Philippine Integrated Management of Acute Malnnutrition PDF

4th National Conference of Nutrition Action Officers
Philippine Integrated
Management of Severe
Acute Malnutrition
15-16 November 2016
Cebu City
(PIMAM)
HAYCE FAMOR-RAMOS, MD., MPM

Medical Coordinator – PIMAM
DOH RO VII
1
Slide 1
Outline
At the end of the session, we will discuss

1. Situation of under 5 year old child wasting.
2. Evidence for community based treatment of SAM.
15-16 November 2016
3. Evidence for integrated management of acute

Cebu City
malnutrition.
4. Roles and Responsibilities as PIMAM Managers
2
Slide 2
15-16 November 2016
Cebu City
Three Stories on
Severe Acute Malnutrition
3
Slide 3
15-16 November 2016
Cebu City Three Stories
4
Slide 4
15-16 November 2016
Cebu City Three Stories
5
Slide 5
15-16 November 2016
Cebu City
6
Slide 6
The Philippines and wasting in
childhood
FNRI DOST, National Nutrition Survey, 2015
% of Under 5 with Wasting

9
7.5 7.7 7.3 7.9
7.1
15-16 November 2016
8 6.8 6.8 6.9

7 6.2 6.2 6 5.8
Cebu City
6
5
4
3
2
1
0
1989 1992 1993 1996 1998 2001 2003 2005 2008 2011 2013 2015
% of Under 5 with Wasting
3
Slide 7
Severe Acute Malnutrition is a
Critical Health Priority for LGUs
15-16 November 2016
Cebu City
FNRI DOST, National Nutrition Survey, 2013, 2015
3
Slide 8
It gets worse in emergencies
208
15-16 November 2016
1643
Cebu City
SAM MAM
63,231 children (under 5 years of age in Regions VI,VII, & VIII were screened)
1,851 were acutely malnourished
FAQs in Emergencies UNICEF
3
Slide 9
0-5months 6-11 months 12 months 24 months 36 months 48-60 months
16
14
12
WASTING
WITH
% 10
8
6
4
15-16 November 2016
2
Cebu City
0
2008 2011 2013
0-5months 11.9 11.1 13.4
6-11 months 11.6 11.9 11.4
12 months 9.4 9.1 10.6
24 months 5.5 6.6 6.4
36 months 4.4 4.5 5.8
48-60 months 4.3 5.5 5.5
Among Filipino children, those 12 months

old and younger are most affected
FNRI DOST, National Nutrition Survey
3
Slide 10
The First 1000 Days!
15-16 November 2016
Cebu City
• UNICEF: Improving Child Nutrition: The achievable imperative for global progress (New York, 2013)
• Global targets to improve maternal, infant and young child nutrition - Policy Brief, 1,000 Days Partnership, n.d., thousanddays.org/wp-content/uploads/2012
05/WHO-Targets-Policy-Brief.pelf [accessed 10 May 2015]
3
Slide 11
15-16 November 2016
Cebu City
Community – Based
Malnutrition (CMAM)
Management of Acute
12
Slide 12
Why do we need to treat SAM?
 Children with SAM are 9

times more likely to die than
those who are well nourished.
15-16 November 2016
(RE Black et al. Maternal and Child Undernutrition. Paper 1. Gllobal and regional exposures and health
consequences. The Lancet 2008)
Cebu City
 Recognized and treated

early, it can be reversed with
proper food, nutrition and care.
13
Slide 13
We had the WHO protocol for ITC
WHO Classification for the

Treatment of Malnutrition
Acute
15-16 November 2016
Malnutrition
Cebu City
Moderate
Severe Acute
Acute
Malnutrition
Malnutrition
Therapeutic Supplementary
Feeding Centre Feeding
3
Slide 14
The evidence looked good for ITC
using the WHO protocol
With the use of the WHO facility based

protocol for children over 6 months to 59
15-16 November 2016
months, the risk of death was reduced by 55%

Cebu City
compared to conventional treatment.
Referring to mortality -- “From 9 pooled studies, summary risk ratio of

0.45 (95% CI 0.32-0.62) when compared with conventional treatment”
Bhutta, ZA et al (2006) The Lancet. Maternal

and child undernutrition Series 3.
3
Slide 15
But how have we fared against
malnutrition using in-hospital
care?
Case fatality rates in developing countries is 20-
15-16 November 2016
30%
Cebu City
DESPITE
WHO management protocols capable of

achieving case-fatality rates of 1–5% in
specialized units
3
Slide 16
Malnutrition treatment primarily
hospital based
Several factors affect success:

• Lack of skilled and motivated personnel
15-16 November 2016
• Lack of appropriate and adequate resources

Cebu City
• Co-existing medical conditions

• Late presentation at hospital
• High risk of cross-infection
• High rate of defaulters
3
Slide 17
The move towards the
community
 Started in the 1970’s to 80’s

 Generally, short hospital stays AND
15-16 November 2016
 Locus of treatment to communities 

Cebu City
• simple nutrition rehabilitation

centers,
• existing primary health-care
clinics,
• or the homes of those affected
3
Slide 18
However…
Review of 27 such programs from the 1980s and 1990s:

Six (22%) of the 27 achieved:
 case-fatality rates of less than 5%,
15-16 November 2016
 average weight gains of more than 5 g/kg/day, and

Cebu City
 relapse or readmission rates of less than 10%
Conclusions:
• home treatment was rarely successful
• early discharge of severely malnourished patients from
inpatient treatment units was usually hazardous
Ashworth, A. Community-based rehabilitation of severely malnourished children: a review of successful

programmes. London School of Hygiene and Tropical Medicine, London; 2001
3
Slide 19
Ready To Use Therapeutic Food (RUTF)
• a suitable high-energy, nutrient-dense food enriched vitamins
• Induces weight gain in emergency settings

15-16 November 2016
(recommended by WHO, UNICEF, and the UN World Food Program)

Cebu City
• Among 23, 511* unselected SAM children:

 Overall case-fatality rate: 4.1%,
 Recovery rate: 79.4%
 Default: 11.0%.
Ashworth, A. Community-based rehabilitation of severely malnourished children: a review of successful

programmes. London School of Hygiene and Tropical Medicine, London; 2001
3
Slide 20
What is the evidence that integrated
management works?
95% vs 78% (p < 0.001)

Rates of weight gain = 5.2 g/kg/day vs 3.1 g/kg/day
15-16 November 2016
AND
Cebu City
Recovery to 100% weight for height among

children
*175 kcal/kg/day
On use of take-home ration RUTF* (vs WFP corn soya blend) given after
early discharge from phase 1 care in a facility following the WHO ITC
protocol:
Manary MJ, Ndkeha MJ, Ashorn P, Maleta K, Briend A. Home based therapy for
severe malnutrition with ready-to-use food. Arch Dis Child 2004; 89: 557–61.
3
Slide 21
So because of RUTF,
• Shortened duration of inpatient treatment

from an average of 30 days to only 5–10 days
15-16 November 2016
• Reduced the resources needed to treat

Cebu City
SAM, which improves cost-effectiveness
Collins S, et al (2006) Management of Severe Acute Malnutrition. The Lancet

3
Slide 22
The Integrated Management of Malnutrition
Classification for the

Community-Based Treatment
of Acute Malnutrition
15-16 November 2016
Acute
Cebu City
Malnutrition
Severe acute Severe acute

Moderate acute
malnutrition malnutrition malnutrition
with medical without medical
complications complications
Supplementary
Feeding
Inpatient Care Outpatient Care
3
Slide 23
From CMAM to PIMAM
What it is:
 Philippine Integrated Management of Acute
Malnutrition
15-16 November 2016
 Includes SAM management as part of

Cebu City
routine health and nutrition services at all

levels
 Updated and evidence-based treatment
 Involves and relies on a strong community
component
24
Slide 24
CMAM in the Philippines
 Began in emergency context

in 2009
 Guidelines first drafted in
15-16 November 2016
2011, only finalized in 2015

Cebu City
 SAM should be implemented

not just during emergencies
but also in “normal” times
 SAM is an emergency!
3
Slide 25
15-16 November 2016
Cebu City
Identification
3
The MUAC tape: Screening and
Slide 26
Medications:Therapeutic Food
Ready-to-Use
Therapeutic Therapeutic Milk (F75, F100)
Food
15-16 November 2016
For SAM without

For SAM with complications
complications
Cebu City
3
Slide 27
Components of PIMAM
1. Management of SAM Outpatient Therapeutic

without Care (OTC)
complications
15-16 November 2016
2. Management of SAM Inpatient Therapeutic Care

Cebu City
with complications (ITC)
3. Management of MAM Supplementary Feeding

Program (SFP)
4. Community Outreach Community Mobilization
Slide 28
Edema Check
Outpatient Therapeutic Care (OTC) Inpatient Therapeutic Care (ITC)

N
Anthropometry U Good Appetite,
Poor Appetite; +3
edema; With
+1,+2 edema; No
T Complications
Complications
S
R
T
I
A
T
MUAC, Weight, T
I Appetite Test and
Height/Length, U SAM
WFH Zscore O Medical
S Assessment
N
A
L MAM Supplementary Feeding Program (SFP)
Normal Counsellin
g
1. National Guidelines on the
Management of Acute
Malnutrition for Children
under 5 years
2. Administrative Order 2015-
0055: SAM is now part of
15-16 November 2016
DOH regular program

Cebu City
3. Budget Allocation: DOH

Central will cover CMAM
supplies and support training
rollout
4. Standardization of Training
Modules
3
Slide 30
16 Priority Areas for 2016
Phase 1
Region V Camarines Sur
Catanduanes
Masbate
Region VI Antique
Iloilo
Region VII Bohol
Cebu
Region VIII Eastern Samar
Leyte
Northern Samar
Zamboanga del
Region IX Sur
Region IX Davao del Sur
Region XII North Cotabato
ARMM Lanao del Sur
Maguindanao
Sulu
12 Add’l Priority Areas 2017
Phase 2
Region I Ilocos Norte
Region II Cagayan
Region III Aurora
Region III Zambales
Region IVA Laguna
Region IVB Occidental Mindoro
Region VII Siquijor
Region VIII Biliran

Region IX Zamboanga Sibugay
Region XII Saranggani
CARAGA Agusan del Norte
CAR Abra
Phase 3
Region I Ilocos Sur
Region I La Union
Region II Nueva Vizcaya
Region III Nueva Ecija
Region IVA Rizal
Region IVB Palawan
Region V Camarines Norte
Region VI Capiz
Region X Lanao del Norte
Region X Misamis Occidental
ARMM Tawi-Tawi
NCR NCR District 4
Phase 4
Region I Pangasinan
Region IVB Oriental Mindoro
Region VI Aklan
Negros Negros Occidental
Region VIII Western Samar
Zamboanga del
Region IX Norte
Region XI Davao del Norte
Region XII Sultan Kudarat
CARAGA Surigao del Norte
ARMM Basilan
CAR Benguet
NCR NCR District 2
Phase 5
Region II Quirino
Region III Pampanga
Region IVA Batangas
Region IVA Quezon
Region V Albay
Negros Negros Oriental
Region VIII Southern Leyte
Region X Camiguin
Region XI Davao Oriental
CAR Apayao
CAR Mountain Province
Phase 6
Region II Isabela
Region III Bulacan
Region III Tarlac
Region IVA Cavite
Region IVB Romblon
Region X Misamis Oriental
Region XII South Cotabato
CARAGA Surigao del Sur
CARAGA Agusan del Sur
NCR NCR District 3
NCR NCR District 1
Phase 7
Region II Batanes*
Region III Bataan
Region IVB Marinduque
Region V Sorsogon
Region VI Guimaras
Region IX Isabela City*

Region X Bukidnon
Region XI Compostela Valley
CAR Ifugao
CAR Kalinga
CAR Dinagat Islands*
15-16 November 2016
Cebu City
Is it possible to solve SAM?
Slide 38
15-16 November 2016
Cebu City
Slide 39
15-16 November 2016
Cebu City
Slide 40
15-16 November 2016
Cebu City
Slide 41
15-16 November 2016
Cebu City
Slide 42
15-16 November 2016
Cebu City
Slide 43
15-16 November 2016
Cebu City
Slide 44
15-16 November 2016
Cebu City
=?
Slide 45
15-16 November 2016
Cebu City
Are you ready to learn and do your role?
Slide 46
Recommendations for Action
• Integrate SAM Management in Local Health Systems
• As you organize and implement your PIMAM

15-16 November 2016
program to ensure that children with SAM are

Cebu City
treated and do not leave the program, seek to ensure

that
1. Your PIMAM adheres to the guidelines in AO 2015-
0055
2. Your PIMAM is integrated into other health
programs in your LGU
3
Slide 47
15-16 November 2016
Cebu City
3
Slide 48
This is what our Filipino babies look like
This is what our Filipino babies look like
Payat?
Sakitin?
15-16 November 2016
Pandak?
Cebu City
Our kids
can really
NOT be.
3
Slide 49
15-16 November 2016
Cebu City
SHOULD look like
This is what our Filipino babies
3
Slide 50
15-16 November 2016
Cebu City
3
Are you ready to learn and do your role?
Slide 51
Conclusion
 A significant number of Filipino children under 5

year olds are wasted.
 The threat of wasting grows worse during times of
emergencies.
15-16 November 2016
 The integrated management of SAM from

Cebu City
community to facility will save lives.
3
Slide 52
Philippine Integrated
Management of Severe
Acute Malnutrition
15-16 November 2016
Cebu City
(PIMAM)
HAYCE FAMOR-RAMOS, MD., MPM

Medical Coordinator – PIMAM
DOH RO VII
53
Slide 53

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4th National Conference of Nutrition Action Officers

HAYCE FAMOR-RAMOS, MD., MPM

At the end of the session, we will discuss

3. Evidence for integrated management of acute

FNRI DOST, National Nutrition Survey, 2015

% of Under 5 with Wasting

8 6.8 6.8 6.9

FNRI DOST, National Nutrition Survey, 2013, 2015

Among Filipino children, those 12 months

 Children with SAM are 9

 Recognized and treated

WHO Classification for the

With the use of the WHO facility based

months, the risk of death was reduced by 55%

compared to conventional treatment.

Referring to mortality -- “From 9 pooled studies, summary risk ratio of

Bhutta, ZA et al (2006) The Lancet. Maternal

WHO management protocols capable of

Several factors affect success:

• Lack of appropriate and adequate resources

• Co-existing medical conditions

 Started in the 1970’s to 80’s

 Locus of treatment to communities 

• simple nutrition rehabilitation

Review of 27 such programs from the 1980s and 1990s:

 average weight gains of more than 5 g/kg/day, and

 relapse or readmission rates of less than 10%

Ashworth, A. Community-based rehabilitation of severely malnourished children: a review of successful

• a suitable high-energy, nutrient-dense food enriched vitamins

• Induces weight gain in emergency settings

(recommended by WHO, UNICEF, and the UN World Food Program)

• Among 23, 511* unselected SAM children:

Ashworth, A. Community-based rehabilitation of severely malnourished children: a review of successful

95% vs 78% (p < 0.001)

Recovery to 100% weight for height among

• Shortened duration of inpatient treatment

• Reduced the resources needed to treat

SAM, which improves cost-effectiveness

Collins S, et al (2006) Management of Severe Acute Malnutrition. The Lancet

Classification for the

Severe acute Severe acute

 Includes SAM management as part of

routine health and nutrition services at all

 Began in emergency context

2011, only finalized in 2015

 SAM should be implemented

For SAM without

1. Management of SAM Outpatient Therapeutic

2. Management of SAM Inpatient Therapeutic Care

with complications (ITC)

3. Management of MAM Supplementary Feeding

4. Community Outreach Community Mobilization

Outpatient Therapeutic Care (OTC) Inpatient Therapeutic Care (ITC)

DOH regular program

3. Budget Allocation: DOH

Region IVA Laguna

Region IVB Occidental Mindoro

Region VII Siquijor

Region VIII Biliran

Region IX Isabela City*

• Integrate SAM Management in Local Health Systems

• As you organize and implement your PIMAM

program to ensure that children with SAM are