement techniques
• Checking for bilateral oedema
Bilateral oedema is the sign o kwashiorkor. Kwashiorkor is always a severe orm o
malnourishment. Children with bilateral oedema are directly identied to be severely
acutely malnourished. These children are at high risk o mortality and need to be treated
in a therapeutic eeding programme urgently.
In order to determine the presence o oedema:
• Normal thumb pressure is applied to the both eet or at least three seconds.
• I a shallow print persists on the both eet, then the child has oedema.
Only children with bilateral oedema are recorded as having nutritional oedema.
123
You must ormally test or oedema with nger pressure, You cannot tell by just looking
• Taking MUAC
MUAC is used as an alternative measure o “thinness” to weight-or-height. It is particularly
used in children rom one to ve years: however, its use has been extended to include
children starting at 6 months o age.
• Ask the mother to remove clothing that may cover the child’s let arm.
• Calculate the midpoint o the child’s let upper arm. This can be done by taking a
piece o string (or the tape itsel), place one end on the tip o the child’s shoulder
(arrow 1) and the other on the elbow (arrow 2), now bend the string up in a loop to
double it so the point at the elbow is placed together with the point on the shoulder
with a loop hanging down – the end o the straightened loop indicates the mid-
point.
124
• As an alternative, place the tape at zero, which is indicated by two arrows, on
the tip o the shoulder (arrow 4) and pull the tape straight down past the tip o the
elbow (arrow 5). Read the number at the tip o the elbow to the nearest centimetre.
• Divide this number by two to estimate the midpoint. Mark the midpoint with a pen
on the arm (arrow 6).
• Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make
sure the numbers are right side up. Make sure the tape is fat around the skin
(arrow 7).
• Inspect the tension o the tape on the child’s arm. Make sure the tape has the
proper tension (arrow 7) and is not too tight so that the skin is compressed or too
loose so that the tape does not contact the skin all the way round the arm (arrows
8 and 9).
• Repeat any step as necessary.
• When the tape is in the correct position on the arm with correct tension, read and
call out the measurement to the nearest 0.1cm (arrow 10).
• Immediately record the measurement.
• Taking the weight
Children may be weighed by using a 25 kg hanging spring scale graduated to 0.1 kg or
an electronic balance (e.g. UNISCALE).
• Do not orget to re-adjust the scale to zero beore each weighing.
• A plastic washing-basin should be attached by 4 ropes that go underneath the
basin. The basin needs to be close to the ground in case the child alls out, and to
125
make the child eel secure during weighing.
• I the basin is dirtied then it should be cleaned with disinectant. This is much more
comortable and amiliar or the child, can be used or ill children and is easily
cleaned. Weighing pants that are used during surveys should not be used; they
are uncomortable, dicult to use, inappropriate or sick children and quickly get
soiled to pass an inection to the next patient.
• When the child is steady, read the measurement to the nearest 100 g, with the
rame o the scale at eye level. Each day, the scales must be checked by using a
known weight.
Mother and child scale 100 g precision and hanging spring scale for children
6months & more
Total
126
• Taking the length/height
©Shorr Productions
For children less than 87 cm, the measuring board is placed on the ground. The child is
placed lying along the middle o the board. The assistant holds the sides o the child’s
head and positions the head until it rmly touches the xed headboard with the hair
compressed. The measurer places her hands on the child’s legs, gently stretches the
child and then keeps one hand on the thighs to prevent fexion. While positioning the
child’s legs, the sliding oot-plate is pushed rmly against the bottom o the child’s eet.
To read the measure, the oot-plate must be perpendicular to the axis o the board and
vertical. The height is read to the nearest 0.1 cm
The longer lines indicate centimetre marking; the shorter lines indicate millimetre.
©WHO Growth standard training
For children more than 87 cm, the measuring board is xed upright on level ground.
The child stands upright in the middle, against the measuring board. The child’s head,
shoulders, buttocks, knees, heels are held against the board by the assistant, while the
measurer positions the head and the cursor. The height is read to the nearest 0.1 cm.
127
128
Annex 2. Nutrition screening tally sheet using MUAC
NUTRITION SCREENING TALLY SHEET using MUAC
DISTRICT................SECTOR………………………. CELL………………………............
Month...............
From ______/_____/ _______ to ______/______/______ Function Signature
_________________________________
Put a cross to the “o” within the dierent categories, according to the MUAC
MUAC <115mm MUAC≥ MUAC≥ 125mm Oedema
115&<125mm
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
ooooo ooooo ooooo ooooo ooooo ooooo ooooo
129
Annex 3. Weight-for-height table (WHO, 2006)
130
Note: These tables are derived from the WHO 2006 standards for boys. Because
using separate tables for boys and girls may lead to many more boys being admitted
to therapeutic programmes than girls, the use of the boys’ table for both sexes is
recommended to avoid discrimination against female children. It is recommended
that the discharge criteria should be -1.5 Z-score where there are adequate follow-up
arrangements and/or a supplementary feeding programme to which the children can
be reerred. © Michael Golden
131
Annex 4. Weight-for-height: adolescents
132
This table has been constructed using the NCHS standards. The height-for-age and
weight-for-age standards were amalgamated to determine the median weight for
height. The sexes were combined when the unisex standard is within 1.5% of the body
weight of the standard for either sex.
133
Annex 5 BMI Chart: Adult
BODY MASS INDEX (ADULTS) (=W/H 2 ) Wt in kg and height in metres.
134
Annex 6. Registration book for OTP and IPF Pages 1 and 2
135
136
12.26
Annex 7. OTP chart page 1 and 2
OTP Chart
ID N0 ………………………………………… Reg N0 of the facility……….............. Admission date……....…........…………
OTP name ….......……………………………………………..District.................................
Reason of Admission MUAC ........…mm W/H...........Z-score OR Œdema Yes No
Breast feeding Yes No Major Problem…………………......
Family Name…………………… Twins ................................................
Age (mo)………......... Sex ....… No
Address……………..………………………………… Caretaker: No
............................................................ Name……………………………….. Measles 1………………..
Phone # 2……………….
Health of caretaker…………….
Before beginning treatment (circle the answer) TYPE of ADMISSION
New admission
During the treatment Internal Transfer-IN
Relapse
if Yes, IPF / Other OTP / District hospital (circle the answer)
<2months
Date of IMAM admission…………………. Date of transfer……………….
Circle the answer Theme Date Signature
: Normal / Sick / Very sick
Handicap: Yes No If yes, ………………….. Diarrhoea, fever, ARI
: Normal / Fast skin, eyes, ear )
Eyes
Skin lesions
Oedema (0, +, ++, +++)…………… Hygiene
Home Visit (HV)
DATE REASON(S) DATE HV CONCLUSION
Internal Transfer-TO-IPF during treatment in OTP
DATE REASON(S) WHERE RESULT (RETURN-DATE/NOT RETURN/DEATH)
Discharge
Date of discharge ………/………./……..
Cured cause.........................................
Dead cause.........................................
Internal Transfer-TO cause..............................................................
Non Response ause…………………………………………………………………………
Follow up in SFC
137
Admission Length / Height.............cm Target Weight ..............kg.g Target MUAC.............mm
Date Adm 2 3 4 5 6 7 8 9 10 11 12
Date (dd/mo)
Weight (kg.g)
Oedema (0,+,++,+++)
MUAC (mm)
Diarrhoea (0
to #d)
Vomiting
(0 to #d)
Fever
(0 to # d)
Cough
(0 to #d)
Pale Conj
(0 to ++)
Respir.rate /min
Temp. C˚
(Axi/Rect )
Malaria test result (0
/-/+)
App.test
(Good/Mod/Poor)
Appetite test
(g/ sachet/ bar)
Trt carer choice
(IPF/OTP)
RUTF (# sachets
given back)
RUTF (# sachets to
caretaker)
Transfer TO /
Absent/Refused
transfer
Need HomeVisit
(Y / N)
Routine Medicine
Drugs Date (dd/mm) Dose Drugs Date (dd/mm) Dose
Amoxycillin Deworming
Vitamin A Measles vaccine
Antimalaria drugs Other
Specific treatment
Date (dd/mm) Observation Treatment
138
Annex 8. Transfer form
139
Annex 9: Variable RUTF in OTP
RUTF Paste - grams per week RUTF Sachets (96g)
Absolute CRITICAL Absolute
CRITICAL stock Intermediate STANDARD Intermediate STANDARD
week of Minimum stock Minimum
shortage (week two) (week two)
treatment (week one) shortage (week one)
Class of 135 170 100 170
100 kcal/kg/d 150 kcal/kg/d 135 kcal/kg/d 150 kcal/kg/d
weight (kg) kcal/kg/d kcal/kg/d kcal/kg/d kcal/kg/d
3.0 - 3.4 440 600 660 750 5 6 7 8
3.5 - 4.9 530 720 800 900 6 8 9 10
5.0 – 6.9 830 1100 1250 1400 9 12 13 15
7.0 – 9.9 1060 1430 1600 1800 12 15 17 20
NOTE: This table can be used if there is a limited supply of RUTF due to a pipeline break (not planned), or if the children have
rates and this needs to be explained to the caretaker and her family.
140
Annex 10. 5% weight loss and weight gain table
How to diagnose 5% W loss in failure in OTP
5% weight loss (for failure-to-respond in OTP) 5% weight gain (for treatment of dehydration)
Ist week loss 2nd week Ist week loss 2nd week initial gain final initial gain final
4,0 0,2 3,8 8,0 0,4 7,6 4,0 0,2 4,2 8,0 0,4 8,4
4,1 0,2 3,9 8,1 0,4 7,7 4,1 0,2 4,3 8,1 0,4 8,5
4,2 0,2 4,0 8,2 0,4 7,8 4,2 0,2 4,4 8,2 0,4 8,6
4,3 0,2 4,1 8,3 0,4 7,9 4,3 0,2 4,5 8,3 0,4 8,7
4,4 0,2 4,2 8,4 0,4 8,0 4,4 0,2 4,6 8,4 0,4 8,8
4,5 0,2 4,3 8,5 0,4 8,1 4,5 0,2 4,7 8,5 0,4 8,9
4,6 0,2 4,4 8,6 0,4 8,2 4,6 0,2 4,8 8,6 0,4 9,0
4,7 0,2 4,5 8,7 0,4 8,3 4,7 0,2 4,9 8,7 0,4 9,1
4,8 0,2 4,6 8,8 0,4 8,4 4,8 0,2 5,0 8,8 0,4 9,2
4,9 0,2 4,7 8,9 0,4 8,5 4,9 0,2 5,1 8,9 0,4 9,3
5,0 0,3 4,8 9,0 0,5 8,6 5,0 0,3 5,3 9,0 0,5 9,5
5,1 0,3 4,8 9,1 0,5 8,6 5,1 0,3 5,4 9,1 0,5 9,6
5,2 0,3 4,9 9,2 0,5 8,7 5,2 0,3 5,5 9,2 0,5 9,7
5,3 0,3 5,0 9,3 0,5 8,8 5,3 0,3 5,6 9,3 0,5 9,8
5,4 0,3 5,1 9,4 0,5 8,9 5,4 0,3 5,7 9,4 0,5 9,9
5,5 0,3 5,2 9,5 0,5 9,0 5,5 0,3 5,8 9,5 0,5 10,0
5,6 0,3 5,3 9,6 0,5 9,1 5,6 0,3 5,9 9,6 0,5 10,1
5,7 0,3 5,4 9,7 0,5 9,2 5,7 0,3 6,0 9,7 0,5 10,2
5,8 0,3 5,5 9,8 0,5 9,3 5,8 0,3 6,1 9,8 0,5 10,3
5,9 0,3 5,6 9,9 0,5 9,4 5,9 0,3 6,2 9,9 0,5 10,4
6,0 0,3 5,7 10,0 0,5 9,5 6,0 0,3 6,3 10,0 0,5 10,5
6,1 0,3 5,8 10,1 0,5 9,6 6,1 0,3 6,4 10,1 0,5 10,6
6,2 0,3 5,9 10,2 0,5 9,7 6,2 0,3 6,5 10,2 0,5 10,7
6,3 0,3 6,0 10,3 0,5 9,8 6,3 0,3 6,6 10,3 0,5 10,8
6,4 0,3 6,1 10,4 0,5 9,9 6,4 0,3 6,7 10,4 0,5 10,9
6,5 0,3 6,2 10,5 0,5 10,0 6,5 0,3 6,8 10,5 0,5 11,0
6,6 0,3 6,3 10,6 0,5 10,1 6,6 0,3 6,9 10,6 0,5 11,1
6,7 0,3 6,4 10,7 0,5 10,2 6,7 0,3 7,0 10,7 0,5 11,2
6,8 0,3 6,5 10,8 0,5 10,3 6,8 0,3 7,1 10,8 0,5 11,3
6,9 0,3 6,6 10,9 0,5 10,4 6,9 0,3 7,2 10,9 0,5 11,4
7,0 0,3 6,6 11,0 0,5 10,5 7,0 0,3 7,3 11,0 0,5 11,6
7,1 0,4 6,7 11,1 0,6 10,5 7,1 0,4 7,5 11,1 0,6 11,7
7,2 0,4 6,8 11,2 0,6 10,6 7,2 0,4 7,6 11,2 0,6 11,8
7,3 0,4 6,9 11,3 0,6 10,7 7,3 0,4 7,7 11,3 0,6 11,9
7,4 0,4 7,0 11,4 0,6 10,8 7,4 0,4 7,8 11,4 0,6 12,0
7,5 0,4 7,1 11,5 0,6 10,9 7,5 0,4 7,9 11,5 0,6 12,1
7,6 0,4 7,2 11,6 0,6 11,0 7,6 0,4 8,0 11,6 0,6 12,2
7,7 0,4 7,3 11,7 0,6 11,1 7,7 0,4 8,1 11,7 0,6 12,3
7,8 0,4 7,4 11,8 0,6 11,2 7,8 0,4 8,2 11,8 0,6 12,4
7,9 0,4 7,5 11,9 0,6 11,3 7,9 0,4 8,3 11,9 0,6 12,5
8,0 0,4 7,6 12,0 0,6 11,4 8,0 0,4 8,4 12,0 0,6 12,6
141
Annex 11: Weight gain (g/kg per day) after 14 days interval
Gain of Weight (gr/kg/day) for a length of stay of 14 days To be start at Day 14 of the OTP visit
Gain of weight (g/kg/day) over 14 days Gain of weight (g/kg/day) over 14 days
2,5 5 10 15 2,5 5 10 15
4,0 4,1 4,3 4,6 4,8 7,0 7,2 7,5 8,0 8,5
4,1 4,2 4,4 4,7 5,0 7,1 7,3 7,6 8,1 8,6
4,2 4,3 4,5 4,8 5,1 7,2 7,5 7,7 8,2 8,7
4,3 4,5 4,6 4,9 5,2 7,3 7,6 7,8 8,3 8,8
4,4 4,6 4,7 5,0 5,3 7,4 7,7 7,9 8,4 9,0
4,5 4,7 4,8 5,1 5,4 7,5 7,8 8,0 8,6 9,1
4,6 4,8 4,9 5,2 5,6 7,6 7,9 8,1 8,7 9,2
4,7 4,9 5,0 5,4 5,7 7,7 8,0 8,2 8,8 9,3
4,8 5,0 5,1 5,5 5,8 7,8 8,1 8,3 8,9 9,4
4,9 5,1 5,2 5,6 5,9 7,9 8,2 8,5 9,0 9,6
5,0 5,2 5,4 5,7 6,1 8,0 8,3 8,6 9,1 9,7
Weight 14 days before
Weight 14 days before
5,1 5,3 5,5 5,8 6,2 8,1 8,4 8,7 9,2 9,8
5,2 5,4 5,6 5,9 6,3 8,2 8,5 8,8 9,3 9,9
5,3 5,5 5,7 6,0 6,4 8,3 8,6 8,9 9,5 10,0
5,4 5,6 5,8 6,2 6,5 8,4 8,7 9,0 9,6 10,2
5,5 5,7 5,9 6,3 6,7 8,5 8,8 9,1 9,7 10,3
5,6 5,8 6,0 6,4 6,8 8,6 8,9 9,2 9,8 10,4
5,7 5,9 6,1 6,5 6,9 8,7 9,0 9,3 9,9 10,5
5,8 6,0 6,2 6,6 7,0 8,8 9,1 9,4 10,0 10,6
5,9 6,1 6,3 6,7 7,1 8,9 9,2 9,5 10,1 10,8
6,0 6,2 6,4 6,8 7,3 9,0 9,3 9,6 10,3 10,9
6,1 6,3 6,5 7,0 7,4 9,1 9,4 9,7 10,4 11,0
6,2 6,4 6,6 7,1 7,5 9,2 9,5 9,8 10,5 11,1
6,3 6,5 6,7 7,2 7,6 9,3 9,6 10,0 10,6 11,3
6,4 6,6 6,8 7,3 7,7 9,4 9,7 10,1 10,7 11,4
6,5 6,7 7,0 7,4 7,9 9,5 9,8 10,2 10,8 11,5
6,6 6,8 7,1 7,5 8,0 9,6 9,9 10,3 10,9 11,6
6,7 6,9 7,2 7,6 8,1 9,7 10,0 10,4 11,1 11,7
6,8 7,0 7,3 7,8 8,2 9,8 10,1 10,5 11,2 11,9
6,9 7,1 7,4 7,9 8,3 9,9 10,2 10,6 11,3 12,0
7,0 7,2 7,5 8,0 8,5 10,0 10,4 10,7 11,4 12,1
142
D Patient N0..................................................................... IPF Multi-Chart Date of Admission___/___/___ Date of Discharge___/___/___
Register N0………………………………………………… Major Problem Hr………………. Successfully Treated
heet No………………………….…………………………IPF Name……………............. New D
atient's name………………………………………… IPF 24h/Day Care /Ped. Ward R Inter. T
amily Name……………………………………………… Age.......................mo / yr Readm A If Yes, OTP……...….....
Address………………………………………………………Birth Date _____/_____/______ (dd/mm/yy) Inter. T Medical Referral
hone........................................................................... Sex……………………………. Breastfeeding Y / N If Yes, OTP………..... D
Referral : S C HC/H Complementary food………………………..…OTP Name …………………………..............
Reason admission 1) Fail Appetite test: Y / N - if Y PPN ........gr - 2) If Complication Y / N if Y ....................... - 3) Œdema Y /N - 4) Non-Response in OTP Y / N
1 2 3 4 5 6 7 8 9 10 11 12 14 15
Date 13
Height/Lenght (cm)
Weight (Kg)
Wt for Ht (Z / %)
age without any carer
MUAC (mm)
Anthropometry
Œdema (0 to +++)
arget weight
...........kg......g
Target Muac
.................mm
Weight Chart
Annex 12. IPF charts for patient and infant less than 6 months of
143
144
145
146
Card Immunisation Date
At Birth 12 3 4
BCG
POLIO
DPT
Extra Extra
Measles
DISCHARGE
HEALTH EDUCATION GIVEN DATESS IG.
Causes of malnutrition
Diarrhoea, ARI, Fever
Sexual transmitted diseases
Pay and stimulation
Nutrition for children
Care of the children
Hygiene
Breastfeeding
Family Planning
Other …………………..
Updated Immunisation YN
Breastfeeding at discharge YN
Version 2011/1.0 ©Golden & Grellety
CRITICAL CARE CHART
ent's Name Reg. No Sheet No Diagnosis:
: ID-No Oedema: 0 + ++ +++ Check the vital signs that are to be monitored in the "check" column and write in
/ emergency ward/ casulty/ paediatr ward/ other the times in the time row (only check those that are needed)
e: Nurse in charge Dr in Charge - attach graph for graphing critical signs if necessary
ck the patient every .....….min/hour Time started....................AM /PM
HOUR check Initial Eval.
amination
el of Consiousness
ght - Kg.g
pillary refill (nail bed) - secs
d extremeties Yes No
piration rate - per min
se - per min
er (cm below costal margin)
Annex 13. Critical care chart
ol (liquid/semi/solid) number
mit - number
sed urine Yes No
mperature ( axilla / rectal )
lids retract/sleep eyes open
r
r
atment given
SoMal................ ml
use another sheet if necessary
luid..................... ml
od/pack cells…......... ml
/sugar water............... ml
lucose 10%.................... ml
gen
cloths
garoo - rewarming
rug
rug
rug
147
Annex 14. How to insert a nasogastric tube
• Choose the appropriate size tube (range is 6, 8 or 10 FG). Lie inant on her back,
swaddled in a small blanket as a mild restraint.
• Measure the tube rom the child’s ear to the tip o the nose and then to just below
the tip o the sternum (or pre-term and neonates rom the bridge o the nose to just
beyond the tip o the sternum). Hold or mark this position so that you know how ar
to insert the tube.
• Lubricate the catheter with a jelly-type lubricant, vaseline or at least water and
insert through the nose, bending the tube slightly upwards to ollow the nasal
passage.
• Bend the head slightly backwards to extend the neck. Insert the catheter smoothly
and quickly at rst pushing upwards (not just backwards) so that the catheter
bends in one loop downwards along the back o the throat. Do not push against
resistance (i you cannot pass the tube through the nose, pass it through the mouth
instead). Take care that the tube does not enter the airway. I the child coughs,
ghts or becomes cyanotic, remove the tube immediately and allow the patient to
rest beore trying again. It is vital to check that the tube is in the stomach beore
anything is put down the tube. This should be re-checked beore each eed is
given in case the tube has been dislodged rom the stomach. Note that sick,
apathetic children and those with decreased consciousness can have the tube
passed directly into their lungs without coughing. It is not a guarantee that the tube
is in the right place just because it has passed smoothly without complaint rom
the child.
• - The best way to test that the tube is ully in the stomach is to aspirate
some o the stomach contents and test or acid with litmus paper. The stomach
contents in normal children are acid and turn blue litmus paper red. However, the
malnourished requently have “achlorhydria” (lack o gastric acid). In the absence
o litmus paper and in the malnourished child, check that there is the characteristic
appearance and smell o stomach contents (“sour” or like vomit).
• - Also check the position by injecting 0.5 – 1 ml o air into the tube whilst
listening to over the stomach with a stethoscope. A “gurgling” or bubbling sound
can be heard as air enters the stomach.
• - It is always best to ask someone else to check i you are not sure the tube is
in the right place, to avoid the risk o milk going onto the lungs. Beore each eed,
aspirate the tube to check that the previous eed has let the stomach; this may be
slow and gentle in very sick children as strong suction can damage the stomach
lining. It is important not to cause gastric distension by giving a new eed on top o
an old one. The fow o the eed should be slow.
• Attach the reservoir (10 or 20 ml syringe) and elevate it 15 – 20 cm above the
patient’s head. The diet should always be allowed to fow into the stomach by
gravity and not pushed in with the plunger. When the eed is complete, irrigate the
nasogastric tube with a ew ml o plain water and stopper the tube (or clamp it).
Place the child on her side to minimise regurgitation and aspiration. Observe the
child ater eeding or vomiting, regurgitation or abdominal distension.
• In an IPF the tube should be changed every 3-5 days.
148
Annex 15. The disadvantages of indwelling cannulae
• They give access to the circulation or antibiotic-resistant bacteria in these immuno-
compromised patients
• The dressings quickly become dirty in conventional hospital settings.
• They oten become colonised with Candida and can give rise to ungal septicaemia.
• They require fuid or anticoagulants to keep the vein open – but these children
have impaired liver unction (bleeding tendency) and are very sensitive to fuid
overload.
• They require skilled health persons to insert, re-site and maintain the cannula: sta
time is the limiting actor in most resource-poor settings.
• The administration o IV drugs takes more time, rom higher grades o sta, than
giving oral drugs.
• IV preparations are much more expensive than oral preparations and the cannula
itsel is expensive.
• Insertion o the cannula is painul and distressing or the child and they requently
need to be re-inserted.
• The cannula restricts the movements o the child and impairs eeding, washing,
play and care.
• Extravasations into the tissue can cause skin necrosis and other complications.
Example o fuid extravasation with scalp necrosis and resiting o cannula several times
149
Annex 16. History and examination sheet
History sheet for severe complicated malnutrition/Failure to respond - page 1
ID N0............... Reg N0…………..Parent’s name:....................... First name:..................... Age.........d/m/y Sex
.......
Date of examination: ...../....../...... Examiner’s name....................................... Status ....................
Who is giving the history? patient/mother/ father/ sister/ grandmother/ aunt/ other ........................
Is this person the main caretaker for the patient at home? yes/ no If not, who is the caretaker?.............................
History of present illness
How long has the patient been ill? ............h/ d/ wk/ mo/ yr
What are the complaints - in the patient’s own words - and how long has each been present?
.h/ d/ wk/ mo/ yr
1.............................................................................................................. ...........
.h/ d/ wk/ mo/ yr
2.............................................................................................................. ...........
.h/ d/ wk/ mo/ yr
3.............................................................................................................. ...........
.h/ d/ wk/ mo/ yr
4.............................................................................................................. ...........
Describe the details of the complaints, how they have progressed, and the factors a ssociated with each one
............................................................................................................................. .........................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
......................................................................................................
Systematic questions (give additional details of abnormal findings above)
Appetite hungry/ normal/ poor/ very poor Weight is decreasing/ steady/ increasing ..........d/ wk/ mo
Swelling: none/ feet/ legs/ face/ all over..........d/ wk/ mo Eyes sunken no/ recent/ longstanding
Diarrhoea N Y ..........h/d/wk/mo stools per day ....... Normal/ watery/ soft/ blood/ mucus/ green/ pale
Vomiting N Y .. .......h/d/wk/mo. No per day............ Repeated episodes of Diarrhoea N Y
Breathing: normal/ fast/ noisy/ difficult for .......h/d/wk Cough: N Y - for.......d/wk/mo
Fever N Y Convulsions N Y Unconsciousness N Y
Treatment: Patient has already seen Dr/ Clinic/ Hospital/ Traditional healer ............times for this illness.
Treatment given ............................................................................................................................. .............
Past and social history
Past diseases: describe...............................................................................................................
Mother / father absent N Y reason........................ .....wk/mo/yr Patient: twin/ fostered/ adopted/ orphan
Gestation: early/ normal or........ wk/ mo Birth weight: large/ normal/ small or .........Kg
Mother’s age .......yr no live births ............ no Living children ..............
Family eating together: no adults.......... n o children..........
Resources (food income crops livestock)..........................................................................................................
Diet history
breast feed alone for .......wk/ mo age stopped breast feeding..........wk/mo
Food before ill breast/ milk/ porridge/ family plate/ fruit/ leaves/ drinks/ other
Food since ill breast/ milk/ porridge/ family plate/ fruit/ leaves/ drinks/ other
L t 24h d ib
150
Examination sheet for severe complicated malnutrition/Failure to respond - page 2 - Examination
SAM Nϒ............... Parent’s name....................... First name..................... Age.........d/m/y Sex..........
General: does the patient look: not-ill/ ill/ very ill/ comatose
Mood and behaviour normal/apathetic/ inactive/ irritable/repeated movements
Development / regression Patient can: sit/ crawl/ stand/ walk
Ear Nose & Throat
Eyes normal/ conjunctivitis/ xerosis/ keratomalacia mild/ mod/ severe
Mouth normal/sore/red/smooth tongue/candida/herpes/angular stomatitis
Membrane Colour: normal/pale/jaundiced/cyanosed Gums normal/ bleeding
Ears normal/ discharging Teeth number __/__ normal/ caries/ plaque
Respiratory system & Chest
Breathing normal/ noisy/ asymmetrical/ laboured/ wheeze/in drawing
Rate ......./min or more /less than 50/60 Chest normal/ asymmetric/ pigeon/ sulcus
Cardiovascular system & Hydration
Oedema none/+/++/+++/uncertain feet/ pretibial/ hands/ face/ generalised
Hydration normal/ dehydrated/ shock/ uncertain Passing urine N / Y
Eyes normal/ sunken/staring Peripheries normal/ warm/ cold
Capillary refill quick/ slow/ very slow ........secs Visible veins full/ normal/ empty
Pulse rate...../min normal/ strong/ weak Heart sounds normal/ gallop/ murmur
Gastro-Intestinal
Stool not seen/ normal/ soft/ watery/ green/ pale/ mucus/ blood
Abdomen: normal/ distended/tender/ visible peristalsis /ascites
Bowel sounds: normal/ active/ quiet/ absent Splash N / Y
Liver .......cm below costal margin normal/ firm/hard/smooth/irregular
Spleen not felt/ felt/ large - normal/ firm/ hard - tender/ painless
Nervous system
Tone normal/ stiff/ floppy
Meninges normal /stiff neck /Brudzinski /fontanelle bulging
Reflexes normal/ symmetrical/ asymmetrical/increased/ decreased/ absent
Skin Hair Bone Lymph Nodes
Skin change none/mild/mod/severe peeling/ raw / ulcers infection/ cuts/ bruises
Perineum normal/rash/raw /candida Purpura N / Y
Hair black/ brown/ red/ blond normal/easily plucked/ balding
Scabies none/ local/generalised Eyelash normal/ long
Lymph nodes none/ groin/ axilla/ neck Tender/ painless Soft/ firm/ hard/ fixed
Ribs’ ends normal/ swollen/ displaced Gynecomastia N / Y
Describe abnormalities below and draw on diagram
...........................................................................................................................…………......
……………………………………………......................................................................……….
.................................................................................................................................…
……………………………………………........................................................................
.................................................................................................................................................
.................................................................................................................................................
Di a g n o s e s 1 : 2: 3:
151
Annex 17. SS chart with SS feeding for infants less than 6 months or 3kg
152
Annex 18. RUTF specications
Ready-to-use therapeutic food (RUTF)
Severely malnourished patients have specic nutrient requirements that dier rom those
o normal children. These are best supplied using specialised therapeutic oods, such as
F75, F100 and RUTF. Ready-to-use therapeutic ood (RUTF) is an essential component o
OTP as it allows patients to be treated at home. RUTF is a complete ood or the severely
malnourished, with a specic nutrient composition equivalent to F100.
There are currently several commercial types o RUTF: lipid-based pastes and bars.
Several countries produce their own RUTF using the standard recipe: these products are
nutritionally equivalent to F100, and have been shown to be physiologically similar to both
F100 and the commercial RUTFs. An important dierence between F100 and RUTF is
that RUTF contains iron (in the correct amount or the recovering severely malnourished
patient) whereas F100 used in the recovery phase requires iron supplementation.
RUTF paste is a ready-to-eat spread usually presented in individual sachets or pots.
It is composed o vegetable at, peanut butter, skimmed milk powder, lactoserum,
maltodextrin, sugar and a mineral and vitamin complex.
Instructions for use: Clean drinking water must be made available to children during
consumption o RUTF. The product should only be given to children who can express
their thirst. It is contra-indicated or children who are allergic to cow’s milk, proteins or
peanuts and those with asthma or other allergic disease.
Recommendations for use: It is recommended that the product is used in phase 2 in the
dietetic management o severe acute malnutrition. In IPFs or phase 1, use milk-based
diet F75.
Storage of RUTF: Some commercial RUTFs (such as Plumpy’nut®) have a shel lie o
24 months rom manuacturing date. Locally produced RUTFs that are not packed under
nitrogen in a sealed container have a shel lie o 3–6 months. Store in a cool dry place.
153
Mean nutritional value o RUTFs (based upon plumpy’nut®)
NUTRIENT PER 100 G PER 92 G NUTRIENT PER 100 G PER 92 G
SACHET SACHET
Energy 545 kcal 500 kcal Vitamin A 910 μg 840 μg
Protein 13.6 g 12.5 g Vitamin D 16 μg 15 μg
Lipid 35.7 g 32.86 g Vitamin E 20 mg 18.4 mg
Calcium 300 mg 276 mg Vitamin C 53 mg 49 mg
Phosphorus 300 mg 276 mg Vitamin B1 0.6 mg 0.55 mg
Potassium 1,111 mg 1,022 mg Vitamin B2 1.8 mg 1.66 mg
Magnesium 92 mg 84.6 mg Vitamin B6 0.6 mg 0.55 mg
Zinc 14 mg 12.9 mg Vitamin B12 1.8 μg 1.7 μg
Copper 1.8 mg 1.6 mg Vitamin K 21 μg 19.3 μg
Iron 11.5 mg 10.6 mg Biotin 65 μg 60 μg
Iodine 100 mcg 92 μg Folic acid 210 μg 193 μg
Selenium 30 mcg 27.6 μg Pantothenic 3.1 mg 2.85 mg
acid
Sodium < 290 mg < 267 mg Niacin 5.3 mg 4.88 mg
RUTF bars (based upon BP-100®)
RUTF bars are a compressed ood product or use in the rehabilitation phase (Phase 2)
o severely malnourished children and adults. The nutritional specications are similar to
therapeutic milk F100. As with the paste the RUTF bars also contain iron.
Who to give RUTF bars to: Children rom 12 months old, adolescents and adults who are
severely malnourished in the rehabilitation phase (Phase 2) o the treatment. RUTF-bars
should never be used or patients below 6 months old.
How to use RUTF bars: they can be eaten as a biscuit directly rom the pack together
with sucient drinking water (250–300ml per bar), or crumbled into water and eaten as
porridge. For children 12–24 months o age, the bars should always be given as porridge
due to their problems demanding water when thirsty.
Storage of RUTF bars: BP100® has a shel lie o 2 years in an unopened package. Ater
breaking the aluminium oil bag the product should be used within 1–2 weeks depending
on the storage conditions. Porridge made o BP100 and water should be used within 3
hours.
Packaging: BP100 is compressed into tablets o 28.4 g. Each package o BP100 (510
g net) contains 18 tablets packed into 9 bars in greaseproo paper (1 bar = 2 tablets =
300 Kcal).
Local production of RUTF
The minimum required ingredients or RUTF are as ollows:
Four basic ingredients: sugar; dried skimmed milk; oil; and a vitamin and mineral
supplement. In addition, up to 25% o the weight o the product can come rom vegetable
sources such as oil-seeds, groundnuts or cereals such as oats provided that the nutrient
154
density is the same as that ound in F100.
In addition to good nutritional quality (protein, energy and micronutrients), RUTF should
have the ollowing attributes:
o taste and texture suitable or young children
o does not need additional processing (such as cooking) beore consumption
o resistant to contamination by microorganisms and a long shel lie without
sophisticated packaging
o ingredients are low-cost and readily available in developing countries.
HO/UNICEF/World Food Programme/UN Standing Committee on Nutrition produced drat
specications or RUTF (Community-based management o severe acute malnutrition, A
Joint Statement by the World Health Organization, the World Food Programme, the United
Nations System Standing Committee on Nutrition and the United Nations Children’s Fund,
2007). They are as ollows:
High-energy ortied ready-to-eat ood suitable or the treatment o severely malnourished
children. This ood should be sot or crushable, palatable and should be easy or young
children to eat without any preparation. At least hal o the protein contained in the product
should come rom milk products.
155
Nutritional composition:
Reerence document or F100 composition: Management o severe malnutrition - a
manual or physicians and other senior health workers. WHO Geneva, 1999. Available at:
http://www.who.int/nutrition/publications/en/manage_severe_malnutrition_eng.pdf
Note: iron is added to RUTF whereas F11 does not have added iron
Saety: The ood shall be ree rom objectionable matter; it shall not contain any substance
originating rom micro-organism or any other poisonous or deleterious substances such
as anti-nutritional actors, heavy metals or pesticides in amounts that may represent a
hazard to health o severely malnourished patients.
- Afatoxin level: 5 ppb maximum.
- Micro-organism content: 10,000/g maximum
- Coliorm test: negative in 1 g
- Clostridium perringens: negative in 1 g
- Yeast: maximum 10 in 1 g
- Moulds: maximum 50 in 1g
- Pathogenic staphylococci: negative in 1 g
- Salmonella: negative in 125g
- Listeria: negative in 25g
The product should comply with the International Code o Hygienic Practice or Foods
or Inants and Children o the Codex Alimentarius Standard CAC/RCP 21-1979. All
added mineral and vitamins should be on the Advisory List o Mineral Salts and Vitamin
compounds or Use in Foods or Inants and Children o the Codex Alimentarius Standard
CAC/GL 10-1979.
The added mineral salts should be water-soluble and readily absorbed - they should not
orm insoluble components when mixed together. This mineral mix should have a positive
non-metabolizable base sucient to eliminate the risk o metabolic acidosis or alkalosis.
Inormation on how to produce RUTF is available at: http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/CBSM/tbp_4.pd
Annex 19. Drug doses in the severely malnourished
ANTIBACTERIALS
o Amoxicillin PO: 50-100 mg/kg/day divided in 2 doses
o Ampicillin IV/ IM: 100 mg/kg/day in divided in 3-4 doses
Note: Give by perusion over at least 30 mins, reduce dose with renal impairment. DO
NOT give alongside gentamicin (separate IV by at least one hour) or give gentamicin IM
as it inactivates the gentamicin.
o Gentamicin IV: 5 mg/kg/day in 1 dose
o Ceotaxime IV: 100 mg/kg/day divided in 3 doses
156
Note: Do not give in same inusion as gentamicin - separate by at least one hour;
ceotaxime can inactivate the gentamicin.
o Cetriaxone IV: 50-100 mg/kg/day in 1 or 2 doses
o Ciprofoxacin PO/IV: 20-30 mg/kg/day divided in 2 doses
o Cloxacillin PO: 50-100mg/kg/day divided in 3 doses
IV: 100-200mg/kg/day divided in 3-4 doses
o Metronidazole PO: 10mg/kg/day in 1 or 2 doses
Note: WHO recommends reduction o standard dose (30 mg/kg/d) to 1/3 with hepatic
impairment - in SAM the maximum dose is 10-12 mg/kg/d by pharmacodynamics studies.
Do not give or more than 7 days.
o Amoxicillin + Clavulanic acid (Augmentin) PO/IV: 25-75/kg/day divide in 2-3 doses
ANTIFUNGALS
o Nystatin PO: 100,000 IU/dose 4 times a day
o Fluconazole PO/IV: 3-6 mg/kg/day in 1 dose
Note: IV preparation give by SLOW inusion over at least one hour. A double dose can be
given on the rst day o treatment. Avoid giving it with lumeantrine-artemether.
Young inants: give same dose but on alternate days.
Miconidazole cream or ointment: application 2 times a day
ANTI-MALARIALS
Artemether + Lumefantrine (Coartem) Oral Malaria treatment
ADMINISTER INITIALLY 8H 24H 48HR TOTAL 1. Dispersible tablets 20
TABLETS
mg/120 mg per tablet
3 – 5 kg 1/2 tab 1/2 tab 1/2 tab x 2 1/2 tab 3 2. 6-dose regimen = initial
x2 dose ollowed at 8, 24, 36,
5 – 10 kg 1 tab 1 tab 1 tab x 2 1 tab x 2 6 48 and 60 hrs by urther
10 – 20 kg 2 tab 2 tab 2 tab x 2 2 tab x 2 12 doses.
20 – 35 kg 3 tab 3 tab 3 tab x 2 3 tab x 2 18 3. Avoid giving with ciprofox-
acin, fuconazole, erythro-
mycin.
4. Tablets can be crushed.
5. I dose is vomited within 1
hour repeat the dose
6. I coartem not available,
use artemether-amodia-
quine tablets at the same
dose (not recommended
because o hepatotoxicity).
157
o Artesunate IV/IM: 2.4 mg/kg/dose at 0, 12, 24 hr and then daily until oral treatment
can be given.
Note: Always ollow with a ull 6-dose course o lumeantrine-artéméther
SCABICIDE
o Permethrin cream 5% or permethrin lotion 1%: Apply over whole body, wash o
ater 12 hours.
HEART FAILURE
o Furosemide PO/IV/IM: 0.5-1 mg/kg/dose 2-3 times per day.
Drugs that should be avoided in severe acute malnutrition inpatients (serious danger
of exacerbating hepatic, renal or cerebral function.) See WHO Model formulary for
children 2010.
o Anti-histamines (serious depression o level o consciousness)
o Anti vomiting drugs (serious depression o level o consciousness and extra-pyramidal
eects – WHO ormulary states: “Antiemetic medications should only be used when the
cause o the vomiting is known. Anti-emetics are unnecessary and sometimes harmul”)
o Anti-diarrhoeal preparations (e.g. bismuth, kaolin, lomotil)
o Paracetamol (do not use in acute phase – hepatic damage)
o Amphoteracin B (do not use in acute phase – nephrotoxic to some extent in ALL
patients, also commonly causes hypokalaemia, hypomagnesaemia, diarrhoea, anaemia,
severe anorexia and, uncommonly, anaphylaxis).
o Potassium permanganate (potent pro-oxidant, causes skin burns).
o Fat-soluble drugs. DOSES o all FAT soluble drugs must be reduced in all cases o
marasmus. Body at is severely reduced, as the majority o lipid is in the BRAIN in these
children standard doses can cause severe cerebral depression including respiratory
arrest – thus, doses o barbiturates, diazepam, metaclopramide etc. should be used with
caution and should be halved in SAM.
158
ID No of the Address
Reg No. patient Type of admission Admission
al (New Adm, Relapse, Sex DOB Age
of the First Name Last name
(Specify if SAM Transfer in from SFC, F/M ddmmyy mo SAM MAM
facility Read<2mo) Height/ Discharge Discharge Ration
cure follow up )
Date Weight W/H Reference Reference MUAC
Village Cell Sector District Length Target Weight Target MUAC Name
ddmmyy kg.g Z Weight Weight mm
cm kg.g mm total kg.g
kg.g / <-3Z kg.g / <-2Z
159
160
Others
Vitamin A Albendazole Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit 9 Discharge
Observatio
Ration Ration Ration Type of discharge
Date Date Date Date Wt MUAC Ration Date Wt MUAC Ration Date Wt MUAC Date Wt MUAC Date Wt MUAC Ration Date Wt MUAC Ration Date Wt MUAC Ration Date Wt MUAC Ration Date Wt MUAC (Cure, Dead, Defaulter, Non
Dosage Dosage Dosage Name Name Name Name Name Name Name Name W/HZ Name
ddmmyy ddmmyy ddmmyy ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm ddmmyy kg.g mm Respond, Referal to hosp/OTP,
total kg.g total kg.g total kg.g total kg.g total kg.g total kg.g total kg.g total kg.g total kg.g Transfer to other SFC)
Annex 20. Registration book for SFP
Admission date (ddmmyy) Target Weight(W)_________MAM W__________ SAM W_______Target MUAC________ Disch. date (ddmmyy)
SFC Name Visit Date mmmdd Weight kg.g MUAC cm
Adm
2 Cured
Refer from 3
4 Defaulter
First Name 5 cause ___________________
Last Name 6 Circle the right answer
Address 7 Transfer ToO TP IPF Other
8 cause _____________________
SFC Reg No 9
10 Non Respond
11 cause _____________________
DoB ddmmyy
Age (mo) Dead
SexM / F cause ____________________
Date Dosage Remarks
Vit A
Annex 23. Nutrient density of RUSP
Alb/Meb
Other
161
Annex 22. Advantages and disadvantages of dry and wet feeding
• WET FEEDING
Advantages
• Useul when rewood and cooking utensils are so dicult to nd that the household
has diculties in preparing meals.
• The security situation is so bad that the beneciaries are put at risk when carrying
supplies o ood home or storing ood at home.
• It is easier to ensure that the beneciary receives the ood s/he requires (less
sharing o the ood).
• It is easier to ensure that the ration is prepared correctly and that the hygiene is
good.
• It is possible to use the mothers’ time in the centre to do nutrition and hygiene
education with them.
Disadvantages
• As the presence o the mother/caretaker and beneciary is required at the centre
every day or most o the day, this causes problems in the daily tasks o the
household.
• There is an increased risk o transmission o diseases when malnourished children
are concentrated together all day.
• The centre requires many more sta than a dry centre.
• The centre requires more inrastructure than a dry centre.
• The capacity or rapid reaction to changes in the situation is lower.
• There is a possibility that the ood in the centre will be used to substitute or
the beneciaries’ share o ood in the household, deeating the purpose o the
supplementary ration.
•DRY FEEDING
Advantages
• Dry eeding requires ewer resources (personnel, structure) than wet eeding and
there is no evidence to show that wet eeding is more eective than dry eeding.
• A greater number o beneciaries can be supported.
• Less disruption o the amilies’ rhythm, as the distribution requires that the mother
or caretaker are away rom home or a shorter time, leading to better coverage and
lower deaulter rates.
• It keeps responsibility or preparation and eeding within the home.
• It is more appropriate or dispersed populations.
• Less risk o cross-inections.
• It is quicker to put in place a dry eeding centre.
Disadvantages
• There is no guarantee that the beneciary will receive the ration.
• Monitoring o the nutritional status o the beneciary is less requent.
162
• More dicult to do educational activities.
• Requires more ood per beneciary.
Annex 23. Nutrient density of RUSP
PER 100 G PER 1,000 KCAL
NUTRIENT UNIT MINIMUM MAXIMUM MINIMUM MAXIMUM
Energy Kcal 350 400 1000 1000
Protein g 8 12 23 35
Fat g 14 18 40 52
Carbohydrate g any any any any
Sodium (Na) mg <300 <860
Potassium (K) mg 630 700 1,800 2,000
Magnesium (Mg) mg 120 150 340 430
Phosphorus (P) mg 370 500 1,000 1,500
Zinc (Zn) mg 9.5 13 27 37
Calcium (Ca) mg 400 500 1,140 1,430
Copper (Cu) mg 1 1.2 2.8 3.4
Iron (Fe) mg 8.5 13 24 37
Iodine (I) µg 100 140 290 400
Selenium (Se) µg 25 35 70 100
Manganese (Mn) mg 0.4 0.45 1.1 1.3
Thiamin (B1) mg >0.50 >1.4
Ribofavin (B2) mg >1.50 >4.3
Pyridoxine (B6) mg >1.10 >3.0
Cabalamine µg >2.30 >6.6
(B12)
Folate µg >240 >680
Niacin mg >15 >40
Ascorbate (Vit C) mg >50 >140
Pantothenic acid mg >2.3 >6.6
Biotin µg >11 >30
Retinol (Vit A) µg 950 1,100 >2,700 3,140
Cholecalciferiol µg 10 20 30 60
(D)
Tocopherol (E) mg >13 >35
Phytomenadione µg >30 >85
(K)
n-6 fatty acid % energy 3 10 3 10
n-3 fatty acid % energy 0.3 2.5 0.3 2.5
The ratios of nutrients should always be within these limits
Ca/P ratio mol/mol 0.8 1.2 0.8 1.2
Zn/Cu ratio mol/mol 5 15 5 15
Zn/Fe ratio mol/mol 0.8 3 0.8 3
Total Fat % energy 30 45 30 45
Protein % energy 7 18 7 18
163
Annex 24. Laboratory tests
Where acilities permit, the tests presented below may help to diagnose specic problems.
However, they are not needed to guide or monitor treatment. The interpretation of test
results is frequently altered by malnutrition. For this reason, laboratory tests may
misguide inexperienced workers. The most important guide to treatment is requent
careul assessment o the child.
TEST RESULT AND SIGNIFICANCE
Haemoglobin or packed- Haemoglobin 4 g/dl (or packed-cell volume 12%) indicates very
cell volume severe anaemia – see chapter on complications.
Haemoglobin or packed- Preparation in case blood transusion is needed (blood must be
cell volume screened or HIV, Hepatitis B and C, syphilis, malarial para-
sites).
Blood glucose Glucose concentration 54 mg/dl or 3 mmol/l indicates hypogly-
caemia.
Rapid diagnostic test (RDT) A positive RDT or blood smear with presence o malaria para-
or blood smear by micros- sites indicates inection.
copy or malaria
Dipstick test or culture o A positive dipstick test indicates inection. The presence o bac-
urine specimen teria on microscopy (Note: >10 leukocytes per high-power eld
indicates inection, but is usually negative in children with SAM
with a urinary tract inection – i.e. not reliable in SAM).
RDT or polymerase chain A positive RDT or PCR indicates inection in children aged 18
reaction (PCR) test or HIV months and older. A positive RDT or inants aged less than
18 months must be repeated with a PCR or interpreted with
the mother’s status. A negative RDT is useul and conrms the
absence of infection.
Skin test or TB Not reliable in SAM. This test is oten negative in TB associated
with SAM or alse positive in children previously vaccinated with
BCG vaccine. It takes 48 hours beore it can be read.
Examination o aeces by The presence o blood indicates dysentery. The presence o
microscopy giardia cysts or trophozoïtes indicates inection.
Chest X-ray Pneumonia causes less shadowing o the lungs in malnourished
children than in well-nourished children: children with SAM and
severe bronchopneumonia are oten reported as normal by
radiologists not amiliar with SAM.
Useul i staphylococcal abscesses are suspected and or TB
pneumonia (but shadowing may be very slight).
Vascular engorgement indicates heart ailure.
Bones are usually osteoporotic, they may also show signs o
rickets or ractures o the ribs – examine spine careully or
Pott’s disease.
164
165
166
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