Untitled

TRAINING COURSE ON THE
MANAGEMENT OF ACUTE
MALNUTRITION
PARTICIPANT MODULE
Federal democratic
Ethiopia, Republic
Ministry of Health of
FirstAbaba,
Addis edition,Ethiopia
2019
Training course on the management of acute malnutrition

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Recommended Citation
Government of Ethiopia, Federal Ministry of Health,

2019. Training course on the management of acute
malnutrition, Participant module.
Contact information:
Federal Ministry of Health
Post Office Box 1234
Sudan Street
Addis Ababa
Ethiopia
Telephone: +25115517011
Fax: +251 115519366
Email: nutriexpert12@gmail.com or moh@ethionet.et

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Acknowledgement
The first National Protocol on the Management of Severe Acute Malnutrition (SAM) for Ethiopia was
developed in 2004 and the 2nd and updated version was made available as of March 2007. The training
course material was developed on 2011 titled “Training Course on the Management of SAM” using the
WHO “Training Course on the Management of SAM, 2002” as template but taking most of the contents
from the “National Protocol for the Management of SAM, 2007”. The Third National Protocol for the
management of acute malnutrition incorporated updates from the 2013 World Health Organization
(WHO) global recommendations on the management of severe acute malnutrition in infants and
children and revised. The revised guideline was launched in June 2019 by the FMOH titled “National
Guideline for Management of Acute Malnutrition, Ethiopia”. Subsequently, the training package has
been revised in line with the national guideline. The training package incorporates both the in-patient
and outpatient management of acute malnutrition.
This third edition of the training materials was developed through the technical and financial support
from World Health Organization (WHO), Ethiopia and the valuable input of from the national experts
from regional referral hospitals and teaching institutions, United Nations Children’s Fund (UNICEF),
World Food Programme (WFP), and experts from implementing Non-Governmental Organizations. It
is our strong belief that this training package will contribute significantly to the efforts being made to
improve the quality of care provided for malnourished children and pregnant & lactating women.
The FMOH sincerely acknowledges the contribution from World Health Organization (WHO), country
office, Ethiopia to coordinate and lead this task and the support of UNICEF, WFP, the national experts,
Concern World Wide, USAID Transform PHC, GOAL Ethiopia, Save the Children International, towards
the development of this training package.
The FMOH sincerely acknowledges the significant contribution of Dr. Blen Teshome (Pediatrician, St.
Paul’s Hospital Millennium Medical College), who served as national consultant for the revision and
development of the revised training materials in line with the WHO recommendations.

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The FMOH gratefully acknowledge the contribution of all who participated in this work especially the
following professionals
• Mr. Shibru Kelbessa from Nutrition case team, FMOH for leading and coordinating the
process
• FMOH; Kidist woldesenbet, Frezer Abebe, Hiwot Darsene

National experts; Dr. Marta Yemane (Ayder referral hospital), Dr. Getnet Aschale
(Gonder regional Referral Hospital), Dr. Mulugeta Sitot (Hawassa regional referral Hospital), Dr.
Negash Tasese (Hawassa regional Referral Hospital), Dr. Abel Gidey (Dubti general hospital), Dr.
Selamawit Assefa (Yekatit 12 teaching Hospital), Dr. Damte Shimelis (Black lion Referral Hospital).
• World Health Organization (WHO); Dr. Betty Lanyero, Dr. Bereket Yalew, Getahun Taka
Beyene
• UNICEF; Jacinta Achen Hyatis, Nyauma Nyasani, Banchiliyew Getahun, Mikiale Abraham,
• ENCU; Cecile Basquin, Bekele Negussie
• World Food Programme (WFP): Kemeria Barsenga, Tayech Yimer, Getu Assefa, Mulu
Gebremedhin
• Concern World Wide: Abdi Yusuf, Annie Zhou
• Goal Ethiopia: Hilina Tufa
• USAID Tranform- PHCU; Dr. Yared Abebe
• USAID: Melanie Thurber
Finally, the Federal Ministry of Health would like to recognize all the program managers and technical
staff in the FMOH who contributed to the finalization of the training materials
Federal Ministry of Health

H.E Dr. Lia Tadesse (MD, MHA)
State Minister of Health

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TABLE OF CONTENTS
SESSION 1: INTRODUCTION 9
1.1 Importance of severe malnutrition as a health problem 10
1.2 Overview of the Management of Acute Malnutrition 10
1.3 Purpose of this training course 11
1.4 Course methods and materials 11
1.5 Learning objectives of the module 13
1.6 Objectives for clinical practice sessions 15
SESSION 2: PRINCIPLES OF CARE 17
2.1 Recognize signs of acute malnutrition 19
2.2 Weigh and measure length/height of the child 25
2.3 Measure mid-upper arm circumference 31
2.4 Identifying a child with severe acute malnutrition 32
2.5 Recommended criteria to diagnose severe acute malnutrition and admission to TFP 36
2.6 How does the physiology of severe acute malnutrition affect care of the child? 42
2.7 Overview of the essential components of care 45
2.8 Process for successful management of children with SAM in Stabilization center 48
(In-patient care)
2.9 Discharge Criteria for a severe acute malnutrition from in-patient care 52
SESSION 3: INTITAL MANAGEMENT 53
3.1 Manage Hypoglycemia 55
3.2 Manage Hypothermia 57
3.3 Manage watery diarrhea and/or vomiting and Dehydration 63
3.4 Manage a severely malnourished child with shock 73
3.5 Manage very severe anemia 75
3.6 Give emergency eye care for corneal clouding and ulceration 81
3.7 Managing Heart failure 82
3.8 Treat Infections 88
3.9 Management of abdominal distension with absent bowel sounds 93
3.10 Management of SAM in TB and HIV infected children 94
SESSION 4: FEEDING 97
4.1 Prepare F-75 and F-100 99
4.2 Feeding children 6– 59 months 102
4.3 Feeding Infants less than 6 months 131
4.4 Infants below six months with possibility of breast feeding 133
4.5 Infants below six months with no prospect to breast-fed 136
4.6 Micronutrient supplementation 138
4.7 Plan feeding for the ward 140
SESSION 5: DAILY CARE 149
5.1 Handle the child gently 151
5.2 Give Routine medicines and other medications 156
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5.3 Care for skin and bathe the child 160
5.4 Care for the eyes 160
5.6 Monitor pulse, respirations, and temperature, and watch for danger signs 164
5.7 Provide continuing care at night 166
5.8 Weigh the child daily and maintain weight chart 177
5.9 Discharge Criteria 181
SESSION 6: MONITORING AND PROBLEM SOLVING 185
6.1 Use a process to identify and solve problems 187
6.2 Monitor and solve problems with an individual patient 192
6.3 Identify the child who is failing to respond 195
6.4 Monitor overall weight gain in the inpatient Care/ward 210
6.5 Monitor patient outcomes 219
6.6 Monitor practices and procedures 235
6.7 Solve problems 239
SESSION 7: INVOLVING MOTHERS (CAREGIVERS) IN CARE 243
7.1 Organize facility routine to encourage mothers’ involvement 245
7.2 Involve mothers in comforting, feeding, and bathing children 247
7.3 Teach mothers about feeding and care 249
7.4 Prepare for feeding the child at home 252
7.5 Teach mothers the importance of stimulation 255
7.6 Give general discharge instructions 256
SESSION 8: OUT-PATIENT THERAPEUTIC PROGRAM (OTP) 259
8.1 Principles of outpatient management of severe acute malnutrition 261
8.2 Case-finding and triage for severe acute malnutrition 263
8.3 Admission procedure to out-patient therapeutic care 264
8.2 Admission Procedure 268
8.3 Medical treatment and care for children 6-59 months with SAM in OTP 273
8.4 Nutritional rehabilitation with RUTF (Plumpy’Nut) 276
8.5 Follow up during treatment in OTP 280
8.6 OTP Discharge criteria and procedure 284
SESSION 9: MANAGEMENT OF MODERATE ACUTE MALNUTRITION 293
(MAM)
9.1 Principles of Supplementary Feeding Program (SFPs) 295
9.2 Blanket Supplementary Feeding Programme (BSFP) 295
9.3 Targeted Supplementary Feeding program (TSFP) 296
9.4 Nutrition Rehabilitation at SFPs 201
9.5 Monitoring During TSFP Follow-Up Visits 303
9.6 Discharge Criteria and Exit Categories 305
9.7 Organization of OTP and TSFP services 307
SESSION 10 - SUPPLY CHAIN MANAGEMENT FOR AM TREATMENT 309
10.1 Essential Supplies for Acute Malnutrition 311
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10.2 Quantifying the Need 311
10.3 Stock Management 315
SESSION 11: MONITORING AND REPORTING IN TFP AND TSFP 319
11.1 MONITORING 321
11.2 Recording in TFP and TSFP Registration book 322
11.3 Prepare Monthly OTP and TSFP Statistic Reports 322
11.4 Monitor Performance of Therapeutic Feeding Program (TFP) 327
11.5 SHPERE standards Outcome Indicators 329
ANNEX 1: Explanation of Z-scores (SD-scores) 346
ANNEX 2A: Weight -for-Length Reference cards 348
ANNEX 2B: Weight-for-height reference card 349
ANNEX 3: Composition of F-75, F-100 and RUTF diets 350
ANNEX 4: Recipes for F-75 and F-100 (only if commercially produced products not 351
available)
ANNEX 5: Composition of mineral and vitamin mix solutions 353
ANNEX 6: Physiological basis for treatment of severe acute malnutrition 354
ANNEX 7: MULTICHART 357
ANNEX 8: Danger signs related to pulse, respiration and temperature 358
ANNEX 9A: F-75 Reference Card 360
ANNEX 9B: F-75 Reference Card 362
ANNEX 10: F-100 Reference Card 364
ANNEX 11: RUTF Reference card (example of suggested quantities) 366
ANNEX 12a: Therapeutic milk feeds in stabilization for infants less than 6 months with 367
or without prospect to breastfed
ANNEX 12b: Therapeutic milk feeds in transition for infants less than 6 months with no 370
prospect to breastfeed
ANNEX 12c: Therapeutic milk feeds in the recovery phase for infants less than 6 months 372
with no prospect to breastfeed.
ANNEX 13: DAILY WARD FEED CHART 374
Annex 14: Key messages about the use of RUTF 375
Annex 15: Monitoring record Chart 376
ANNEX 16: Monitoring checklists 377
ANNEX 17: BIN CARD 381
ANNEX 18: STOCK CARD 382

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ACRONYMS
BSFP Blanket Supplementary Feeding Programme
EPI Expanded Programme on Immunisation
F-100 Formula 100
F-75 Formula 75
FBF Fortified Blended Foods
FMOH Federal Ministry of Health
GAM Global Acute Malnutrition
HAD Health Development Army
Hb Hemoglobin
HDG Health Development Group
HEW Health Extension Worker
HP Health Post
IU International Units
IYCF Infant and Young Child Feeding
LoS Length of Stay
LRTI Lower Respiratory Tract Infection
MAM MAM Moderate Acute Malnutrition
MUAC Mid Upper Arm Circumference
NGT Naso-Gastric Tube
OPD Out Patient Department
ORS Oral Rehydration Salt
OTP Out-patient Therapeutic Program
PHU Primary Health Care Unit
PLW Pregnant and Lactating Women
PSNP Productive Safety Net Programme
ReSoMal Rehydration Solution for severely malnourished
RUSF Ready-to-Use Supplementary Food
RUTF Ready-to-Use Therapeutic Food
RWG Rate of Weight Gain
SAM Severe Acute Malnutrition
SC Stabilization center
SFP Supplementary Feeding Program
TB Tuberculosis
TFP Therapeutic Feeding Program
TFU Therapeutic Feeding Unit
TSFP Targeted Supplementary Feeding Programme
WASH Water Sanitation and Hygiene
WFH Weight for Height
WFL Weight for Length

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S-1 Introduction
SESSION 1: INTRODUCTION
S-1 Introduction
1.1 Importance of severe malnutrition as a health problem

Severe malnutrition is one of the common causes of morbidity and mortality among children under
the age of 5 years worldwide. Based on the 2019 Ethiopia Demographic Health survey (EDHS), 7%
of children under five are wasted and 1% of these severely wasted1. Children with severe acute
malnutrition (SAM) have a nine-fold risk of mortality compared to well-nourished children hence the
need for appropriate management.
Mortality remains high among children with severe acute malnutrition often die because of several
factors such as associated childhood co-morbidities e.g. diarrhea, pneumonia, shock and non-
adherence to management protocols by health care professional2. With the implementation of
appropriate case management practices in health facilities and follow-up care, the lives of many
children can be saved and dramatically lower the case fatality rates. In certain hospitals that have used
these case- management methods, the case fatality rate has been reduced from over 30% to less than
5%3.
The Federal Ministry of Health (FMOH), Ethiopia developed a National Guideline for Management of
Acute Malnutrition in May 2019. This training course has been revised to incorporate the revision made
in the national guideline and will teach the case management practices required for the treatment of
children with acute malnutrition.
1.2 Overview of the Management of Acute Malnutrition
Until 2000, the management of Acute Malnutrition has been restricted to facility-based approaches,
greatly limiting coverage. In response, the Community-Based Therapeutic Care (CTC) approach to the
management of acute malnutrition was developed in 2001. The approach aims to reach the maximum
number of children with acute malnutrition and to ensure access and coverage by providing treatment
at many decentralized sites instead of a few centrally located inpatient facilities.
The Community-Based Management of Acute Malnutrition (CMAM), consists of four main components:
1. Community outreach/mobilization: Health Extension workers conduct community

screening for early case finding; give basic nutritional advice to mothers; and provide patient
follow up for defaulters and encourage them to the program. Community mobilization also
includes sensitization of the population to promote understanding of therapeutic program
objectives and methods. Session 7 of the module deals with the OTP care.
2. Supplementary Feeding Program (SFP): SFP is an intervention that aims to treat patients
with moderate acute malnutrition (MAM), and prevents deterioration to SAM. There are two
forms of SFP; Targeted supplementary feeding program (TSFP) and Blanket supplementary
feeding program (BSFP).
3. Outpatient Treatment Program (OTP): Outpatient care is intended for children presenting
SAM without medical complications and for children that have recovered in inpatient care
after they have regained their appetite. They receive ready-to-use therapeutic food (RUTF)
and routine medicines, which are taken at home, and the child attends the outpatient care
site every week. Most children with SAM have no medical complications and can be treated in
outpatient care.
4. Inpatient Treatment/ stabilization Centre (SC): Children who are acutely malnourished with
associated medical complications and/or poor appetite; need to be treated in inpatient care
facility until they are well enough to continue nutritional rehabilitation in OTP. All children
under 6 months with SAM are also admitted to in-patient care/stabilization center.
1 https://dhsprogram.com/pubs/pdf/PR120/PR120.pdf
2 F. Wagnew, D. Tesgera, M. Mekonnen, A.A. Abajobir, Predictors of mortality among under-five children with severe
acute malnutrition, Northwest Ethiopia: an institution based retrospective cohort study, Arch. Public Health. 76 (2018)
64. doi:10.1186/s13690-018-0309-x.
3 http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf, accessed 26 September 2013
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S-1 Introduction
This module deals with the inpatient, OTP and MAM management and partly community mobilization.
SC
Figure 1: Components of community management of acute malnutrition
1.3 Purpose of this training course

This course is designed for nurses, health officers, nutritionists, and doctors in health centers and
hospitals that have or plan to have stabilization center (SC) or wards for children less than 5 years with
SAM, are providing OTP and TSFP services for individuals with SAM or MAM. The course will teach skills
and knowledge specifically needed for management of children with SAM as in-patient and outpatient
at the health centers and hospitals and individual with MAM. The course will not teach basic medical
techniques that are taught in schools of medicine and nursing (such as how to insert an IV or take a
blood sample).
It is expected that participants will return to their health facilities and begin to implement the in-patient,
OTP and MAM case management practices described in this course. The implementation of these
practices at the health facilities therapeutic feeding units/stabilization centers or OTP or TSFP will need
certain basic supplies and equipment listed in Annex A of the module.
1.4 Course methods and materials
This course uses a variety of methods of instruction, including reading, written exercises, discussions,
role plays, video, and demonstrations and practice in a stabilization centers, OTP and TSFP units.
Practice, whether in written exercises or on the ward, is considered a critical element of instruction.
Small groups of participants are led and assisted by “facilitators” as they work through the course
sessions. The facilitators are not lecturers, as in a traditional classroom. Their role is to answer questions,
provide individual feedback on exercises, lead discussions, structure role plays, etc.
To a great extent, participants work at their own pace through the sessions, although in some activities,
such as role plays and discussions, the small group will work together.
The participant manual is organized into eleven Sessions. Session 1; is an introduction to the course,
session 2 to 7 discusses the in-patient care for SAM; Session 8 discusses out-patient therapeutic
program, session 9; discusses the supplementary feeding program and session 10 explains supply chain
management and session 11 focuses on monitoring and reporting in the TFP and SFP.

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S-1 Introduction
Session 1: Introduction
Session 2: Principles of Care
Session 3: Management of Medical Complications
Session 4: Feeding
Session 5: Daily Care
Session 6: Monitoring and Problem Solving of In-patient Care
Session 7: Involving Mothers during in-patient
Session 8: Outpatient therapeutic program
Session 9: Supplementary feeding program
Session 10: Supply chain management
Session 11: Monitoring and reporting in TFP and SFP
In addition to the participant manual, you should have the following course materials:
• Chart booklet
• Photographs booklet
• 5 laminated reference cards:
Weight-for-height (Z-score) reference card
F-75 reference card for stabilization phase
F-100 and RUTF reference card for transition and Rehabilitation Phase
SAM classification wall chart
All other course materials, such as the video and blank recording forms, will be provided in your
classroom as needed.
Optional reference materials:

FMOH 2019: National guideline for the management of acute malnutrition, in Ethiopia
WHO 2003: Guidelines for the inpatient management of severely malnourished children
WHO 1999. Management of severe malnutrition: a manual for physicians and other senior
health workers.
WHO 2013: Updates on the Management of Severe acute malnutrition in children 6-59
months

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S-1 Introduction
1.5 Learning objectives of the module

Each session in this course will provide information and examples and allow you to practice skills
necessary for managing severely malnourished children. The skills and information presented in each
session are briefly outlined below:
Session 2: Principles of care

• Recognizing signs of severe acute malnutrition
• Weighing and measuring height/length of children (in clinical session)
• Determining a Z- score (or standard deviation Score) based on the child’s weight and length.
• Recognizing bilateral edema
• Measuring mid-upper arm circumference (MUAC)
• Admission procedure for severely malnourished children
• How the physiology of severe malnutrition affects care of the child.
• Essential components of care
• Important things NOT to do and why.
• Recommended admission criteria and discharge criteria for in-patient care
Session 3: Initial management

• Identifying and managing the severely malnourished child with:
• Hypoglycemia
• Hypothermia
• Shock
• Severe anemia
• Corneal clouding and ulceration
• Watery diarrhea and/or vomiting and dehydration
• Heart failure
• Infections
• Abdominal distension
• Preparing ReSoMal
• Selecting appropriate antibiotics and calculating dosages
• Keeping a written record of initial findings and treatments
Session 4: Feeding
• Preparing F-75 and F-100
• Planning feeding for a 24-hour period for a child who is -taking F-75; or -adjusting to RUTF/F-100
during transition; or -feeding freely on RUTF/F-100.
• Measuring and giving feeds to children
• Recording intake and output
• Planning feeding for a ward
Session 5: Daily care

• Handling a child with SAM appropriately
• Caring for the skin and bathing a child with SAM.
• Giving routine medicines and other prescribed antibiotics, medications and supplements
• Caring for the eyes
• Monitoring pulse, respirations, and temperature and watching for danger signs
• Completing and interpreting the sections of the multi-chart relevant for daily Care and
Monitoring Record, Preparing and maintaining a weight chart (graph)

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S-1 Introduction
Session 6: Monitoring and problem solving

• Identifying problems by monitoring:
• Individual patient progress, weight gain and care
• Overall weight gain on the ward
• Patient outcomes (such as recovery, referral, death)
• Case-fatality rate for the ward
• Case management practices
• Food preparation, ward procedures, and hygiene
• Investigating causes of problems
• Determining solutions appropriate for causes
• Conducting a problem-solving session with a group
Session 7: Involving mothers in care

• Ways to encourage involvement of mothers in hospital care; and ways to prepare mothers to
continue good care at home, including proper feeding of the child and stimulation using play.
• On the ward or in role-plays,
• Practice teaching a mother to bathe or feed a child; and
• Giving complete discharge instructions.
Session 8: Out-patient therapeutic program

• Explain the admission procedures of OTP
• Manage children in OTP
• Routine medicines
• Nutritional rehabilitation with RUTF
• key Messages for Mothers/Caregivers Used in Outpatient Care
• Emotional and psychosocial stimulation
• Follow up a child with SAM as outpatient.
• Fill child information in OTP card.
• Describe Discharge Criteria and Procedures
• Mobilize community and ensure early identification of cases
Session 9: Supplementary feeding program

• Describe the Principles of Supplementary Feeding Programs (SFPs)
• Identify the types of the Supplementary Feeding Programs (SFPs)
• Describe the admission to SFP and discharge criteria
• Know the admission procedure to SFPs and steps to follow.
• Discuss Medical Treatment and Nutrition Rehabilitation for the Management of MAM
• Know the Organization of OTP &TSFP services
Session 10: Supply Chain management in acute malnutrition treatment

• Identify the essential supplies needed for AM management
• To estimate the needed commodity for AM treatment service
• Know proper handling and storing methods of AM treatment commodities and supplies
Session 11: Monitoring and reporting in TFP and SFP
• Describe the principles of a monitoring system for TFP
• Describe how the individual’s child is tracked and monitored
• Complete TFP tally sheets and facility report/ interpretation of the findings
• Calculate and discuss the program performance
• Prepare a monthly TFP statistics report

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S-1 Introduction
1.6 Objectives for clinical practice sessions

Each clinical session has specific objectives for observation and practice. The course schedule is
designed so that participants learn the content in the participant module before practicing those skills
in a clinical session.
Day 2: Tour of ward(s) and Clinical Signs

• Observe the admissions area
• Observe the emergency treatment area
• Observe how the stabilization center or in-patient care ward or area is organized
• Observe kitchen area
• Observe any special areas for play, health education, etc.
• Look for clinical signs of severe acute malnutrition
• Weigh, and measure height and MUAC of children
• Identify children who are severely malnourished
Day 3: Initial management

• Observe initial management of severely malnourished children
• Identify clinical signs of severe malnutrition, hypoglycemia, hypothermia, shock, and
dehydration
• Practice filling the initial management section of the multi-chart during
• Assist in doing initial management, if feasible, such as:
• Taking temperature,
• Measure and give ReSoMal
• Monitor a child on ReSoMal
• Giving bolus of glucose for hypoglycemia
• Warming child
• Giving first feed
• Determine antibiotics and dosages
Day 4: Feeding and Daily Care

• Observe nurses measuring and giving feeds
• Practice measuring, giving, and recording feeds
• Review Therapeutic diet section of the multi-chart and plan feeds for next day
• Determine if child is ready for transition and Rehabilitation phase
• Assist with feeding (continued practice)
• Participate in daily care tasks, as feasible:
• Measure respiratory rate, pulse rate and temperature
• Administer eye drops, antibiotics, multivitamins; change eye bandages, etc.
• Weigh child and record (on the anthropometric chart section of the Multi-Chart)
• Provide feedback on the recording and reporting formats of the facility
Additional Objectives for In-Patient Clinical Practice

• Observe teaching session with mothers
• Observe play session

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S-1 Introduction
Day 5: Out-patient therapeutic program (OTP) and Supplementary feeding program (SFP)
• Observe the organization of OTP and SFP
• Assess and admit a child to OTP or TSFP
• Assess children with bilateral pitting edema
• Measure MUAC, weight, height
• Classify nutrition status
• Test appetite
• Decide on referral to in-patient or OTP or TSFP
• Treat a child in OTP and TSFP
• Calculate the doses and give routine medicines
• Explain the medical treatment to mother/caregiver
• Calculate amount of RUTF, RUSF or FBF
• Discuss key messages with mothers and care givers
• Recording in the registration books
• Assess and treat a child during the OTP, TSFP follow up sessions

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S-2 Principles
of Care
SESSION 2: PRINCIPLES OF CARE

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S-2 Principles of Care
Introduction
This session will describe how to recognize a child with acute malnutrition and outline the essential
components of care. The severely malnourished child is likely to have many serious health problems in
addition to malnutrition. In many cases these problems may not be clinically apparent. In some cases,
the usual treatment for a problem may be harmful or even fatal for a severely malnourished child.
In this session we will not discuss about stunting and underweight. Stunting is low length or height-
for-age often due to chronic malnutrition. A stunted child may have an adequate weight-for-height,
but low weight- for-age, because they are very short. Stunted children who are not wasted should
not be managed as children with acute malnutrition. Underweight is abnormally low weight-for-age,
often due to a mixed form of acute and chronic malnutrition (stunting). A child with growth failure may
not be wasted (WFH normal) but may be stunted (low HFA), or may be wasted (low WFH) without
growth retardation (normal HFA), or may be wasted with growth retardation.
This session will describe how the physiology of the severely malnourished child is different, and how
these differences affect care.
Learning objectives
This session will describe and allow you to practice the following skills needed to identify children with
severe malnutrition:
• Recognizing signs of acute malnutrition
• Weighing and measuring children (in clinical session)
• Determining a Z- score (or standard deviation Score) based on the child’s weight and length.
• Recognizing bilateral pitting edema
• Measuring mid-upper arm circumference (MUAC)
• Admission procedure for acutely malnourished children
In addition, the session will describe:

• How the physiology of severe malnutrition affects care of the child.
• Essential components of care
• Important things NOT to do and why.
• Recommended admission criteria and discharge criteria for in-patient care

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2.1 Recognize signs of acute malnutrition

You may be familiar with the following signs that are related to SAM. Some of the signs help to
determine whether a child has SAM, and whether to admit for in-patient or out-patient care. The other
signs are used in determining treatments needed.
Visible severe wasting

A child with severe wasting has lost fat and muscle and has a “skin and bones” appearance1. Another
term used for this condition is non-edematous malnutrition (Marasmus”)1.
To look for severe wasting, remove the child’s clothes. Look at the front view and lateral view of the
child:
• Is the outline of the child’s ribs easily seen?

• Does the skin of the upper arms look loose?
• Does the skin of the thighs look loose?
Look at the back view of the child:

• Are the ribs and shoulder bones easily seen?
• Is flesh missing from the buttocks?
When wasting is extreme, there are folds of skin on the buttocks and thighs. It looks as if the child is
wearing “baggy pants”.
Because a wasted child has lost fat and muscle, this child will weigh less than other children of the
same height/length and will have a low weight-for-height/Length Z-score. The child’s upper arm
circumference (MUAC) will also be small.
Figure 2: Child with visible severe wasting
1
Marsmus is currently replaced by Non- edematous SAM.
Note visible severe wasting is no longer recommended as Diagnostic criteria of SAM, due to its subjective nature, but can be
used during community screening, so as to refer to health facility for further evaluation.

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Edema
Edema is swelling from excess fluid in the tissues. Edema is usually seen in the feet and lower legs and
arms. In severe cases it may also be seen in the upper limbs and face.
To check for edema, grasp both feet so that they rest in your hand with your thumbs on top of the feet.
Press your thumbs gently for three seconds (e.g. count 101, 102, 103….). The child has edema if a pit
(dent) remains in both feet when you lift your thumbs (see Fig. 2).
To be considered a sign of severe malnutrition, edema must appear in both feet. If the swelling is only in
one foot, it may just be a sore or infected foot. The extent of edema is commonly rated in the following
way:
Grade +
In this child, there is bilateral pitting oedema in both
feet. This is grade + bilateral pitting oedema (mild);
however, the child might have grade ++ or +++, so
legs and face will also need to be checked.
Grade ++
In this child, both feet plus the lower legs, hands and
lower arms are swollen. This is grade ++ bilateral
pitting oedema (moderate).
Grade +++
This child has +++ bilateral pitting oedema (severe). It

is generalized, including both feet, legs, arms, hands
and face.
Note: Kwashiorkor was the term used previously to refer to edematous SAM. The term kwashiorkor will not be used
in this course.
Figure 3: Grading of edema in severe acute malnutrition
Dermatosis
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Dermatosis is a skin condition. In severe malnutrition, it is more common in children who have edema
than in wasted children. A child with dermatosis may have patches of skin that is abnormally light or
dark in color, shedding of skin in scales or sheets, and ulceration of the skin of the perineum, groin,
limbs, behind the ears, and in the armpits. There may be weeping lesions or severe rash in the nappy
area. Any break in the skin can let dangerous bacteria get into the body. When the skin is raw and
weeping, this risk is very high.
The extent of dermatosis can be described in the following way:
• + (mild): discoloration or a few rough patches of skin

• + + (moderate): multiple patches on arms and/or legs
• + + + (severe): flaking skin, raw skin, fissures (openings in the skin)
Treatment of dermatosis will be discussed in Daily Care Session.
Eye signs
Children with severe malnutrition may have signs of eye infection and/or vitamin A deficiency.
• Bitots’ spots – superficial foamy white spots on the conjunctiva (white part of the eye). These
are associated with vitamin A deficiency.
• Pus and inflammation (redness) are signs of eye infection.
• Corneal clouding is seen as an opaque appearance of the cornea (the transparent layer that
covers the pupil and iris). It is a sign of vitamin A deficiency.
• Corneal ulceration is a break in the surface of the cornea. It is a severe sign of vitamin A deficiency.
If not treated, the lens of the eye may push out and cause blindness. Corneal ulceration is urgent
and requires immediate treatment with vitamin A and atropine (to relax the eye).
Treatment of all eye signs will be discussed in Management of medical Complications and in Daily Care
Sessions.
Figure 4: Picture of an eye

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Medical Complications associated with severe acute malnutrition

Children with severe acute malnutrition and medical complications are at high risk of death. Medical
complication must be identified and addressed with urgency; the child must be hospitalized and
treated by staff with specialized skills. The treatment of medical conditions of patients with severe acute
malnutrition differs from traditional protocols of medical treatment.
Any one of the following complications* associated with severe acute malnutrition requires immediate
medical attention and admission to inpatient care:
• Poor appetite
• Intractable Vomiting
• Convulsion
• Lethargy, not alert
• Unconsciousness
• Hypoglycemia
• High fever (Axillary Temperature ≥38.50.C)
• Hypothermia
• Dehydration
• Lower respiratory tract infection (e.g. Pneumonia)
• Severe anemia
• Persistent diarrhea
• Eye sign of vitamin A deficiency
• Severe Skin lesions (e.g. severe dermatosis)
Note: It is not possible to classify malnourished children with watery diarrhea as severely dehydrated,
due to unreliable clinical signs of dehydration. Usually, classification is “with dehydration” or “no dehy-
dration”. Also, observe changes in pulse, respirations and temperature.
*Medical complications not listed here should also be addressed according to IMCI

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EXERCISE A
In this exercise you will look at photographs of children and identify signs related to SAM.
Open your photo booklet. Each photo is numbered. For each photo listed below in this exercise, write
down all the following signs you see:
• Severe wasting
• Edema
• Dermatosis,
• Eye signs (Bitot’s spots, pus, inflammation, corneal clouding, corneal ulceration)
If the child has dermatosis or edema, try to estimate the degree of severity (+, ++, or +++). If you see
none of the signs, write NONE. When everyone in the group has finished, there will be a discussion of
the photographs. Photo 1 is described below as an example.
Photo 1: Moderate (++) edema, seen in feet and lower legs Severe wasting of upper arms -- Ribs and
collar bones clearly show.
Photo 2:
Photos 3 and 4 (front and back view of same child):
Photo 5:
Photo 6:
Photo 7:
Photo 8:

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Photo 9:
Photo 10:
Photo 11:
Photo 12:
Photo 13:
Photo 14:
Photo 15:
When you have completed this exercise, tell a facilitator that you are ready for the group discussion.

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2.2 Weigh and measure length/height of the child

In addition to looking for visible signs of severe acute malnutrition, it is important to weigh and measure
the child. Then the child’s weight-for-height can be compared to WHO growth reference standards.
Measure Length/height
Carefully measure the child’s length or height once on the first day.
Length is measured lying down on the back (recumbent). Height is measured standing upright.
• For children under 2 years (or is less than 87cm, or, if the age is not available), measure the
length.
• For children 2 years or older (or is 87cm or more, if the age is unknown) and able to stand,
measure the height.
Note: Length is usually greater than standing height by 0.7cm. This difference is taken into account in
the weight-for-height reference chart in the chart booklet. If the child is 87 cm or more, but cannot be
measured standing, subtract 0.7 cm from the supine length4.
Whether measuring length or height, the mother should be nearby to help soothe and comfort the
child.
To measure length:
• Use a measuring board with a headboard and sliding foot piece.
• Lay the measuring board flat, preferably on a stable, leveled table. Cover the board with a thin
cloth or soft paper to avoid causing discomfort and the baby sticking to the board.
• Measurement will be most accurate:
• When the child is naked; (diapers make it difficult to hold the infant’s legs together and
straighten them). However, if the child is upset or hypothermic, keep the clothes on, but
ensure they do not get in the way of measurement.
• Always remove shoes and socks.
• Undo braids and remove hair ornaments if they interfere with positioning the head.
• After measuring, re-dress or cover the child quickly so that he does not get cold.
Work with a partner, One person should

stand or kneel behind the head board and:
• Position the child lying on his back on the
measuring board, supporting the head and
placing it against the headboard.
• Position the crown of the head against the
headboard, compressing the hair
• Hold the head with two hands and tilt upwards
until the eyes look straight up, and the line of
sight is perpendicular to the measuring board.
• Check that the child lies straight along the
center line of the measuring board and does not change position.
Figure 5: Positioning of the head
4 https://www.who.int/childgrowth/standards/Growth_standard.pdf

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The other person should stand alongside the measuring board and:
• Support the child’s trunk as the child is positioned on the board.
• Place one hand on the shin or knees and press gently but firmly.
• Straighten the knees as much as possible without harming the child.
• With the other hand, place the foot piece firmly against the feet. The soles of the feet should
be flat on the foot piece, toes pointing up. If the child bends the toes and prevents the foot
piece touching the soles, scratch the soles slightly and slide in the foot piece when the child
straightens the toes.
• Measure length to the last completed 0.1 cm and record immediately on the Multi-chart.
Figure 6: Measuring length
To measure standing height:

• Use a stadiometer with a vertical back board, a fixed base board, and a movable head board. A
stadiometer is any device used to measure standing height. The stadiometer should be placed
on a leveled floor.
• Remove the child’s socks and shoes for accurate measurement. Also remove hair ornaments and
undo braids if they interfere with measurement.
Work with a partner. One person should kneel or crouch near the child’s feet and:
• Help the child stand with back of the head, shoulder blades, buttocks, calves and heels touching
the vertical board.
• Hold the child’s knees and ankles to keep the legs straight and feet flat. Prevent children from
standing on their toes.
• Young children may have difficulty standing to full height. If necessary, gently push on the
tummy to help the child stand to full height.

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The other person should bend to level of the child’s face and:
• Position the head so that the child is looking straight ahead (line of sight is parallel to the base of
the board).
• Place thumb and forefinger over the child’s chin to help keep the head in an upright position
• With the other hand, pull down the head board to rest firmly on top of the head and compress
hair.
• Measure the height to the last completed 0.1 cm and record it immediately on the Multi chart.
Figure 7: Measuring Height
Note: Although the terms “length” and “height” are often used interchangeably in the text of this training manual, it should be
understood that length is measured for children less than 2 years or less than 87 cm, and standing height is measured for children 2
years or more or 87 cm or more.

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Weigh the child

Weigh the child as soon as possible after he arrives. If the child is admitted, weigh the child once daily,
preferably at about the same time each day. The weighing time should be about one hour before or
after a feed.
There are many types of scales currently in use.
• Uni-scale (has the recommended features listed below)
• Salter Scale (hanging scale)
• Beam Scale etc.
To weigh the child using Uni-Scale: -

A Uni-scale is recommended to be used where it is available. It uses tared weighing.
“Tared weighing” means that the scale can be reset to zero (“tared”) with the person just weighed still
on it. Thus, a mother can stand on the scale, be weighed, and the scale tared.
While remaining on the scale, if she is given her child to hold, the child’s weight alone appears on the
scale.
Tared weighing has two clear advantages:
• There is no need to subtract weights to determine the child’s weight alone (this reduces the risk
of error).
• The child is likely to remain calm when held in the mother’s arms for weighing.
 If the child is aged under 2 years or is unable to stand, carry out tared weighing.
Explain the tared weighing procedure to the mother as follows. Explain that the mother must stay on
the scale until her child has been weighed in her arms.
Be sure that the scale is placed on a flat, hard, even surface. It should not be placed on a loose carpet
or rug, but a firm carpet that is glued down is acceptable. The scale may be solar powered, ensure that
there must be enough light to operate the scale.
• To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale
is ready.
• Check to see that the mother has removed her shoes. You or someone else should hold the
naked baby wrapped in a blanket.
• Ask the mother to stand in the middle of the scale, feet slightly apart (on the footprints, if
marked), and remain still. The mother’s clothing must not cover the display or solar panel.
• Remind her to stay on the scale even after her weight appears, until the baby has been weighed
in her arms.
• With the mother still on the scale and her weight displayed, tare the scale by covering the solar
panel for a second. The scale is tared when it displays a figure of a mother and baby and the
number 0.0.
• Gently hand the naked baby to the mother and ask her to remain still.
• The baby’s weight will appear on the display. Record this weight in the child’s multi-chart. Be
careful to read the numbers in the correct order (as though you were viewing while standing on
the scale rather than upside-down).

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Figure 8: Tarred weighting

 If the child is 2 years or older, you will weigh the child alone if the child will stand still
• Explain that the child will need to step on the scale alone and stand very still.
• Explain that the child needs to remove outer clothing in order to obtain an accurate weight.
• Undress the child. A wet diaper, or shoes and jeans, can weigh more than 0.5 kg.
• Babies should be weighed naked;
• Wrap them in a blanket to keep them warm until weighing.
• Older children should remove all their clothes except minimal clothing, such as their
underclothes.
 If the Uni-scale is not available, a beam scale or a hanging scale (Salter type) can be used to
weigh the child.
• Remove the child’s clothes but keep the child warm with a blanket or cloth while carrying to the
scale.
• Put a cloth in the scale pan to prevent chilling the child.
• Adjust the scale to zero with the cloth in the pan. (If using a scale with a sling or pants or basin,
adjust the scale to zero with that in place.)
• Place the naked child gently in the pan (or in the sling or pants).
• Wait for the child to settle and the weight to stabilize.
• Measure weight to a precision of 0.1 kg (100gm). Record immediately on multi-chart.
• Wrap the child immediately to re-warm.

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Figure 8: Salter Scale
Standardize scales
Standardize scales daily or whenever they are moved:
• Set the scale to zero.
• Weigh one object of known weight and record the measured weight. (A container filled with
stone or IV fluids etc. if the weight is accurately known.)
• Repeat the weighing of these objects and record the weights again.
• If there is a difference of 0.01 kg or more between duplicate weighing, or if a measured weight
differs by 0.01 kg or more from the known standard, check the scales and adjust or replace them
if necessary.

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2.3 Measure mid-upper arm circumference

MUAC is measured on the upper left arm. To locate the correct point for measurement,
• The child’s elbow is flexed to 90°, with the palm facing upwards.
• A measuring tape is used to find the midpoint between the end of the shoulder (acromion) and
the tip of the elbow (olecranon); this point should be marked.
• The arm is then allowed to hang freely, palm towards the thigh,
• The measuring tape is placed snugly around the arm at the midpoint mark.
• The tape should not be pulled too tight or too loose.
• Read the measurement to the nearest 0.1 cm. Further details of the procedure are illustrated
below.
Figure 9: Procedure for measuring MUAC

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2.4 Identifying a child with severe acute malnutrition

Determine Z-score (or standard deviation) based on child’s weight and length/ height What is a
Z-score?
A Z- score (also known as a standard deviation or SD) is a way of comparing a measurement of the
child’s weight-for-length or weight-for-height, to an average. The averages used in this course are WHO
child growth standards values for weight-for-length and weight-for-height (seen on Annex 2a and
Annex 2b).
Note:
The WHO child growth standards use Z-score classification system, which is comparable across ages and
heights, and among different indicators. To learn more about the Z-score, how they are calculated, and how
they relate to percentage of median, refer to annex 2 of this module.
It is important to consider a child’s weight-for-height rather than simply weight-for-age. The latter is affected
by stunting. Stunting may cause low weight-for-age when a child is adequate weight-for-height.
How to determine the Z-score using the Weight-for-Height Reference table

To use the reference table in the chart booklet or on your Weight-for-Height Reference Card:
1. First, find the child’s length or height in the middle column of the table, under the appropriate
heading
2. If the length or height is between those listed in the table, round up or down as follows: if the
length /height is 0.5 cm or greater than the next lower length/height, round up. Otherwise, round
down. (e.g. length 65.5 cm round up to 66 cm and length 65.4 cm round down to 65 cm)
3. Then look in the left columns for boys and right columns for girls in the same row to find the
weight that correspond to the height of the child.
4. Look at the top of the column to see what the child’s Z- score is.
Note: The child’s weight may be between two Z-score. If so, indicate that the weight is between these scores
by writing less than (<). For example, if the weight is between -1 SD and -2 SD, write as < -1SD.
Examples
• A boy: - 63 cm length and weighs 6.1kg
WFL Z-score between -1 SD & -2 SD, so record as < -1SD
• A girl: - 78 cm length and weighs 7.5 kg
WFL Z-score on -3SD, so record as -3SD
• A girl: - 90 cm Height and Weighs 10.3 kg
WFH Z-score between -2 SD & -3 SD, so record as < -2SD

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Determine severe wasting based on mid-upper arm circumference

(MUAC)
Children aged 6 to 59 months with MUAC less than 11.5 cm are severely wasted

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EXERCISE B
Refer to weight for height or length reference table in your chart booklet or on your Weight-for-Height
Reference Card). Indicate the Z- score for each child listed below.
• Shetaye, girl, length 63 cm, weight 5.0 kg
• Robel, boy, height 101 cm, weight 11.8 kg
• Tigist, girl, length 69.8 cm, weight 6.3 kg
• Kumsa, boy, length 82 cm, weight 7.5 kg
When you have completed this exercise, please discuss your answers with
facilitator.

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Flow
FlowChart
Chart ononthe
Flow Chart the
on Management
the Management ofofAcute
Management of Acute AcuteMalnutrition
Malnutrition
Malnutrition
Screen for Acute Malnutrition in the Community

•
•
Diagnose Acute Malnutrition at the Health Facility

•
•
•
•
•
•
SAM (< 6 months) SAM (> 6 months) MAM

• •
•
•
•
•
• •
• •
• •
• •
SC
OTP TSFP
*SAM medical complications include: Poor appetite, intractable vomiting, convulsions, lethargy, not alert, unconsciousness, high fever
(axillary temperature >38.5 °C), lower respiratory tract infection (LRTI), dehydration, persistent diarrhoea, severe anaemia, hypoglycaemia,
hypothermia (axillary temp. < 35 °C), severe skin lesions, eye signs of vitamin A de ciency.
**MAM cases with medical complications need to be managed at TSFP and provided medical care based on the ICCM/IMNCI protocol.
Training course
Training onon
course the management
the ofof
management acute malnutrition
acute malnutrition
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2.5 Recommended criteria to diagnose severe acute malnutrition and

admission to TFP
All children who fulfill any of the following criteria have SAM and they should be admitted to a
Therapeutic Feeding Program (In-patient care also called “Stabilization center” or Out-Patient
Treatment Program (OTP)):
Infants less than six months:

• Weight –for- Length (WFL) < -3Z score
OR
• Presence of bilateral pitting edema
Children 6 to 59 months:
• Weight –for- Length (WFL) / WFH < -3Z score
OR
• Presence of bilateral pitting edema
OR
• MUAC <11.5 cm
Medical Complications*
If a child is 6 to 59 months and has SAM according to the above criteria, check for the following medical
complications that will determine the choice of treatment modalities (In-patient (SC) or Out-patient
(OTP)):
• Poor appetite
• Intractable vomiting
• Convulsions
• Unconsciousness
• High fever (axillary temp ≥ 38.5 0C)
• Lower respiratory tract infection
• Dehydration
• Persistent Diarrhea
• Severe anemia
• Hypoglycemia
• Hypothermia (axillary temperature < 35°C)
• Severe skin lesions
• Eye signs of vitamin A deficiency

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Appetite Test
An appetite test is done for children aged 6 to 59 months who have no medical complications. This is
done to determine whether the child can eat the RUTF (e.g. Plumpy Nut) and can be treated at home.
The test shows whether the child has appetite, accepts the RUTF’s taste, consistency and can swallow.
If a child fails the appetite test, it reflects a severe disturbance of the metabolism and this child needs
to be treated in the stabilization center. A poor appetite indicates that the child has significant infection
or a major metabolic abnormality such as electrolyte imbalance etc.
Passed Appetite Test Failed Appetite Test
The child refuses to eat the RUTF after 30
The child eats some of the RUTF within 30 minutes.
minutes.
See the chart booklet (page 3) for the appetite test steps and interpretation. If a child passes the
appetite test, he/she should be treated as out-patient if OTP service is available.
Recommended criteria and procedure for admission for acute malnutrition
Children with SAM are treated at OTP or in Stabilization center (SC). The age of a child, presence
or absence of medical complications and result of the appetite test determine whether a child
with SAM should be treated in OTP or in-patient care (stabilization center). In-patient and OTP are
different components of the same program. Use the Assessment and Classification of a Child with
Acute Malnutrition table 1.1 or on your chart booklet (pages 4 & 5) to determine which treatment is
appropriate for a child with SAM.
Out-patient Treatment Program (OTP): Children with SAM and have no medical complications, and
who pass the appetite test are classified as uncomplicated SAM and they are treated in OTP with RUTF
and routine medicines. These treatments are taken at home, and the child attends the outpatient care
site every week. Read session 8 of the module for brief description on the management protocol of
OTP.
In-patient care (SC): All children with SAM need to be treated in an in-patient care facility if they fulfill
any one of the following*:
1. Infants below six months of age with SAM
OR
2. Children 6 to 59 months with SAM who have any one of the medical complications
OR
3. Children 6 to 59 months with SAM who have failed appetite test
OR
4. Children with SAM and referred from OTP for in-patient care
• When OTP is not available in your working area or where the care taker lives or if the care taker’s
choice is inpatient care, all SAM children need to be admitted for in-patient care even if they do
not fulfill the In-patient admission criteria.
*A child who fulfills any of the four above criteria is classified as complicated severe acute
malnutrition
Note: Children with severe acute malnutrition that need in-patient care are in danger of death from
hypoglycemia, hypothermia, fluid overload, and undetected infections. They cannot be treated like other
children. Their feeding and fluids must be carefully controlled, or they could die. To ensure the proper feeding
and treatment routines, it is critical to keep these children in SC or separate rooms within a ward
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Supplementary Feeding programme (SFP): Individuals with moderate acute malnutrition (MAM) are
treated in the supplementary feeding programme and should meet the following criteria:
A. Children 6-59 months
MUAC =11.5 to <12.5 cm
OR
WFH =-3 to <-2 Z scores
AND
No bilateral pitting oedema
B. Pregnant and lactating women (PLW) (up to 6 months post-partum)
MUAC < 23.0 cm

Note:
If moderately malnourished child in TSFP has medical complication/disease, then treat
based on ICCM/IMNCI or refer for treatment as needed.
If MUAC of PLW is < 18.5 cm admit in TSFP and refer to HC for further investigation.

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Table 1: Asses and Classify infants age UNDER 6 MONTHS for Severe Acute Malnutrition (SAM)
Signs
Ask Look and Feel Sign Classify Treat
Ask for signs of 1. Check for presence of

medical
bilateral pitting edema
• Does the infant
complications: have bilateral pitting
edema?
• Is the infant’s WFL < -3
z-score?
2. Check for medical
Is the patient: complications for treatment
purposes SAM with
• Too weak • Hypoglycemia, or without Refer/
to suckle • Hypothermia (axillary • Any grade medical Admit in
effectively? of bilateral complications. SC.
temp.<35°C)
• Vomiting pitting
everything? • Poor appetite edema (+,
• Intractable vomiting ++ or +++)
• Convulsions
OR
• Unconsciousness
• High fever (axillary • WFL < - 3 z
temp. >38.5 °C) score
• Lower respiratory
tract infection (LRTI)
• Dehydration
• Persistent diarrhea
• Severe anemia

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Table 2: Asses and Classify Children age 6 TO 59 MONTHS f or SAM

Ask Look and Feel Sign Classify Treat
Ask for signs of 1. Check for presence of  Bilateral pitting edema +++
medical bilateral pitting edema
complications: • Does the child have bilateral  Any grade of bilateral pitting
pitting edema? edema combined with severe
• If yes, is it +++ (generalized wasting, (MUAC <11.5 cm or
involving upper arms and face)? WFH <-3 z score)
Is the patient:  Bilateral pitting edema +, ++,
2. Check MUAC OR
• Unable to  Severe wasting, (MUAC <11.5
breastfeed, • Is the child’s MUAC < cm or WFH <-3 z score) Complicated
drink or feed? 11.5cm? AND SAM
any of the following medical
• Vomiting 3. Check the WFH
everything? complications: Refer/
 Is the child’s WFH <-3 z-score?  Poor appetite Admit
4. Check for medical  Intractable vomiting
in SC.
Does the patient
complications:  Convulsions
have:
 Poor appetite  Lethargy, not alert
• Blood in  Intractable vomiting  Unconsciousness
stool?  Convulsions  High fever
• Diarrhea >  Lethargy, not alert  Lower respiratory tract infec-
14days?  Unconsciousness tion (LRTI)
• Cough > 14  High fever (axillary temp.  Dehydration
days, or had >38.5 °C)
contact with  Lower respiratory tract infec-  Persistent diarrhea
TB patients? tion (LRTI)  Severe anemia
• Bleeding  Dehydration  Hypoglycemia
tendencies?  Persistent diarrhea  Hypothermia
• History  Severe anemia  Severe skin lesions
of recent  Hypoglycemia,  Eye signs of vitamin A defi-
sunken eyes?  Hypothermia (axillary ciency
• Convulsion(s) temp.<35°C)
 Bilateral pitting edema +
 Severe skin lesions or ++
 Eye signs of vitamin A deficiency. OR
 MUAC <11.5 cm
OR Uncomplicated
Admit in OTP
 WFH <-3 z-score SAM
AND
 Appetite test passed
 Clinically well and alert
 MUAC ≥11.5 to <12.5 cm Admit in TSFP
OR and counsel
 WFH ≥ -3 to <-2 z scores on appropriate
AND MAM IYCF
 Clinically well and alert Practices
 No bilateral pitting edema
 MUAC ≥ 12.5 cm Congratulate

OR and
 WFH ≥ -2 z score counsel the
AND No acute mother on
 No bilateral pitting edema Malnutrition appropriate
IYCF practices

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EXERCISE C
In this exercise, you will look at photographs and consider information about a child in order to
determine if the child should be admitted for In-patient care. Use the criteria and the Assessment and
Classification of a Child with Acute Malnutrition table given on the previous page in this session. Refer
to Annex 2 Weight-for-Height Reference Card as needed.
Photo 18: This child is a girl, age 20 months. She is 67 cm in length. She weighs 6.5 kg and fails the
appetite test. She has no medical complication. Should she be admitted to In-patient care? Why or why
not?
Photo 19: This child is a girl, age 6 months. She is 60 cm in length and weighs 4.6 kg. Does she have
Severe Acute Malnutrition? Why or why not?
Photo 20: This child is a boy, age 18 months. He is 65 cm in length and weighs 4.8 kg. He has no medical
complication and passed appetite test. Should he be admitted to the in-patient care? Why or why not?
No Photo: This child is a girl, age 5 months. She is 65 cm in length and weighs 4.0 kg. Should she be
admitted to the in-patient care? Why or why not?
No Photo: This child is a boy, age 7 months. His length is 60 cm. He weighs 3.5 kg and has edema of
both feet. Should he be admitted to the in-patient care? Why or why not?
When you have completed this exercise, tell a facilitator that you are ready for the group
discussion and drill.

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2.6 How does the physiology of severe acute malnutrition affect care
of the child?
Children with severe acute malnutrition must be treated differently because their physiology is
abnormal due to reductive adaptation.
What is reductive adaptation?
The systems of the body begin to “shut down” with severe malnutrition. The systems slow down and do
less in order to allow survival on limited calories. This slowing down is known as reductive adaptation.
As the child is treated, the body’s systems must gradually “learn” to function fully again. Rapid changes
(such as rapid feeding or fluids) would overwhelm the systems, so feeding must be slowly and
cautiously increased.
A simplified explanation of the implications reductive adaptation for care is provided below.
How does reductive adaptation affect care of the child?
Reductive adaptation affects treatment of the child in a number of ways. Three important
implications for care are described in the next paragraphs.
Presume and treat infection
Nearly all children with severe malnutrition have bacterial infections. However, as a result of reductive
adaptation, the usual signs of infection may not be apparent, because the body does not use its limited
energy to respond in the usual ways, such as inflammation or fever.
Examples of common infections in the severely malnourished children are ear infection, urinary tract
infection and pneumonia. Assume that infection is present and treat all severe malnutrition admissions
with broad spectrum antibiotics. If a specific infection is identified (such as Shigella), add specific
appropriate antibiotics to those already being given.
Note: Choices of antibiotics will be discussed in the initial management session
1. Do not give iron early in treatment

Due to reductive adaptation, the severely malnourished child makes less hemoglobin than usual. Iron
that is not used for making hemoglobin is put into storage. Thus, there is “extra” iron stored in the body,
even though the child may appear anemic. Giving iron early in treatment will not cure anemia, as the
child already has a supply of stored iron.
Giving iron early in treatment can also lead to “free iron” in the body. Free iron can cause problems in
three ways:
• Free iron is highly reactive and promotes the formation of free radicals, which may engage in
uncontrolled chemical reactions with damaging effects.
• Free iron promotes bacterial growth and can make some infections worse.
• The body tries to protect itself from free iron by converting it to ferritin. This conversion requires
energy and amino acids and diverts these from other critical activities.
Later, as the child recovers and begins to build new tissue and form more red blood cells, the iron in
storage will be used and supplements will be needed.

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2. Provide potassium and restrict sodium

Normally the body uses a lot of energy maintaining the appropriate balance of potassium inside the
cells and sodium outside the cells. This balance is critical to maintaining the correct distribution of water
inside the cells, around the cells and in the blood.
In reductive adaptation, the “pump” that usually controls the balance of potassium and sodium runs
slower. As a result, the level of sodium in the cells rises and the potassium leak out of the cells and is lost
(for example, in urine or stools). Fluid may then accumulate outside of the cells (as in edema) instead of
being properly distributed through the body.
All severely malnourished children should be given potassium to make up for what is lost. (They should
also be given magnesium, which is essential for potassium to enter into the cells and be retained.). The
commercially prepared F-75 and F -100 have enough potassium and magnesium and there is no
need to supplement. However, if you use the F-75 and F-100 recipe that are prepared by the health
facility locally, Combined Mineral Vitamin mixes (CMV) should be given to supplement potassium,
Magnesium, and other important minerals and vitamins.
Malnourished children already have excess sodium in their cells, so sodium intake should be restricted.
If a child has diarrhea, a special rehydration solution called ReSoMal should be used instead of regular
WHO ORS. ReSoMal has less sodium and more potassium than regular WHO ORS.

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Briefly answer these questions as a review of the previous section:
1. When a child is severely malnourished, why is it important to begin feeding slowly and cautiously?
2. Why should all severely malnourished children be given antibiotics?
3. Why is it dangerous to give iron early in treatment?
4. Why is ReSoMal preferable than Regular ORS for SAM children with diarrhea?
Tell the facilitator when you are ready to discuss these questions with the group.

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2.7 Overview of the essential components of care

Feeding formulas:
F-75, F-100 Formulas and RUTF
F-75 is the “starter” formula used during Stabilization phase, beginning as soon as possible and
continuing for 2-7 days until the child is stabilized. Severely malnourished children cannot tolerate
usual amounts of protein and sodium at this stage, or high amounts of fat. They may die if given too
much protein or sodium. They also need glucose, so they must be given a diet that is low in protein
and sodium and high in carbohydrate. F-75 is specially made to meet the child’s needs without
overwhelming the body’s systems in the initial stage of treatment. Use of F-75 prevents deaths.
F-75 contains 75 kcal and 0.9 g protein per 100 ml.
F-100 contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml
RUTF is an energy-dense food equivalent to F-100. It is made from peanut butter paste, vegetable oil,
skimmed milk, maltodextrin, sugar, and combined minerals and vitamins (CMV) mix. RUTF is similar in
composition to F-100, the major difference being the added iron in RUTF.
Since no water is added during preparation, bacteria cannot grow on RUTF and it has a shelf-life of 24
months. It is often packaged in a 92 g packet, which contains 500 kcal.
RUTF is given with clean drinking water. The number of sachets to be consumed per day is based on the
severely malnourished child’s weight. As soon as the child is stabilized on F-75, F-100 or RUTF can be
used as a “catch-up” formula to rebuild wasted tissues.
RUTF enables severely malnourished children to be discharged from inpatient care early, so they
can continue care from home while attending a weekly outpatient therapeutic programme. RUTF is
given after each weekly nutritional and medical assessment until full recovery and discharge from the
programme.
The compositions of F-75, F-100 and RUTF are described in Annex 3 to this module.
Several recipes are given below for F-75 and F-100. The choice of recipe may depend on the availability
of ingredients, particularly the type of milk. The first three recipes given for F‑75 include cereal flour and
require cooking. The F-100 recipes do not require cooking as they do not contain cereal flour.
The principle behind the recipes is to provide the energy and protein needed for stabilization and
catch-up. For stabilization (F-75), it is important to provide a formula with the energy and protein as
shown (no less and no more). For catch-up (F-100), the recipes show the minimum energy and protein
contents needed.
More instructions on how to prepare F-75 and F-100 will be given in the module on feeding.

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Mineral mix
Mineral mix is included in each recipe for F-75 and F-100. It is also used in making ReSoMal. The mix
contains potassium, magnesium, and other essential minerals. It is included in F-75 and F-100 to
correct electrolyte imbalance.
If you are preparing a locally made F 75, F 100 or ReSoMal, the mineral mix could be made in the
pharmacy of the hospital. Annex 4 a commercial product called Combined Mineral Vitamin Mix (CMV)
may be used to provide the necessary minerals in the constitution of the preparations.
Vitamins
Vitamins are also needed in or with the feed. Vitamin mix cannot be made in the hospital pharmacy
because amounts are so small. Thus, children are usually given multivitamin drops as well. The
multivitamin preparation should not include iron.
If available, CMV may be used to provide the necessary vitamins. If CMV is used, separate multivitamin
drops are not needed.
Note: The commercially manufactured F75 and F100 have all the necessary minerals and vitamins. Thus,
there is no need to add mineral mix or vitamins or CMV in to these feeds.

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1. What are the two important differences between F-75 and F-100?
2. Why is it important to have two different formulas (F-75, and F-100) for treating severe malnutrition?
3. Mineral mix (or CMV) is included in F-75 and F-100 to correct electrolyte imbalance. What are two
important minerals in this mix and why?
Tell the facilitator when you are ready to discuss these questions with the group

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2.8 Process for successful management of children with SAM in

Stabilization center (In-patient care)
The following process is essential for successful in-patient management of the severely malnourished
child. You will learn how to do these important steps in initial management, Feeding and Daily Care.
1. Treat/prevent hypoglycemia
2. Treat/ prevent hypothermia by feeding, keeping warm and treating infection.
3. Treat/prevent dehydration using Rehydration Solution for Malnutrition (ReSoMal).
4. Correct electrolyte imbalance (by giving feeds and ReSoMal with mineral mix/CMV).
5. Presume and treat infection with antibiotics.
6. Correct micronutrient deficiencies (by giving feeds and extra vitamins like vitamin A and
folic acid as needed).
7. Start cautious feeding with F-75 to stabilize the child (usually 2-7 days).
8. Rebuild wasted tissues through higher protein/calorie feeds (F-100 or RUTF).
9. Provide stimulation, play, and loving care.
10. Prepare parents to continue proper feeding and stimulation after discharge.
Management of Child with SAM in Stabilization Center
It is divided into three phases: -

1. Initial treatment: Life-threatening problems are identified and treated in a hospital or a health
centre, specific deficiencies are corrected, metabolic abnormalities are reversed, and feeding is
begun.
2. Rehabilitation: Intense feeding is given to recover most of the lost weight, emotional and
physical stimulation is increased, the mother or caregiver is trained to continue care at home,
and preparations are made for discharge of the child
3. Follow-up. After discharge, the child and the child’s family are followed to prevent relapse and
ensure the continued physical, mental and emotional development of the child.
Successful management of the severely malnourished child does not always require sophisticated
facilities and equipment. It does, however, require that each child be treated with proper care and
affection, and that each phase of treatment be carried out properly by well trained and dedicated health
workers.
When this is done, the risk of death can be substantially reduced and the opportunity for full recovery
greatly improved.

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Timeline for the management of children with severe acute malnutrition

Activity Initial treatment Rehabilitation Follow-up
Days 1–2 Days 3–7 Weeks 2–6 Weeks 7–26
Treat and prevent:
Hypoglycaemia
Hypothermia
Dehydration
Correct electrolyte imbalance
Treat infections
Correct micronutrient deficiencies Without iron With iron
Start feeding
Increase quantity to compensate
weight loss (catch-up growth)
Provide stimulation and nurturing
care
Prepare for discharge and follow up
Important things NOT to do and why

• Do not give diuretics to treat edema. The edema is partly due to potassium and magnesium
deficiencies that may take about 2 weeks to correct. The edema will go away with proper
feeding including a mineral mix containing potassium and magnesium. Giving a diuretic will
worsen the child’s electrolyte imbalance and may cause death.
• Do not give iron during initial feeding (Stabilization) phase. Add iron only after the child
has been on F-100 for 2 days (usually during week 2). Do not give iron if on RUTF. As described
earlier, giving iron early in treatment can have toxic effects and interfere with the body’s ability
to resist infection.
• Do not give high protein formula (over 1.5 g protein per kg body weight daily). Too much
protein in the first days of treatment may be dangerous because the severely malnourished
child is unable to deal with the extra metabolic stress involved. Too much protein could overload
the liver, heart, and kidneys and may cause death.
• Do not give IV fluids routinely. IV fluids can easily cause fluid overload and heart failure in a
severely malnourished child. Only give IV fluids to children with signs of shock. (Treatment will
be described in the next session Initial management.)
Be sure that personnel in the emergency treatment area of the hospital know these important things NOT to
do, as well as what to do.

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Fill in the blanks based on your reading in the Session:
1. Two conditions that are related and must be treated immediately in a severely malnourished
child are _________________ and __________________.
2. Cautious feeding with _______ is necessary at first to stabilize the child. Later, ______is given to
rebuild wasted tissues and gain weight.
3. To correct electrolyte imbalance, it is important to give feeds prepared with ___________ mix or
pre-packaged CMV mix.
4. If a severely malnourished child has diarrhea, a special rehydration solution called___________
should be given. This solution has less ____________ and more ________________ than regular
ORS.
Indicate in the blank whether the statement is true or false:

5. ______ Giving IV fluids too quickly can cause heart failure in a severely malnourished child.
6. ______All severely malnourished children should be given antibiotics.
7. ______ Diuretics should be given to reduce edema.
Check your own answers to this exercise by comparing them to the

answers given on next page.

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Answers to short answer exercise (see previous page)

1. Two conditions that are related and must be treated immediately in a severely malnourished child
are hypoglycaemia and hypothermia.
2. Cautious feeding with F-75 is necessary at first to stabilize the child. Later, RUTF/ F-100 is given to
rebuild wasted tissues and gain weight.
3. To correct electrolyte imbalance, it is important to give feeds prepared with vitamin and mineral mix
or pre-packaged CMV mix.
4. If a severely malnourished child has diarrhoea, a special rehydration solution called ReSoMal should
be given. This solution has less sodium and more potassium than regular ORS.
5. Note: ReSoMal also has more sugar than regular ORS.
6. True
7. True
8. False

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2.9 Discharge Criteria for a severe acute malnutrition from in-patient

care
If an outpatient programme on management of severe acute malnutrition is in place:
The national protocol recommends that children 6-59 months be kept in the severe acute malnutrition
ward or Stabilization Centre until their condition is stabilized (regained appetite, reduced oedema and
good acceptance of RUTF during the transition phase).
It usually requires about 2 to 7 days for a child to be stabilized (return of appetite, medical
complications managed, reduced oedema + or ++). The child should then be referred for outpatient
care after transitioning to an RUTF that can be consumed at home.
If a child leaves before being stabilized, they are likely to get worse and have to return or may die.
If no outpatient programme on management of severe acute malnutrition is in place:
The national protocol recommends that children 6-59 months be kept in the severe acute malnutrition
ward or Stabilization centre until they are above or equal to –2 Z-score weight-for-height/length and
have had no oedema for at least 2 weeks; or their MUAC is above or equal to 12.5 cm and they have
had no oedema for at least 2 weeks.
If a child leaves before achieving the recommended weight-for-height or MUAC cut-off, they are likely
to get worse and have to return, or may die.
If early discharge is necessary, many preparations must be made to ensure that the parents can
continue care at home. Follow-up visits are essential. There will be a discussion exercise about early
discharge situations in Session 7, on involving mothers in care.
If infant under 6 months with severe acute malnutrition:
The national protocol recommends that for infants with prospect of breastfeeding are kept in the severe
acute malnutrition ward or stabilization center until successful re-lactation and effective breastfeeding
has been achieved, child is gaining weight on exclusive breastfeeding (i.e. more than 5 g/kg/day for at
least 3 successive days), no bilateral pitting edema and are clinically well and alert.
Infants with no prospect of breastfeeding should be kept in the stabilization center until they have a
WFL ≥ -2 z-score and no bilateral pitting edema. The infant should be checked for immunization and
other routine interventions while the mothers or caregivers linked with community-based follow-up
and support.
Tell a facilitator when you have reached this point in the session. There will be a brief video
showing signs of severe malnutrition and the transformations that can occur when severely
malnourished children are correctly managed. You will also discuss photos 21 – 29, which show
children before and after treatment for severe malnutrition. Look at these photos while waiting
for the video.

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S-3 Initial
Management
SESSION 3: INTITAL MANAGEMENT

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S-3 Initial Management
Introduction
The focus of initial management is to prevent death while stabilizing the child. The first step is to check
the child for emergency signs and provide emergency treatment as necessary. Any child presenting to
the hospital or health center should be checked for serious medical complications as part of standard
procedure.1
If emergency situation, many procedures must be done very quickly, almost simultaneously. Practice
and experience is needed to perform efficiently in an emergency room as a team. This course obviously
cannot teach the entire process of emergency management, but it will focus on the steps that must be
added or adjusted to treat the severely malnourished child.
Some of the initial management procedures described in this session may be performed in the
emergency room or triage area or OPD before the child is admitted to SC or wards for children with
SAM. It is very important that emergency room staff know how to treat the severely malnourished child
appropriately. They must be taught to recognize severely malnourished children and to understand that
these children may be seriously ill even without showing signs of infection. A severely malnourished
child should be seen as quickly as possible in the emergency room or triage area or OPD. Staff must
understand that they should not put up a rapid IV but should follow procedures as outlined in the
module, session 3.
When any necessary emergency treatment has been provided, the child should be moved immediately
to the wards for children with SAM. For several days, it is critical to watch for and treat or prevent such
life threatening problems as hypoglycemia, hypothermia, shock, dehydration and infection. Only later,
after these problems are under control and the child is stabilized, is the child expected to gain weight.
This session describes the life-saving tasks that are essential to initial management of the severely
malnourished child.
Learning Objectives
This session will describe and, to the extent feasible, allow you to observe and/or practice the following
skills:
• Identifying and managing the severely malnourished child with:

• Hypoglycemia
• Hypothermia
• Shock
• Severe anemia
• Corneal clouding and ulceration
• Watery diarrhea and/or vomiting and dehydration
• Heart failure
• Infections
• Abdominal distension
• Preparing ReSoMal
• Selecting appropriate antibiotics and calculating dosages
• Keeping a written record of initial findings and treatments
Basic emergency treatment is taught in medical schools and will not be taught in this course. For additional information, you
1
may refer to the National Protocol

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3.1 Manage Hypoglycemia

What is Hypoglycemia?
Hypoglycemia is a low level of glucose in the blood. In severely malnourished children, the level
considered low is less than <54 mg/dl (< 3 mmol/L). The hypoglycemic child is usually hypothermic
(low temperature) as well.
Other signs of hypoglycemia include
• Lethargy,
• Limpness,
• Loss of consciousness.
• Eye-lid retraction (due to overactive sympathetic nervous system, thus a child sleep with eyes
slightly open).
Note: -Sweating and pallor may not occur in malnourished children with hypoglycemia. Often the
only sign before death is drowsiness.
The short-term cause of hypoglycemia is lack of food. Severely malnourished children are more at
risk of hypoglycemia than other children and need to be fed more frequently, including during the
night. Malnourished children may arrive at the health center/hospital hypoglycemic if they have been
vomiting, if they have been too sick to eat, or if they have had a long journey without food. Children
may develop hypoglycemia in the hospital if they are kept waiting for admission, or if they are not fed
regularly or if there is a long time between feeds. Hypoglycemia and hypothermia are also signs that the
child has a serious infection.
Hypoglycemia is extremely dangerous. The child may die of hypoglycemia if not given glucose followed
by F-75 immediately.
Test blood glucose level

If blood was not taken during emergency procedures, take a sample on admission to the ward. The
same sample can be used to determine blood glucose level, hemoglobin level and blood type, in case a
transfusion is needed.
There may not be enough time to take and test a blood sample right away. If hypoglycemia is
suspected, give treatment immediately without laboratory confirmation. If no testing strips are
available, or if it is not possible to get enough blood to test, assume that the child has hypoglycemia.
Blood glucose level can be tested using treated paper strips such as Dextrostix, Glucostix, or other
similar products if available.
Prevent Hypoglycemia: - Begin F-75

If the child’s blood glucose is not low, begin feeding the child with F-75 right away. Feed the child every 2
hours (12 feeds per day), even during the night especially in the first 24 hours. Appropriate amounts are
given in your F-75 Reference Card. These frequent, small feeds will prevent hypoglycemia and provide
nutrients for the child during the initial period of stabilization.
Look at F-75 reference card now.

There are two F-75 reference card tables. One shows amounts for children without oedema or with mild
(+) or moderate (++) oedema, and the other one (on the reverse side) presents amounts for children
with severe oedema (+++). Notice that the amounts for children with severe oedema are smaller. Notice
that the first column shows the weight of the child, and the next column shows the amount of F-75 to
give every 2 hours. The remaining columns, which show amounts for 3-hourly and 4‑hourly feeds, will
be used later, as the child progresse

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Treat Hypoglycemia
If blood glucose is low or hypoglycemia is suspected, immediately give the child a 50 ml bolus of 10%
glucose or 10% sucrose orally or by NG tube. Though 50 ml is a very small amount, but it can make a
big difference to the child.
Glucose is preferable because the body can use it more easily; sucrose must be broken down by the
body before it can be used. However, give whichever is available most quickly. If only 50% glucose
solution is available, dilute one part to four parts sterile or boiled water to make a 10% solution as
shown in the table 2.
Table 2: preparations for 10% dextrose

Mixture Gives
12.5 ml of 40% dextrose + 37.5 ml of Distilled water
7.5 ml of 40% dextrose + 42.5 ml of 5% dextrose

50 ml of
10 ml of 50% dextrose + 40 ml Distilled water 10% Dextrose
6 ml of 50% dextrose + 44 ml of 5% dextrose
• If the child can drink, give the 50 ml bolus orally. If the child is alert but not drinking, give the 50 ml
by NG tube (i.e., 37.5 ml of distilled water with12.5 ml of 40% dextrose).
• If the child is lethargic, unconscious, or convulsing, give 5 ml/kg body weight of sterile 10%
glucose by IV, followed by 50 ml of 10% glucose or sucrose by NG tube. If the IV dose cannot be given
immediately, give first dose through NG tube.
*Note:-If the child will be given IV fluids for shock, there is no need to follow the 10% IV glucose with an NG
bolus, as the child will continue to receive glucose in the IV fluids.
Start feeding F-75 half an hour after giving glucose and give it every half-hour during the first 2 hours
(giving 1/4 of the 2-hour F-75 feed each time).
For a hypoglycemic child, the amount to give every half-hour is ¼ of the 2-hourly amount shown on
your F-75 Reference Card.
Take another blood sample after 2 hours and check the child’s blood glucose again.
• If blood glucose is now 54 mg/dl (3mmol/l) or higher, change to 2-hourly feeds (12 feeds per
day) of F-75.
• If still low, make sure antibiotics and F-75 have been given. Keep giving F-75 every half-hour and
treat with second-line antibiotics
Example
Araya weighs 7.4 kilograms. He has hypoglycemia and is given a 50 ml bolus of 10% glucose orally
shortly after arrival at the hospital. One half-hour after taking the glucose, Araya should be
given ¼ of the 2-hourly amount of F-75 for his weight. The 2-hourly amount is 80 ml, so Araya should
be given at least 20ml every half-hour for two hours. Then, if his blood glucose is 54 mg/dl (3mmol/l) or
higher, he should be given 80ml of F-75 every 2 hours

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3.2 Manage Hypothermia

What is Hypothermia?
Hypothermia is low body temperature. A severely malnourished child is hypothermic if the rectal
temperature is below 35.5 0C or if the axillary temperature is below 35 0C.
Severely malnourished children are at greater risk of hypothermia than other children and need to
be kept warm. The hypothermic child has not had enough calories to warm the body. If the child is
hypothermic, he is probably also hypoglycemic. Both hypothermia and hypoglycemia are signs that the
child has a serious systemic infection.
Take temperature
Rectal temperatures are preferred because they more accurately reflect core body temperature. If
axillary temperatures are taken, convert them to rectal by adding 0.5 0c.
If possible, use a low-reading thermometer (it is a type of thermometer that reads body temperature as
low as 300C). If not available, use an accurate digital thermometer.
For using an axillary thermometer:

• Place in the arm pit
• If below 35.00C, take rectal temperature for more accurate reading.
Warm the child

Severely malnourished children have difficulty controlling their body temperature and so must be kept
warm and fed frequently. Keeping them warm also conserves their energy.
Hypothermia is very dangerous. If the child is hypothermic, re-warming is necessary to raise
temperature.
Maintain temperature (prevent hypothermia)

The following measures are important for all severely malnourished children:
• Feed F-75 every 2 hours, starting straight away.
• Always give feeds throughout the day and night.
• Keep the patient covered and away from draughts.
• Warm your hands before touching the patient (both health service providers and caregivers).
• Keep the child dry and promptly change wet nappies, clothes, and bedding.
• Avoid prolonged exposure (e.g., bathing, prolonged medical examinations).
• Let the child sleep with the mother/caregiver at night for warmth.
• Maintain room temperature between 28° C and 32° C.
• Dry the child thoroughly after bathing.
If it is not possible to warm the room, let the child sleep with skin to skin contact to the mother or
caretaker, and cover them with a blanket.

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Actively re-warm the hypothermic child

In addition to keeping the child covered and keeping the room warm, use one of the following re-
warming techniques if the child is hypothermic:
• Have the mother hold the child with his skin next to her skin when possible (technique
kangaroo), Keep the child’s head covered and cover both of them.
• Give warm Fluid to the mother.
• Use a heater or incandescent lamp with caution. Use indirect heat (not too close).
• Monitor temperature every 30 minutes to make sure the child does not get too hot. Stop re-
warming when the child’s temperature becomes normal.
• Do NOT use hot water bottles due to danger of burning fragile skin.
Note: - All hypothermic children are more likely to have hypoglycemia and infection as well.
Figure 11: Kangaroo technique

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Example of initial management section of the Multi-chart
STABILISATION CENTRE (SC) MULTI-CHART FOR SEVERE ACUTE MALNUTRITION
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kg (child’s wt
kg (child’s wt) = kg (child’s wt) =

kg (child’s wt) =
59
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666
650

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3.3 Manage watery diarrhea and/or vomiting and Dehydration

Recognize Dehydration and the need for ReSoMal
Misdiagnosis and incorrect treatment for dehydration is among the common causes of death in children
with SAM undergoing rehabilitation.
It is often difficult to determine hydration status in a severely malnourished child, as the usual signs of
dehydration (such as lethargy, sunken eyes and skin pinch) may be present in these children all of the
time, whether or not they are dehydrated.
Diagnosis of dehydration is mainly based on the history rather than on patient’s examination alone.
Ask the mother if the child has had watery diarrhea or vomiting, recent change in the child’s appearance
and recent sunken eyes.
Consider the diagnosis of dehydration in non-edematous child and give ReSoMal if there are:
• Definite history of significant recent fluid loss (watery diarrhea, not just ‘loose’ stools, appearing
with sudden onset in the last hours or days)
• Clear history of a recent change in the child’s appearance
• If the eyes are sunken then the mother must say that the eyes have changed to become sunken
since the diarrhea or vomiting started
Edematous children are over-hydrated, but they are frequently hypovolemic due to extravasation
fluid. If the child with edema has definite watery diarrhea and is deteriorating clinically (excessive
weight loss, more than 2% of the body weight per day), the child is dehydrated.
Note: The following signs of dehydration are important to detect improvements later during
rehydration and not necessarily for initial diagnosis. (Also ask about blood in the stool, as this will affect
choice of antibiotics.)

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General Signs of Dehydration to follow during rehydration
Lethargic A lethargic child is not awake and alert when he should be. He is drowsy and
does not show interest in what is happening around him.
A severely malnourished child is usually apathetic and, as dehydration worsens,

the child progressively loses consciousness.
Restless, irritable The child is restless and irritable all the time, or whenever he is touched or
handled.
A severely malnourished child is usually irritable when handled.

Sunken eyes The eyes of a severely malnourished child may always appear sunken,
regardless of the child’s hydration status. Ask the mother if the child’s eyes
appear unusual. Photographs 6, 30, and 31 (in the Photographs booklet)
show sunken eyes.
Thirsty See if the child reaches out for the cup when you offer ReSoMal. When it is
taken away, see if the child wants more.
Dry mouth and Feel the child’s tongue and the inside of the mouth with a clean, dry finger to
tongue determine if they are dry.
The salivary and lacrimal glands are atrophied in severe acute malnutrition, so
the child usually has a dry mouth and absent tears.
Skin pinch goes Using your thumb and first finger, pinch the skin on the child’s abdomen
halfway between the umbilicus and the side of the abdomen. Pinch the skin
back slowly for one second and then release. If the skin stays folded for a brief time after
you release it, the skin pinch goes back slowly. (Note: the skin pinch may
always go back slowly in a wasted child.)
Edema may mask diminished elasticity of the skin. Also, in severely malnourished
children, the loss of supporting tissues and absence of subcutaneous fat make the
skin thin and loose.
*Note: Although these changes can indicate that rehydration is proceeding, many severely malnourished
children will not show all these changes even when fully rehydrated.

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What is ReSoMal?
ReSoMal is a rehydration solution for malnutrition. It is a modification of the standard Oral Rehydration
Solution (ORS) recommended by WHO. ReSoMal contains less sodium, more sugar, and more potassium
than standard ORS and is intended for severely malnourished children with diarrhea.
It should be given by mouth or by nasogastric tube. Do not give standard ORS to severely malnourished
children. However, if a child with severe acute malnutrition has profuse watery diarrhea as in the case of
cholera, he or she should be given standard ORS and not ReSoMal
ReSoMal is available commercially in some places, but it may also be prepared from standard ORS and
some additional ingredients.
Contents of ReSoMal as prepared from standard ORS:

Water 2 liters
WHO-ORS one 1 liter packet
Sugar 50 g
Mineral mix solution* 40 ml or one leveled scoop CMV
*The mineral mix solution is the same as that is used in making F-75 and F-100. Composition of mineral mix is
described in principle of care annex 4. It may be prepared by the hospital pharmacy. Alternatively, a commercial
product, called Combined Mineral Mix (CMV), may be used. If CMV or mineral mix is not available, prepare without
the mixes

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Prepare ReSoMal
If using commercial ReSoMal, follow the package instructions. If preparing ReSoMal from standard ORS
and mineral mix solution, prepare as follows:
• Wash hands.
• Empty one 1-litre standard ORS packet into container that holds more than 2 liters.
• Measure and add 50 grams of sugar. (It is best to weigh the sugar on a dietary scale that weighs
to 5 g.)
• Measure 40 milliliters or one leveled scoop of CMV in a graduated medicine cup or syringe; add
to other ingredients.
• Measure and add 2 liters cooled boiled water.
• Stir until dissolved.
• Use within 24 hours.
Calculate amount of ReSoMal to give
For a child who has dehydration but no sign of shock, give ReSoMal as follows, in amounts based on the
child’s weight:
Table 1: Amount of ReSoMal to offer

How often to give ReSoMal Amount to give
Every 30 minutes for first 2 hours 5 ml/kg body weight
Alternate hours for up to 10 hours 5 - 10 ml/kg*
*The amount offered in this range should be based on the child’s willingness to drink and the amount of ongoing
losses in the stool. F-75 is given on alternate hours during this period until the child is rehydrated.
If the child has already received IV fluids for shock and is switching to ReSoMal, omit the first 2-hour
treatment and start with the amount for the next period of up to 10 hours.

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Figure 12: Algorithm for treatment of dehydration in children with SAM
*F-75 is given on alternate hours during this period until the child is rehydrated

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Fill in the blanks in the following case studies:
1. Rediet has watery diarrhea and is severely malnourished with no edema. He weighs 6.0
kilograms. He is dehydrated but has no shock. He should be given ________ ml ReSoMal every
_____ minutes for ____ hours. Then he should be given ____ - ____ ml ReSoMal in
_____________ hours for up to ____ hours. In the other hours during this period, ______
should be given.
2. Yetayesh arrived at the hospital in shock and received IV fluids for two hours. She has improved
and is now ready to switch to ReSoMal. Yetayesh weighs 8.0 kilograms. For up to _____ hours,
she should be given ReSoMal. The amount of ReSoMal to offer is ________ milliliters per hour.
3. After the first two hours of ReSoMal, a child is offered 5 -10 ml/kg of ReSoMal. What two factors
affect how much to offer in this range?
a. ____________ b. _______________
Check your own answers to this exercise by comparing them to the answers given at the end of the
session.

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Determining target weight for rehydration: -

For children with non-oedematous severe acute malnutrition with watery diarrhoea:
• if pre-diarrhoeal weight is known, use it to control weight gain during hydration;
• If pre-diarrhoeal weight is not known, presume a 5% loss of body weight and determine the
target weight before giving the ReSoMal.
For example: Weight of child = 5.3kg

5.3kg +5% = 5.56 kg (expected rehydration weight)
For severely malnourished children with oedema and with watery diarrhoea:
• Rehydration must be done more cautiously
• Give 30 ml of ReSoMal per watery stool until diarrhoea stops
Give ReSoMal slowly

It is essential to give ReSoMal slowly, much more slowly than you would give ORS to a well-nourished
child. Too much fluid, too quickly, can cause heart failure.
The best way to give ReSoMal is by cup, even with a very sick child. The child may need to be gently
persuaded, or you may need to use a spoon or syringe. If the mother is able to give the ReSoMal, she
should be taught to give it slowly.
A nasogastric (NG) tube can be used for giving ReSoMal at the same rate if the child is too weak to take
enough fluid voluntarily. An NG tube should be used in weak or exhausted children, and in those who
vomit, have fast breathing, or painful mouth sores.
IV fluids should not be used to treat dehydration (except in case of shock as discussed earlier). Since
the degree of dehydration cannot be determined by clinical signs, and too much fluid could cause heart
failure, it is very important that fluids not be forced on the child. When fluids are given orally, the child’s
thirst helps to regulate the amount given.
It is essential to stop giving ReSoMal when the child reaches the target weight
Monitor the child who is taking ReSoMal
Monitor the child’s progress every half hour for the first two hours; and do major reassessment of the
child’s condition after the first 2 hours.
Then monitor hourly, i.e., every time the child takes F-75 or ReSoMal (see the monitoring algorithm (Fig
13) on next page.
Signs to check
• Respiratory rate - Count for a full minute.
• Pulse rate - Count for 30 seconds and multiply by 2.
• Weight
• Urine frequency – Ask: Has the child urinated since last checked?
• Liver size: mark before any infusion
• Stool or vomit frequency – Ask: Has the child had a stool or vomited since last checked?
• Signs of hydration - Is the child less lethargic or irritable?
Record the above information on the initial management Section of the multi-chart; then give ReSoMal
and record the amount taken. Notice any changes when you check the signs above.

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Signs of improving hydration status

Fewer or less pronounced signs of dehydration, for example:
• less thirsty*
• less lethargic*
• Slowing of rapid respiratory and pulse rates
• Passing urine
• Gaining weight with clinical improvement
If a child has three or more of the above signs of improving hydration status, stop giving ReSoMal.
Instead, offer ReSoMal after each watery diarrhea. Continue monitoring even after improved hydration
status and ReSoMal stopped.
Signs of over hydration
Stop ReSoMal if any of the following signs appear:
• Child’s weight exceeds the target weight
• Increased respiratory rate by 5 breaths and pulse rate by 25 beats per minute. (Both must
increase to consider it a problem.)
• Jugular veins engorged. (Pulse wave can be seen in the neck.)
• Sudden increase in liver size and tenderness
• Increasing edema (e.g., puffy eyelids).
• Increasing weight with clinical deterioration
Figure 13: Monitoring a child on rehydration with ReSoMal

*Note: Alternate ReSoMal every hour with F-75 during the 10 hours rehydration

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After rehydration, offer ReSoMal after each loose stool

When the child has three or more signs of improving hydration (see above), stop giving ReSoMal
routinely in alternate hours. However, watery diarrhea may continue after the child is rehydrated.
If diarrhea continues, give ReSoMal after each watery diarrhea to replace stool losses and prevent
dehydration:
• < 2 years: give 50-100 ml after each watery stool
• 2 years and older: give 100 – 200 ml after each watery stool.
Base the amount given in these ranges on the child’s willingness to drink and the amount of stool loss.
F-75 is given in alternate hours during this period until the child is rehydrated.
Cases with profuse (acute) watery diarrhoea

In cases of profuse (acute) watery diarrhoea (e.g. cases of cholera), ReSoMal should not be given and
should be replaced by a standard ORS without changing the amounts and frequency. Further details
on chart booklet page 14-17

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EXERCISE A
In this exercise, the group will prepare and taste ReSoMal and will measure appropriate amounts to give
to severely malnourished children.
A facilitator will lead this exercise. When the group has prepared and tasted the ReSoMal, each person
should answer the following questions individually. Then a facilitator will ask each person to measure
the amount of ReSoMal given in one of the answers.
1. Rafael has severe acute malnutrition with no edema. He has diarrhea and signs of dehydration but
has no signs of shock. He is just starting ReSoMal. He weighs 7.3 kg.
a) How much ReSoMal should Rafael be given every 30 minutes for the next 2 hours?
b) After 2 hours, what is the least amount of ReSoMal that Rafael should be offered in
alternate hours?
c) What is the greatest amount of ReSoMal that Rafael Should be offered in alternate
hours?
2. Selamawit has severe acute malnutrition with severe edema. She has vomiting and watery diarrhea.
She weighs 11.6 kilograms. She has dehydration, but not in shock.
a) How much ReSoMal should Selamawit be given every 30 minutes for the next 2 hours?
b) After 2 hours, what is the least amount of ReSoMal that Selamawit should be offered in the
alternate hours?
c) What is the greatest amount of ReSoMal that Selamawit should be offered in alternate
hours?
Tell a facilitator when you have answered the above questions and are ready to measure
the amounts of ReSoMal

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3.4 Manage a severely malnourished child with shock

What is shock?
Shock is a generalized hypo perfusion of tissues and a dangerous condition with severe weakness,
lethargy, or unconsciousness, cold extremities, and fast, weak pulse. It is caused by diarrhea with
severe dehydration, hemorrhage, burns, or sepsis. In severely malnourished children, some of the signs
of shock may not appear all the time, so it is difficult to diagnose. Thus, IV fluids are given in severe
malnutrition only if the child meets the following criteria:
The severely malnourished child is considered to have shock if he/she is lethargic or unconscious and
has cold hands plus either:
slow capillary refill* (longer than 3 seconds), or
weak, fast** or absent radial or femoral pulses
*To check capillary refill:

Press the nail of the thumb or big toe for 2 seconds to produce blanching of the nail bed.
Count the seconds from release until return of the pink color. If it takes longer than 3 seconds, capillary
refill is slow.
** Pulse rate
Age (years) Pulse rate (range)5
0 to 1 100–160
1 to 3 90–150
3 to 6 80–140
Give oxygen, IV glucose, and IV fluids for shock

If the child is in shock (meets criteria in the box above):
• Give oxygen (for infants 0.5 to 1 lit per minutes and for older children 1 to 2 lit per minute).
• Give sterile 10% glucose 5 ml/kg by IV (as described in section 3.1)
• Give IV fluids as described on the next page.
• Keep the child warm.
Giving IV fluids
Shock resulting from dehydration and sepsis are likely to coexist in severely malnourished children.
They are difficult to differentiate on clinical signs alone. Children with shock due to dehydration will
respond to IV fluids. Those with septic shock and no dehydration will not respond. The amount of IV
fluids given must be guided by the child’s response. Over-hydration can cause heart failure and death.
5
Source: WHO Pocket book of hospital care for children, second edition

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To give IV fluids:
Check the starting respiratory and pulse rates and record them including the starting time on the Multi-
chart and shock follow up chart below
Infuse IV fluid at 15ml/kg over 1 hour. Use one of the following solutions, listed in order of preference:
• Ringer’s lactate solution with 5% glucose*
• 0.45 % normal Saline with 5% glucose*
• *If either of these is used, add sterile potassium chloride (20 mmol/l) if possible.
Observe the child and check respiratory and pulse rates every 10 minutes (see the instructions on shock
in the initial management section of the multi-chart). Follow the liver size, child is passing urine and
weight gain.
• If the respiratory rate and pulse rate increase and child is gaining weight, stop the IV rehydration
and assume septic or cardiogenic shock.
• If respiratory rate and pulse rate are slower after 1 hour, the child is improving. Repeat the same
amount of IV fluids for another hour. Continue to check respiratory and pulse rates every 10
minutes.
After 2 hours of IV fluids, switch to oral or nasogastric rehydration with ReSoMal (special rehydration
solution for children with severe malnutrition). Give 5-10 ml/kg ReSoMal per hour and continue to give
F-75 alternate hours for up to 10 hours.
If no improvement with IV fluids, give blood transfusion

If the child fails to improve after the first hour of IV fluids, then assume that the child has septic shock.
Give maintenance IV fluids (4 ml/kg/hour) while waiting for blood. When blood is available, stop all oral
intake and IV fluids, give a diuretic to make room for the blood, and then transfuse whole fresh blood at
10 ml/kg slowly over 3 hours. If there are signs of heart failure, give packed cells instead of whole blood
as these have a smaller volume. (See steps below in section 3.5 for more details.)

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3.5 Manage very severe anemia

What is very severe Anemia?
Anemia is a low concentration of hemoglobin in the blood. Very severe anemia is a hemoglobin
concentration of < 4 g/dl (or hematocrit <12%). If it is not possible to test hemoglobin, rely on clinical
judgment. For example, you can judge the degree of anemia based on paleness of gums, lips, palm, and
inner eyelids.
Severe anemia can cause heart failure and must be treated with a blood transfusion. As malnutrition is
usually not the cause of the anemia, it is important to investigate other possible causes such as malaria
and intestinal parasites (for example, hookworm).
Mild or moderate anemia is very common in severely malnourished children and should be treated later
with iron, after the child has stabilized. (Do NOT give iron during stabilization phase as it can damage
cell membranes and make infections worse.)
Symptoms of moderate and severe anemia may appear between day two and day 14 of treatment
of malnutrition, due to the movement of fluids from tissues (edema and intracellular water) to
vascular space. This temporary excess of fluids will produce dilutional anemia (i.e. pseudo-anemia)
that should never be treated with blood transfusions (this risk aggravating the problem and inducing
cardiac overload and death). Pseudo-anemia normally resolves spontaneously after 2 or 3 days
when kidney function recovers, and excess fluids can be eliminated. For these reasons, transfusion is
not recommended between 48 hours and day 14 unless there is heart failure and the cause is other than
dilution anemia.
Give blood transfusion
• Give blood transfusion in the first 48 hours if:

• Hgb is < 4 g/dl, (Hct is < 12 %), or
• Hgb 4 to 6 g/dl (Hct 12 to 18%) and respiratory distress
• Stop all oral intake and IV fluids during the transfusion.
• Look for signs of congestive heart failure such as fast breathing, respiratory distress, rapid pulse,
engorgement of the jugular vein, cold hands and feet, cyanosis of the fingertips and under the
tongue.
• Give a diuretic* to make room for the blood. Furosemide (1 mg/kg, given by IV) is the most
appropriate choice.
• If there are no signs of congestive heart failure, transfuse whole fresh blood at 10 ml/kg slowly
over 3 hours. If there are signs of heart failure, give 5-7 ml/kg packed cells over 3 hours instead of
whole blood.
*
Diuretics should never be used to reduce edema in children with severe malnutrition. The purpose of giving a
diuretic before a blood transfusion is to prevent congestive heart failure from overloading the circulation with the
transfusion.

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EXERCISE B
In this exercise, you will be given some information and partially completed Multi-chart for several
children. You will then answer questions about treatment needed. Use your module or reference cards
as needed.
Case 1: Teblets
Teblets is an 18-month-old girl referred from a health center. Her arms and shoulders appear very thin.
She has moderate edema. She does not have diarrhea or vomiting, and her eyes are clear. She has no
other medical complication. Additional information is provided in the multi-chart below.
SD
1 2 3
Date 16/03/11
70
Height/Length (cm)
Anthropometric
BLOOD GLUCOSE 60 m g/ d l
Weight (kg) (mg/dl):
6 .3
Chart
If <54mg/dl and alert, give 50 ml bolus of 10% glucose or sucrose<(oral

- 3 or NG). If <54mg/dl and lethargic,
WFH/L z-score
unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s wt) = ml Then give
50 ml bolus NG. Time(cm)
glucose given: Oral NG
1 1 .3IV
MUAC
Bilateral pitting oedema9(0,g/+,d ++,
l ++
HAEMOGLOBIN (Hb) (g/dl): +++) Blood type:
Wt gain (g/kg/day)
If Hb <4g/dl or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg
packed cells) slowly over 3 hours. Amount: Time started:
Ended:

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a. What is Teblets’s weight-for-height Z- score?
b. Should Teblets be admitted for in-patient care? Why or why not?
c. Is Teblets hypothermic?
d. Is Teblets hypoglycemic?
e. Does Teblets have severe anemia?
f. Teblet is alert and does not have cold hands. Her capillary refill is 2 seconds. Her pulse does not seem
weak. According to the definition given in this module, is Teblet in shock?
g. What two things should be done for Teblets immediately based on the above findings?
When you have finished this case, discuss your answers with a facilitator

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Case 2 – Kedija
Kedija is a 3-year-old girl. She is very pale when she is brought to the hospital, but she is alert and
can drink. She has no signs of shock, no diarrhea, no vomiting, and no eye problems. She passed the
Appetite test. Additional findings are described in her initial management chart sections below.
HAEMOGLOBIN (Hb) (g/dl): 3 .9 g/ d l Blood type:

If Hb <4g/dl or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg
packed cells) slowly over 3 hours. Amount: Time started:
Ended:
a. What should Kedija be given immediately to treat her hypoglycemia? How should it be given?
b. When should Kedija begin taking F-75? How often? How much should she be fed?
c. Does Kedija have very severe anemia? If yes, what should be done? Kedija has no signs of congestive
heart failure

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Case 3 Yohannes
Yohannes is a 15-month-old boy who has been unwell since the rains fell 5 weeks ago. For the last 3
days he has had no food but has been given home fluids for diarrhea. Yohannes is lethargic and limp on
arrival at the hospital, and the doctor assumes his blood glucose is low without taking time for a blood
sample and Dextrostix test. Yohannes’s temperature does not record on a standard thermometer. His
gums, lips, and inner eyelids appear normal in color (not pale). Additional information is given below:

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a. What are four treatments that Yohannes needs immediately?
b. What amount of sterile 10% glucose should be given by IV?
c. What amount of IV fluids should be given over the first hour?

Yohannes is given IV fluids starting at 9:45 a.m. His respiratory rate at that time is 60 breaths per minute,
and his pulse rate is 130. Yohannes is monitored every 10 minutes over the next hour, and both his
respiratory and pulse rates slow down during this time. At 10:45 a.m. his respiratory rate is 40 and his
pulse rate is 105.
d. What should be done for the next hour?

After two hours of IV fluids, Yohannes is alert enough to drink, although he still appears unwell. His
blood glucose has been tested and is now up to 90 mg/dl. His hemoglobin is 8.2 g/dl. He is weighed
again, and his new weight is 6.0 kg.
e. What should Yohannes be given in over the next period of up to 10 hours?
f. How much F-75 should be given at each feed? (Hint: Use Yohannes’s new weight to determine
amount.)
When you have finished this exercise, discuss your answers with a facilitator.

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3.6 Give emergency eye care for corneal clouding and ulceration
Examine the eyes
Wash your hands. Touch the eyes extremely gently and as little as possible. The child’s eyes may be
sensitive to light and may be closed. If the eyes are closed, wait until the child opens his eyes to check
them or gently pull down the lower eyelids to check. Wash your hands again after examining the eyes.
What are corneal clouding and ulceration?
Corneal clouding is haziness of the surface of the cornea (eye surface), whereas corneal ulceration is
a break in the surface of the cornea. In the latter case the eye may be extremely red or bleeding, or
the child may keep the eye closed. In corneal ulceration, if there is an opening in the cornea the lens
of the eye may extrude (push out) and cause blindness. Photo 12 in the photo booklet shows corneal
ulceration.
Corneal clouding and ulceration are dangerous conditions that may lead to loss of vision if not treated
urgently.
Give vitamin A and atropine eye drops immediately for corneal ulceration
If the child has corneal clouding and ulceration, give vitamin A immediately as in table 2 below.
Table 2: Dosage of Vitamin A

Child’s age Vitamin A Oral Dose
< 6 months 50, 000 IU
6 - 11 months 100, 000 IU
≥12 months 200, 000 IU
You should instill one drop atropine (1%) into the affected eye(s) to relax the eye and prevent the
lens from pushing out. Tetracycline eye drops and bandaging are also needed but may wait until later in
the day. Daily Care session describes other treatments of corneal ulceration.
All severely malnourished children with eye signs need vitamin A on Day 1, and many may need
additional eye care which can wait until later in the day. Daily Care Session describes treatment of
various eye signs.

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3.7 Managing Heart failure

Diagnosis
• Physical deterioration with weight gain,
• Sudden increase in liver size,
• Tenderness of the liver,
• Crackles in lungs,
• Prominent superficial and neck veins,
• Engorgement of the neck veins when the abdomen (right upper quadrant) is pressed,
• Increased edema or reappearance of edema, among other clinical signs and symptoms.
It may progress to marked respiratory distress (Increased respiratory rate, ‘grunting’, etc.) with rapid
pulse, cold hands and feet, edema and cyanosis and sudden death from cardiac shock.
Heart failure and pneumonia may be difficult to tell apart as they can be clinically similar. When
weight gain precedes or is associated with signs of respiratory distress, heart failure should be the first
diagnosis. If there is loss of weight, consider pneumonia instead.
Note: Children with edema do not necessarily present with weight gain during heart failure if the expanded
circulation is due to mobilization of edema fluid from the tissues to vascular space.
Treatment
• Stop all intakes of oral or IV fluids. No fluid or therapeutic feeds should be given until heart failure
has improved (even if this takes 24 to 48 hours). Small amounts of sugar-water can be given orally to
prevent hypoglycemia.
• Give Furosemide (1 mg/kg) single dose, repeat if necessary.
• If it is due to severe anemia, manage as in section 3.5.

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EXERCISE C
In this exercise, you will be given information and a partially completed In-patient Multi-chart or a blank
Multi-chart for several children. You will then answer questions about treatment needed or complete
the Multi-chart.
Case 1: Mola
Mola is an 11-month-old boy. Additional information is given on the initial management chart below.
Mola is awake, has no signs of shock, and has no diarrhea or vomiting. He has left eye corneal ulceration
and recent attack of Measles. His dextrostix shows blood sugar in the range of 27 mg/dl
kg (child’s wt
≥ 12 months
kg (child’s wt) =
a. What are three things that should be done immediately for Mola?
b. In a half-hour, what should be given to Mola? How much should be given?
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Case 2 – Radiel (For this case, use a blank initial management chart available in your classroom)
Radiel is a 9-month-old boy. He has not been feeding well in the last 3 weeks. He has had watery
diarrhea and vomiting in the last 3 days. There has been no blood in the stool. Radiel is severely wasted
and has some mild dermatosis. He has no edema. His weight is 4.4 kg and length is 64 cm. His mother
reported Radiel has recent sunkening of his eyes
Radiel’s axillary temperature is 38°C, and his blood glucose is 90 mg/dl. His hemoglobin is 12.0 g/dl. His
eyes appear clear, and he has not had measles. Radiel drinks eagerly. He has no signs of shock. His pre-
diarrheal weight is not known. It is presumed he has 5% weight deficit.
a. Using the above information about Radiel, complete as many parts of the initial management chart as
you can.
Note: You will not complete the section of the initial management chart for Antibiotics in this exercise.
Although it is important to give antibiotics quickly, you will learn about these later. In the diarrhea
section, complete only the top part now and the amount of ReSoMal to give. Do not
complete the therapeutic diet (Feeding) section yet.
Since Radiel has diarrhea but no signs of shock, he needs ReSoMal. Radiel is first given ReSoMal at 9:00
a.m. His respiratory rate is 28 and his pulse rate is 105. He eagerly takes the full amount. At 9:30 his
respiratory rate is still 28 and his pulse rate is 105. Radiel has not passed urine. He has had one episode
of diarrhea but no vomiting. There has been no change in hydration signs. Again, Radiel takes the full
amount of ReSoMal.
The columns below show Radiel’s progress during the next hour. He continues to take the full amount
of ReSoMal.
Time 10:00 10:30

Resp. rate 28 25
Pulse rate 105 100
Liver Size (cm) 0 0
Passed urine (Y/N) N Y
Number stools 0 0
Number vomits 1 0
Hydration signs Same Moist mouth
A. At 11:00, Radiel is ready to begin the next period of treatment, during which ReSoMal and F-75
are given. How much ReSoMal should Radiel be given in alternate hours? Enter this information
on the initial management chart.
B. What signs of overhydration should be watched for during this period?
At 11:00 Radiel’s respiratory rate remains at 25 and his pulse rate at 100. He has passed no
urine, but he has had one watery diarrhea in the past hour. He has not vomited. Radiel takes the
maximum amount of ReSoMal in his range, but he no longer seems thirsty and eager to drink.
C. Complete Radiel’s observation section of the initial management chart for 11:00.
At 12:00 Radiel’s respiratory rate remains at 25 and his pulse rate at 100. He has passed urine or
stools in the past hour, and he has not vomited. Radiel is weighed again. He now weighs 4.5 kg.
Radiel continues to be willing to drink within the recommended range, although he does not
drink eagerly.

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D. What signs of improving hydration does Radiel show? Has he attained the target weight?
E. What should be given to Radiel in the next hour (starting at 12:00)? How much should be given?
Radiel should continue taking F-75 every 2 hours, even during the night. He must also be
kept warm. Radiel should also be given antibiotics, which you will learn about in the next
section of this Session.
F. If Radiel’s diarrhea continues, what should he be given after each diarrhea? How much should
he be given?
Case 3 – Etaferaw (For this case use the first page of a blank initial management section of the multi-
chart available in your classroom this case will be done as a group.
Etaferaw is a 25-month-old girl. She arrives at the hospital at 10:00 a.m. on March 3rd. She has had
diarrhea and vomiting for 10 days. She is severely wasted. She has no edema and no dermatosis. She
weighs 6.1 kg and is 74 cm in length.
Etaferaw has an axillary temperature of 36°C and a blood glucose level of 4 mmol/L. Her hemoglobin
has not been tested. Her left eye appears normal, but her right eye has some pus draining from it. She
has not had measles.
Etaferaw has cold hands and is lethargic. When the doctor presses her thumbnail, it takes longer than 3
seconds for the pink color to return to the nail bed. Her pulse is fast (140 per minute).
There has been no blood in the stool. She seems to have sunken eyes, but her mother says they are
always that way.
Using the information about Etaferaw, complete as many parts of the initial management chart as you
can.

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Note: You will not complete the section for Antibiotics in this exercise.
Although it is important to give antibiotics quickly, you will learn about these later. In the Diarrhea section,
complete only the top part at this point (through dehydration signs). Do not complete the Feeding section
yet.
a. Is Etaferaw hypoglycemic?
Is she hypothermic?
b. Does Etaferaw need vitamin A? Does she need it immediately?
c. What signs of shock does Etaferaw have?
d. What amount and type of IV fluids should Etaferaw be given in the first hour? Enter the amount
on the initial management chartin the special medicine section and on the shock follow up chart.
Etaferaw’s IV is started at 10:30 a.m. Her respiratory rate is 40 breaths per minute and her pulse rate is
140 per minute. The nurses monitor Etaferaw every 10 minutes. The results of monitoring are as follows.
Time Respiratory Pulse Remark

rate rate
10:40 38 130
10:50 36 120
Etaferaw sits up, seems
11:00 35 100 alert
11:10 33 90
11:20 32 85
11:30 30 80
e. Enter Etaferaw’s starting time and rates on her initial management Section. What should be done
next for Etaferaw?
Etaferaw is given IV fluids for another hour. During the second hour her respiratory rate remains
steady at 30 and her pulse rate at 80. After receiving IV fluids, Etaferaw weighs 6.2 kg.
f. What should be given to Etaferaw at 12:30? How much should be given? Enter the amount on the
initial management chart in the second part of the diarrhea section..
At 12:30, Etaferaw’s respiratory rate is still 30 and her pulse rate is still 80. She has not passed
urine. She has had one diarrhea stool but no vomiting. She is alert and her eyes are still sunken.

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g. The nurse offers Etaferaw the maximum amount of ReSoMal in her range, and Etaferaw eagerly
takes it all. So at 01;30 what should be given to Etaferaw.
Twelve hours after her arrival at the hospital, Etaferaw is much better. Since she responded so well
to IV fluids and ReSoMal, it is clear that she was dehydrated. She needs to continue 2-hourly feeds
of F-75, but she no longer needs ReSoMal routinely. She needs antibiotics, which you will learn
about in the next section of the Session.
h. Etaferaw’s diarrhea continues after she is rehydrated. What does she need after each watery
diarrhea? How much does she need?
When you have finished these cases, discuss your answers with a facilitator

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3.8 Treat Infections

Give all severely malnourished children antibiotics for presumed infection even if they do not have
clinical sign of systemic infections. Give the first dose of antibiotics while other initial treatments are
going on, as soon as possible.
Select antibiotics and prescribe regimen

Selection of antibiotics depends on the presence or absence of complications. Complications include
septic shock, hypoglycemia, hypothermia, skin infections or dermatosis (+++ with raw skin/fissures),
respiratory or urinary tract infections, or lethargic/sickly appearance.
As shown on the summary chart on the next page:
• If no medical complications or only failed appetite test, give first line antibiotics: Oral
Amoxicillin (preferred).
• If medical complications present, Give, Gentamicin, plus IV Ampicillin for 2 days followed by
oral Amoxicillin, and continue Gentamycin IM.
• If the child fails to improve within 48 hours, change to Ciprofloxacin and Ceftriaxone)
• If specific infections are identified which require a specific antibiotic not already being
given, give an additional antibiotic to address that infection.
• For example, dysentery may require additional antibiotics. Certain skin infections such as
Candidiasis require specific treatments. Antimalarial treatment should be given according to the
national protocol.
Different formulations of drugs are available (e.g., tablets or syrups of varying strengths). The
formulation of the drug will affect the amount to measure for a dose. Some common formulations are
given in the dosage tables on the Antibiotics Reference Card, which is also found in the chart booklet on
page 16
For each formulation of a drug, the dosage tables have rounded practical doses to use for children of
different weights. Note: Never base the dose on age.
You can use other additional second or third option drugs according to your clinical judgment.

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Table 3: Summary: Antibiotics for Severely Malnourished Children
If: Give:
No complications Amoxicillin oral: 25 mg/kg every 12 hours for 5-7 days
Complications (shock, Gentamycina IV or IM (7.5 mg/kg), once daily for 7 days, plus:
hypoglycaemia, Ampicillin IV or IM (50 mg/kg), Followed by amoxicillin oral: 25
hypothermia, every 6 hours for 2 days mg/kg, every 12 hours for 5 daysb
dermatosis with
raw skin/fissures,
respiratory or urinary
tract infections,
or lethargic/sickly
appearance)
If resistance to See details of drug on standard treatment guideline
amoxicillin and
ampicillin, and In the case of sepsis or septic shock: IM ceftriaxone (for children/
presence of medical infants beyond 1 month: 50 mg/kg every 8 to 12 hours) + oral
complications: ciprofloxacinc (5–15 mg/kg 2 times per day)
If suspected staphylococcal infections: add Cloxacillin (12.5–50 mg/
kg/dose 4 times a day, depending on the severity of the infection)
If HIV-positive or HIV Treat of medical complications should be like any SAM patient
Exposed Child without HIV-infection or exposure. Give Cotrimoxazole prophylaxis
as well in addition to antibiotic selected. Medical treatment and
care should follow the National Guidelines for Comprehensive HIV
Prevention, Treatment and Care.
If a specific infection Specific antibiotics as directed in the standard treatment guideline
requires an additional
antibiotic, also give:
If the child is not passing urine; Gentamicin may accumulate in the body and cause renal failure and
a
deafness. Do not give the second dose until the child is passing urine.
b
If amoxicillin is not available; give Ampicillin, 50 mg/kg orally every 6 hours for 5 days.
c
If ciprofloxacin bioavailability decreases when given with the milk, so should be given 2 hours after the
milk is given.
Example of determining a dose:
Khalid is 82 cm in height and weighs 7.8 kg. He has severe acute malnutrition of less than- 3 Z-score.
He failed appetite test. His rectal temperature is 36°C and his blood glucose is about 72 mg/dl. He is
alert and irritable. He has no dermatosis. He has no signs of shock. He has had some loose stools but no
blood in the stools. There is no evidence of respiratory or urinary tract infections.
• Khalid has no complications, so he should be given Amoxicillin. It should be given orally

every 12 hours for 5 days.
• Khalid’s body weight is 7.8 kg.
• The hospital has Amoxicillin syrup containing 125 mg per 5 ml.
• The doctor looks up the dose for this strength Amoxicillin syrup and Khalid’s weight. The
dose is 7.8 ml. He prescribes 7.8 ml Amoxicillin syrup to be taken orally every 12 hours for 5
days.
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Choose and use the best route of administration
Wherever possible, antibiotics should be given orally or by NG tube. Infusions containing antibiotics
should not be used unless indicated because of the danger of inducing heart failure and introducing
infections.
Sometimes there is a need for parenteral antibiotics and choice of whether to give a drug intravenously
(IV) or by intramuscular (IM) injection. IM injections are very painful for a severely malnourished child. If
an IV line is in and being used for giving fluid, use it for the antibiotic as well.
If there is no IV line in, and only one IM injection is needed, give the IM injection, but take special care
to avoid bruising tender skin. The child will not have much muscle, so look for the sites with the most
muscle and rotate sites (e.g., buttocks, thighs). If more than 2 ml is to be injected, divide the dose
between two sites.
If frequent injections would be needed, it is preferable to use a 21 or 23-gauge butterfly needle to keep
a vein open for injecting antibiotics. Use the IV dose. This option allows the staff to give conveniently
the antibiotic intravenously without leaving an IV bag up, and it is less painful for the child.

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EXERCISE D
In this exercise, you will select antibiotics and determine dosages for several children. Refer to the
Antibiotics Reference Card or the chart booklet page 17 & 18 as needed. When there are different drug
formulations listed, choose the drug formulation that is most likely to be available in your hospital
Case 1 – Debebe
Debebe is 77 cm long and weighs 8.0 kg. He has edema of both feet. He has no hypoglycemia, no
hypothermia, no signs of shock, and no other complications.
a. What antibiotic does Debebe need? By what route should it be given?
b. Summarize the prescription for Debebe in the table below:
Drug Route Dose Frequency Duration

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Case 2: Hana
Hana weighs 6 kg. She is severely malnourished and has hypoglycemia, hypothermia, and mild
dermatosis. She does not have shock and will not be given IV fluids.
a. What two antibiotics should Hana be given now?
b. Assuming that all of the necessary supplies are available, what route should be chosen?
c. Given Hana’s body weight, summarize the prescription for each antibiotic below:
Hana improves within 48 hours. Her temperature rises and stays above 35.5°C, and her blood glucose
level rises above 54 mg/dl. She has not gained weight, but she is alert and is taking F-75 well.
d. After two days, how should Hana’s drug regimen change?

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3.9 Management of abdominal distension with absent bowel sounds

Abdominal distension can occur because of reduced gastrointestinal motility due to electrolyte
disturbance (Hypokalemia).
The following measures should be taken:
• Give Gentamicin IV once daily plus Ampicillin IV every 6 hours
• Consider adding Ceftriaxone IV
• Stop all other drugs that may be causing toxicity (such as metronidazole)
• Give a single IM injection of magnesium sulphate (2ml of 50% solution).
• Pass an NG-tube and aspirate the contents of the stomach, then “irrigate” the stomach with
isotonic clear fluid (5% dextrose or 10% sucrose –the solution does not need to be sterile). Do
this by introducing 50ml of solution into the stomach and then gently aspirating all the fluid
back again. This should be repeated until the fluid that returns from the stomach is clear.
• Put 5 ml/kg of sugar-water (10% sucrose solution) into the stomach and leave it there for one
hour. Then aspirate the stomach and measure the volume that is retrieved. If the volume is less
than the amount that was introduced, then either a further dose of sugar-water should be given
or the fluid returned to the stomach.
• There is frequently gastric and esophageal candidiasis: give oral nystatin suspension or
fluconazole.
• Keep the child warm.
• If the child’s level of consciousness is poor give intravenous glucose,
• Do not put up a drip at this stage. Monitor the child carefully for 6 hours, without giving any
other treatment
• Improvement is measured first by a change in intestinal function (decrease in the distension
of the abdomen, visible peristalsis seen through the abdominal wall, return of bowel sounds,
decreasing size of gastric aspirates) and second by improvement in the general condition of the
child.
If there is intestinal improvement, then;

• Start to give small amounts of F-75 by NG tube (half the quantities given in the feeding table –
subsequently adjust by the volumes of gastric aspirated).
If there is no improvement after 6 hours, then:
• Consider putting up an IV drip. It is very important that the fluid given contains adequate
amounts of potassium. Sterile Potassium Chloride (20mmol/l) should be added to all solutions
that do not contain potassium. Use Ringer-Lactate in 5% dextrose or half-strength saline in 5%
dextrose. The drip should be run VERY SLOWLY – the amount of fluid that is given should be NO
MORE THAN 2 to 4 ml/kg/h.
• When the gastric aspirates decrease so that one half of the fluid given to the stomach is
absorbed, discontinue the IV treatment and continue with oral treatment only.

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3.10 Management of SAM in TB and HIV infected children

Recovery from malnutrition is possible in children with TB and HIV/AIDS, but it may take longer and
treatment failures are more common. The treatment of severe acute malnutrition in children with HIV/
AIDS should be the same as for HIV-negative children. Exactly the same protocol is used in HIV positive
and negative children as explained in this training manual and the national protocol.
The drugs that are used for TB and HIV are quite toxic to the liver and pancreas. These organs are
particularly affected by SAM. If treatment with anti-TB drugs or ARVs is started in the severely
malnourished patient they are likely to develop very severe side effects from the drugs. This leads to
withdrawal from the treatment program. Neither TB nor HIV are rapidly fatal illnesses. Thus, it is better
to treat first severe malnutrition in all patients and to delay introduction of ARVs or Anti-TB drugs for
one or two weeks until the liver, pancreas and intestine have recovered sufficiently to metabolize the
drugs safely.
TB, HIV and SAM are linked and frequently appear in the same patient. Thus, children with SAM should
be particularly screened for TB and HIV.
Record initial findings and treatments and communicate to staff
In all cases, but especially if a child is being transferred from an emergency room, it is important to
communicate in writing and orally to key staff:
• the child’s symptoms
• treatments already given
• what needs to be done to continue care and feeding
• whether or not the child has complications that require being near the nurses’ station for careful,
constant observation
The initial management Chart is an example of a tool to help communicate what has been done and
what needs to be done for the child.
When everyone is ready, the group will view a video segment about treatment of medical complication.
This video will show many of the steps described so far in this session.

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Answers to short answer exercise

The answers to the exercise on page 57 of the module are written in the blanks below.
1. Redit has watery diarrhoea and is severely malnourished. He weighs 6.0 kg. He should be given
30 ml of ReSoMal every 30 minutes for 2 hours. Then he should be given 30–60 ml of ReSoMal in
alternate hours for up to 10 hours. In the other hours during this period, F-75 should be given.
2. Yetayesh arrived at the hospital in shock and received IV fluids for 2 hours. She has improved and
is now ready to switch to ReSoMal. Yuma weighs 8.0 kg. For up to 10 hours, she should be given
ReSoMal and F-75 in alternate hours. The amount of ReSoMal to offer is 40–80 ml per hour.
Answers:
a. The child’s willingness to drink
b. The amount of ongoing losses in the stool.

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S-4 Feeding

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S-4 Feeding
SESSION 4: FEEDING
S-4 Feeding
Introduction
Feeding is obviously a critical part of managing severe malnutrition; however, as explained in Principles
of Care, feeding must be started cautiously and given in frequent, small amounts. If feeding begins too
aggressively, or if feeds contain too much protein or sodium, the child’s systems may be overwhelmed,
and the child may die.
To prevent death due to hypoglycemia, feeding should begin as soon as possible with F-75, the “starter”
formula used until the child is stabilized. F-75 is specially made to meet the child’s needs without
overwhelming the body’s systems at this early stage of treatment. F-75 contains 75 kcal and 0.9 g
protein per 100 ml. F-75 is low in protein and sodium and high in carbohydrate, which is more easily
handled by the child and provides much-needed glucose.
When the child is stabilized (usually after 2 to 7 days), the “catch-up” formula F-100/ RUTF is used to
rebuild wasted tissues. F-100 contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml.
RUTF is an energy-dense food equivalent to F-100. It is made from peanut butter paste, vegetable oil,
skimmed milk, maltodextrin, sugar, and combined minerals and vitamins (CMV) mix.
This session describes the contents of F-75, F-100, and RUTF need for these contents, how to prepare
the feeds, plan feeding, and give the feeds according to plan.
Learning Objectives
This will describe and allow you to practice the following skills:
• Preparing F-75 and F-100
• Planning feeding for a 24-hour period for a child who is taking F-75; or adjusting to RUTF/F-100
during transition; or feeding freely on RUTF/F-100.
• Measuring and giving feeds to children
• Recording intake and output
• Planning feeding for a ward
In addition, the session will allow you to discuss ideas for training staff at your health facilities to do
feeding-related
4.1 Prepare F-75 and F-100

There are two types of F-75 and F-100: commercially or locally prepared

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S-4 Feeding
Preparation of F-75/ F-100 Feeds using the Tin Formulation

1. Boil water to make it safe for drinking.
2. Ensure that the water temperature is not below 70°C (i.e., cooled for not less than 3-5 minutes after
boiling).
3. Add the water to the F-75/ F-100 therapeutic milk powder. See Table 4 & 5
4. Whisk the mixture vigorously until the powder dissolves in the water.
5. Cool the prepared milk to feeding temperature before administering
Table 4: Quantities for reconstitution of F-75 using the tin formulations

WHITE scoop F75 Amount of water (ml) Reconstituted F75 (ml)
1 25 28
2 50 56
3 75 84
4 100 112
5 125 140
6 150 168
7 175 196
8 200 224
9 225 252
10 250 280
20 500 560
1 Tin (400 G) 2200 2480

2 Tins (800G) 4400 4960
Table 5: quantities for the reconstitution of F-100 using tin formulation

BLUE scoop F-100 Amount of water (ml) *Volume of F-100 Milk (ml)
1 25 29
2 50 58
3 75 87
4 100 116
5 125 145
6 150 174
7 175 203
8 200 232
9 225 261
10 250 290
20 500 580
1 Tin (400g) 1850 2158

2 Tins (800G) 3700 4316

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S-4 Feeding
Locally prepared F-75 and F-100 recipe that are prepared by the health facilities
The choice of recipe may depend on the availability of ingredients, particularly the type of milk, and the
availability of cooking facilities. In the next exercise, you will prepare F-75 and F -100 using one of these
recipes, or a similar recipe used in the severe malnutrition ward that you will visit during this course (see
preparation on Annex 4).
Ready- to-Use Therapeutic Food (RUTF)
RUTF is an energy dense paste usually made from peanut butter, sugar, maltodextrin, oil, skimmed milk,
minerals and vitamin mix. It is an oil-based feed equivalent to F-100.
The advantage of RUTF is that it is a ready-to-use paste which does not need to be mixed with water,
thereby avoiding the risk of bacterial proliferation in case of accidental contamination. The product can
only be given to children aged six months or above and provides sufficient nutrient intake for complete
recovery. It can be stored for three to four months without refrigeration, even at tropical temperatures.

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S-4 Feeding
EXERCISE A
In this exercise, your group will prepare F-75 and F-100 in small and large volume. Your facilitator will
demonstrate F-75 and F-100 milk powder, materials that will be used for preparation, and how to
prepare.
Notice the differences in the F-75 and F-100 preparation. You will have a chance to taste each formula.
While preparing, think about the following issues in relation to your own hospital, and be prepared to
discuss them with the group:
A. What aspects of preparation would be difficult in my hospital?
B. How can I make sure that the milks are prepared correctly?

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S-4 Feeding
4.2 Feeding children 6– 59 months

Feed the child with F-75 in Stabilization Phase
Determine frequency of feeds
On the first day, feed the child a small amount of F-75 every 2 hours (12 feeds in 24 hours, including
through the night). If the child is hypoglycemic, give ¼ of the 2-hourly amount every half-hour for the
first 2 hours or until the child’s blood glucose is at least 54 mg/dl (3 mmol/l).
Night feeds are extremely important. Many children die from hypoglycemia due to missed feeds at
night. Children must be awakened for these feeds.
After the first day, increase the volume per feed gradually so that the child’s system is not overwhelmed.
The child will gradually be able to take larger, less frequent feeds (every 3-4 hours).
Criteria for increasing the volume and decreasing the frequency of feeds will be presented in later in this
session.
Determine amount of F-75 needed per feed

Given the child’s starting weight and the frequency of feeding, use a table to look up the amount
needed per feed. Annex 9, you have been given a table that describes the amount of F-75 reference card.
Look at your F-75 reference card or chart booklet now, the required daily amount has been divided by
the number of feeds to show the amount needed per feed.
Notice that the amounts per feed ensure that the child will be offered a total of 130 ml/kg/day of F-75.
This amount of F-75 will give the child 100 kcal/kg/day and 1 - 1.5 g protein/kg/day. This amount is
appropriate until the child is stabilized.
If the child has severe (+++) edema, his/her weight will not be a true weight; the child’s weight may be
30% higher due to excess fluid. To compensate, the child with severe edema should be given only 100
ml/kg/day of F-75. Amounts per feed for the child with severe edema are shown on the reverse side of
the F-75 Reference Card.

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Tips for using the F-75 Reference Card

Be sure that you use the correct side of the card. Use the front side for most children, including those
with mild or moderate oedema. Use the reverse side only if the child is admitted with severe (+++)
edema.
Note that children’s weights listed on the F-75 Reference Card are all in even digits (2.0 kg, 2.2 kg, 2.4 kg,
etc.). If a child’s weight is between these (for example, if the weight is 2.1 kg or 2.3 kg), use the amount
of F-75 given for the lower weight.
While the child is on F-75, keep using the starting weight to determine feeding amounts even
if the child’s weight increases because the weight is not expected to increase on F-75. For an
edematous child, also continue using the child’s starting weight to determine the amount of
F-75, even when the edema (and weight) decreases. The volume per feed on the chart is already
based on the child’s estimated true weight.

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S-4 Feeding
For each child listed below, use your F-75 table to determine the amount of F-75 to give per feed. The
starting weight and edema classification is given for each child, as well as the current frequency of feeds
for the child.
Child 1: 6.8 kg, no edema, 3-hourly feeds Give ______ml F-75 per feed.
Child 2:
8.5 kg, mild (+) edema, 4-hourly feeds Give ______ml F-75 per
feed.
Child 3:
5.2 kg, severe (+++) edema, 2-hourly feeds Give ______ml F-75
per feed.
Child 4:
7.0 kg, severe (+++) edema, hypoglycemia, ½-hourly feeds Give
______ml F-75 per feed.
Child 5: 9.6 kg, moderate (++) edema, 6- feeds per day, Give ______ml
F-75 per feed.
Session.
When everyone is ready, there will be a group oral drill on determining amounts of F-75 to give.

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S-4 Feeding
Record the child’s 24 hour feeding plan

Information about feeding is recorded on the Therapeutic Diet part of the Multi-Chart, record the phase,
diet name (type of feed) to be given (F-75 or F-100/RUTF), ml per feed, the number of feeds to be given
daily, and ml per day (volume taken per day). For example, if the child is on a 2-hourly feeding schedule,
record that 12 feeds will be given. At the end of the day, record the total amount taken that day. The
multi-chart will provide a brief summary of feeds, as opposed to the detailed record on the 24-Hour
Food Intake Chart.
Record the time the feed is given and mark with × in one of the four small boxes.

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S-4 Feeding
Feed the child F-75 orally, or by NG tube if necessary

Oral feeding
It is best to feed the child with a cup (and spoon, if needed). Encourage the child to finish the feed.
It may be necessary to feed a very weak child with a dropper or syringe. Do not use a feeding bottle.
*Bottle feeding should be strongly discouraged
It takes skill to feed a very weak child, so nursing staff should
do this task at first if possible. Mothers may help with feeding
after the child becomes stronger and more willing to eat.
Never leave the child alone to feed. Spend time with the
child, hold the child, and encourage him/her to eat. Catch
dribbles by holding a saucer under the cup, as shown in
photograph 33 of the Photo booklet or figure 14 below. The
saucer will allow feeding more quickly without worrying about
spilling. At the end of the feed, give the child the amount
caught in the saucer.
Figure 14: Feeding using a cup and saucer
Encourage breastfeeding on demand and between formula
feeds. Ensure that the child still gets the required feeds of F-75
even if breastfeeding.
Feeding children who have diarrhea and vomiting

If the child has continuing watery diarrhea after he has been
rehydrated, offer ReSoMal between feeds to replace losses
from stools. As a guide, non-edematous children under 2 years
should be given 50-100 ml of ReSoMal after each loose stool,
while older children should be given 100-200 ml. The amount given in this range should be based on
the child’s willingness to drink and the amount of ongoing losses in the stool.
If the child vomits during or after a feed, estimate the amount vomited and offer that amount of feed
again. If the child keeps vomiting, offer half the amount of feed twice as often. For example, if the child
is supposed to take 40 ml of F-75 every 2 hours, offer half that amount (20 ml) every one hour until
vomiting stops.

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S-4 Feeding
Nasogastric (NG) feeding

It may be necessary to use a nasogastric (NG) tube if the child is very weak, has mouth ulcers that
prevent drinking, has pneumonia with rapid respiration or if the child cannot take enough F-75 by
mouth. The minimum acceptable amount for the child to take is 80 % of the amount offered. At each
feed, offer the F-75 orally first. Use an NG tube if the child does not take 80% of the feed (i.e., leaves
more than 20%) for 2 or 3 consecutive feeds.
A child with an NG tube is shown in photograph 6. The NG tube should be checked every time food
is put down. Check placement by injecting air with a syringe and listening for gurgling sounds in the
stomach. Change the tube if blocked. Do not plunge F-75 through the NG tube; let it drip in, or use
gentle pressure.
The use of the NGT should not normally exceed 3 days and should only be used in Phase 1
Abdominal distension can occur with oral or NGT feeding, but it is more likely with NG feeding. If the
child develops a hard-distended abdomen with very little bowel sound, give 2 ml of a 50% solution of
magnesium sulphate IM.
Remove the NG tube when the child takes:
• 80% of the day’s amount orally; or
• Two consecutive feeds fully by mouth.
Exception: If a child takes two consecutive feeds fully by mouth during the night, wait until morning to
remove the NG tube, just in case it is needed again in the night.
Record intake and output on the the therapeutic diet section of the multi-Chart
Instructions for completing chart:
• In the spaces above the chart, record the child’s name, hospital ID number, admission weight
and today’s weight. (If the child was rehydrated on the first day, list the rehydrated weight as the
admission weight.)
• On the top part of the chart, record the date, the type of feed to be given (diet name), the
number of feeds per day, and the amount to give at each feed (ml/day).
• At each feed: On the left column, record the time that the feed is given. Then record in each
column of the days as follows:
• Record the amount of feed offered. After offering the feed orally, measure and record the
amount left in cup.
• Subtract the amount left from the amount offered to determine the amount taken orally by the
child
• If necessary, give the rest of the feed by NG tube, and record this amount, and if the feed has
vomited and estimate the proportion of the feed vomited and record the amount (and not
replaced by more feed).
• Ask whether the child had watery diarrhea (any loose stool) since last feed. If so, record as “yes”.

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S-4 Feeding
At the end of 24 hours:

• Total amount of feed taken orally
• Total amount of feed taken by NG tube, if any
• Total estimated amount lost through vomit.
Add the totals taken orally and by NG tube. Then subtract any loss from vomiting. The result is the total
volume taken over 24 hours. Record this in the therapeutic diet section of the multi chart.
Mattios multi-chart
Full Name: Mattios Samson
Page 108 Mattios Admission weight (kg):3.2 kg Today’s weight (kg):3.2 kg
1 2 3 4 5
Date 11/1/2010
Phase I
Diet Name F-75
ml/feed 35
#/feed/day 12
Total ml offered per day 416
Total ml taken per day 382
Iron added in F-100 Begin iron after 2 days on F-100, donot give iron if on RUTF
2-hrly 3-hrly 4-hrly

1 X X
06:00 am X X
A= Absent
V= Vomit 2 08:00 X X
am X R
R= Refuse
NG = NG
3 10:00 X X
THERAPEUTIC DIET
Tube
IV = IV am
Fluid
X R
4 X X
12:00 pm R R
5 NG NG
>80% 2:00 pm NG NG
6 NG NG
75% 4:00 pm NG NG
X X
X 7 NG NG
50% 6:00 pm NG X
X
X 8 NG NG
25% 8:00 pm NG X
X
9 10:00 X X
pm NG NG
10 12:00 X X
am NG NG
11 2:00 X X
am X X
12 4:00 X X
am X X
Porridge
Family Meal
Other
Tell a facilitator when you have reached this point. When everyone is ready, there will be a
demonstration of how to fill therapeutic diet section of the multi-chart.

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S-4 Feeding
Answer the following questions about the therapeutic diet section for Mattios on the previous page:
1. How many times was Mattios fed during the 24-hour period?
2. What amount of F-75 was Mattios offered at each feed?
3. At 10:00 am did Mattios take enough (80%) of the F-75 orally? At 12:00 pm did he take
enough of the offered F-75?
4. What apparently happened at 10:00 am &12:00 pm feed?
5. How was the feeding method changed at 2:00 pm? Why do you think the staff changed the
feeding method?
6. How was Mattios fed from 6:00 pm to 12:00 am?
7. Should Mattios’s NG tube be removed?
Check your own answers to this exercise by comparing them to the answers
given at the end of the Session

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S-4 Feeding
Adjust the ward’s feeding plan for the next day

The total amount of F-75 given per day is based on the admission weight and does not change. (If the
child is rehydrated on the first day, use the rehydrated weight.) As the child stabilizes, the child can take
more at each feed, and feeds can be less frequent.
Each day, review the child’s multi-chart (therapeutic diet section) to determine if the child is ready for
larger and less frequent feeds.
Criteria for change of volume and frequency of F-75 feeds

• If vomiting, lots of diarrhea, or poor appetite, continue 2-hourly feeds.
• If little or no vomiting, modest diarrhea (for example, less than 5 watery stools per day), and
finishing most feeds, change to 3-hourly feeds.
• After a day on 3-hourly feeds: If no vomiting, less diarrhea, and finishing most feeds, change to
4-hourly feeds.
Compare the total amount of F-75 taken for the day to the 80% column on the F-75 Reference Card
to confirm that the child has taken enough. If not, NG feeding may be needed. Continue to offer each
feed orally first; then use an NG tube to complete the feed if the child does not take at least 80% orally.

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EXERCISE B
In this exercise, you will review 24-Hour Food Intake Chart and descriptions of children in order to
determine their feeding plans for the next day.
Case 1 – Dendir
Dendir was admitted with diarrhea. He had no edema. At the first two feeds of the day, Dendir was
still being given ReSoMal. After he was rehydrated, he began 2-hourly feeds of F-75 at 10:00am. His
rehydrated weight was 4.0 kg, so he was given 10 feeds of 45 ml each to finish the day. He took all of his
feeds very well, although he continued to have small watery diarrhea.
Dendir’s completed therapeutic diet section of the Multi-chart for Day 1 is given on the next page. Study
the completed chart. Then answer the following questions about Dendir’s feeding plan for Day 2.
a. Since Dendir only had 10 feeds rather than 12, his total food intake cannot be compared to the
80% column on your F-75 Reference Card. Instead, look at how much of each feed he took. Did
Dendir take at least 80% of each feed?
b. increasing volume/decreasing frequency of feeds in section 2.6 of this module, is Dendir ready to
change to 3-hourly feeds?
c. Enter instructions for Dendir’s feeding plan for Day 2 on the following excerpt from the24-Hour
Food intake chart:
Date:_________ Type of feed ______________Give_____ feeds ___ ml
d. Starting with the first feed at 6:00 am, list the times at which Dendir will need to be fed on Day 2

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Multi-chart
Name: Dendir Admission Weight:4.0 Kg Current Weight: Same

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Case 2 – Petros
Petros weighed 4.8 kilograms when he was admitted to the ward on Day 1. He had no edema. He was
given 12 feeds of 55 ml F-75
On Day 1, Petros was a reluctant eater, but he finished most of his feeds and changed to 3-hourly feeds
(8 feeds per day) on Day 2.
On Day 2, Petros was still reluctant to eat. At two feeds he took less than 80% of the amount offered, but
he took more at the next feeds, so an NG tube was never used.
Petros’s completed 24-Hour Food Intake Chart for Day 2.
a. Did Petros take at least 80% of the expected daily total?
b. Should Petros continue on 3-hourly feeds on Day 3, or should he change to 4-hourly larger feeds?
Why?
c. Enter instructions for Petros’s feeding plan for Day 3 on the following excerpt from the 24-Hour
Food Intake Chart:
DATE: ____________________ TYPE OF FEED: __________
Name: Petros
Admission weight (kg): 6.4 kg

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Case 3 – Rosa
When Rosa was admitted, she had severe (+++) edema. She weighed 6.4 kg and was 66 cm long. She
refused to eat, so an NG tube was inserted. On Days 1 and 2 she was given 55 ml of F-75 every 2 hours
by NG tube. On Day 3 her weight was down to 6.1 kg and her edema was moderate++). Rosa’s 24-Hour
Feeding Chart for Day 3 is shown below.
3a. At what time did Rosa start taking feeds entirely by mouth?
3b. Rosa’s NG tube was left in during the night, although it was not needed. On Day 4 should the NG
tube be removed?
3c. Should Rosa continues on 2-hourly feeds on Day 4, or should she change to 3-hourly larger feeds?
Why?
3d. On Day 4 Rosa weighs 5.8 kg and her edema is mild (+). Enter instructions for Rosa’sfeeding plan for
Day 4 on the following excerpt from the Therapeutic Diet Section.
Date:- ___________ Type of Feed:- ___________ Give:- ____ feeds of ______ ml
Name: Rosa Today’s weight (kg):
475
When you have finished this exercise, please discuss your answers with facilitator

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Transition Phase
Feeding the child in transition with RUTF and F-75, or F-100
It may take up to 7 days or longer for the child to stabilize on F-75. Once the child is stable, has
appetite and reduced edema and is therefore ready to move into the rehabilitation phase, the child is
transitioned from F-75 to F-100 or RUTF over 2-3 days, as tolerated.
The recommended energy intake during this period is 100- 135 kcal/kg/day. RUTF has higher energy
and protein content than F-75 and is used as a “catch-up” feed intended to rebuild wasted tissues.
The child should be able to tolerate RUTF before being referred to outpatient care.
For this, perform a test to determine whether the child accepts the RUTF because eventually the child
will be offered RUTF. However, it is extremely important to make the transition to RUTF gradually and
monitor the child carefully. If transition is too rapid, heart failure may occur.
Recognize readiness for transition
Look for the following signs of readiness usually after 2-7 days
• Return of appetite (easily finishes the F-75 feeds) and
• Reduced edema or minimal edema (++ or less) and
• No IV line, No NGT
The child may also smile at this stage.
Note; children with +++ edema should wait in stabilization phase until the edema has reduced to ++
edema. These children are particularly vulnerable to fluid overload and heart failure.
Begin giving RUTF slowly and gradually
Perform acceptance testing of RUTF:
This test should be conducted in a quiet and separate corner.
• Tell the mother that one wishes to test the appetite of the child for the RUTF before you start
giving it regularly.
• Counsel the mother to wash her hands before giving the food, take the child on her lap and give
him the RUTF with patience in small quantities, offer drinking water regularly to the child.
• Observe the child for 30 minutes.
• The RUTF is considered acceptable if the child has eaten at least 30 g (one third of a sachet of 92
g).
Transition can then be conducted as follows:

Transition can take around 2 to 3 days, during which RUTF is introduced and if needed F-75 should be
given according as described below.
Start giving RUTF as prescribed for the transition phase. If the child does not take the prescribed
amount of RUTF, then top up the feed with F-75 (if not taking sufficient RUTF). Increase the amount of
RUTF over 2–3 days until the child takes the full requirement of RUTF. See Annex 11 for recommended
quantities, RUTF reference card.

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Feeding Procedure during Transition

• Provide RUTF to the caregiver.
• Do not give RUTF to infants 0-6 months.
• Encourage the patient to have small, frequent RUTF feeds every 4 hours (six times per day).
• Breastfed children should be offered breast milk on demand before being fed RUTF.
• Offer clean, safe drinking water during and after the RUTF feed.
• Every 4 hours, provide a top up amount of F-75 therapeutic milk as in the stabilization phase.
• When the patient finishes 50 percent of the RUTF, reduce the volume of F-75 provided by 50
percent.
• Stop providing F-75 when the patient can finish 75–100 percent of the daily RUTF ration
During this period of transition, it is important to encourage the mother to:

• Regularly offer the RUTF to the child
• Let the child drink water freely
• Respect food hygiene (washing hands before eating, close and cover the sachet after opening)
• Breastfeed between rations.
If the RUTF is not available or if the child does not accept it, give F-100:
The transition is spread over three days, during which the F-100 is administered according to the
following:
Important point: F-100 should never be given to take home.

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Example of feeding program during transition for a child who has an appetite for RUTF
Take the following case:
Rediet is 10 months old, severely wasted; his admission weight is 5.5 kg and his length is 65 cm He
started taking 45 ml of F-75 every 2 hours. He continued to eat well the next two days. Day 2, he took
70 ml of F-75 every 3 hours. On Day 3, he took 95 ml of F-75 every 4 hours and easily completed all his
meals.
Therefore, on Day 4, the child is ready for transition. During the transition phase, the feeding program of
Rediet will be:
• 155 g (1.75 sachet) of RUTF to be given to the mother early in the day. The RUTF will be given
regularly to the child throughout the day, and additional F-75to top up if needed.
• Rediet will also receive water freely and breastfed in-between rations.
Example of feeding schedule during transition for a child who does not accept the RUTF
Diborha weight after rehydration is 3.0kg. On Day 1 she is started on 35 ml of F-75 every 2 hours. On
Day 2 she took 3-hourly feeds of 50 ml F-75. On Day 3 he took 4-hourly feeds of 65 ml F-75. He also
smiled at his mother and the nurses. On Day 3 Diborha easily finished all of his 4-hourly feeds. Thus, on
Day 4 Diborha is ready for transition.
Deborah’s feeding schedule during transition will be as follows:
• Day 4: 65 ml of F-100 every 4 hours (same amount and frequency as he previously took F-75).
• Day 5: 65 ml of F-100 every 4 hours (same as Day 4).
• Day 6: Continue 4-hourly feeds, increasing amount by 10 ml each time: 75 ml, 85 ml, 95 ml, etc.
If Deborah does not finish a feed, give the same amount at the next feed. Continue increasing
the amount until some food is left after most feeds.

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Name: Diborha
Monitor the child carefully during transition

Every 6 hours check the child’s respiratory and pulse rate. If F-100 is introduced carefully and gradually,
problems are unlikely; however, increasing respiratory and pulse rate may signal heart failure. Call a
physician for help. (More information on danger signs and monitoring is given in Daily Care.)

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Record intake/output; plan child’s feeds for next 24 hours

Record the amount of F-75, RUTF or F-100 offered at each feed, and the child’s intake and output
(vomiting or diarrhea) on the 24-Hour Food Intake Chart. Also enter the total amount taken during the
day on the multi-chart.
Enter the feeding plan for the next day on a therapeutic feeding section of the multi-chart. If the child is
receiving F-100, on the third day, when feeds should increase by 10 ml (as long as the child is taking all
that is offered), mark an arrow by the starting amount per feed. For example, 95 ml:
DATE: 9/12/01 TYPE OF FEED: F-100 GIVE: 6 feeds of 95 ml
Record the amount of F-100 or RUTF offered at each feed, and the child’s intake and output (vomiting or
diarrhea) on the therapeutic diet and surveillance charts of the multi -Chart. Enter the feeding plan for
the next day on a therapeutic diet chart.
Criteria to move back from transition phase to Stabilization Phase

The patient should be moved back to the stabilization phase if there is:
• Weight gain of more than 10 g/kg/day in association with an increase in respiratory rate
(indicative of excess fluid retention)
• Increasing or developing edema
• A rapid increase in the size of the liver
• Any sign of fluid overload
• Tense abdominal distension
• A complication that necessitates an IV infusion
• A need for feeding by NGT
• Significant refeeding diarrhea leading to weight loss
*NOTE: It is common for patients to have some change in stool frequency when their diet changes. This does
not need to be treated unless there is weight loss. Having several loose stools without weight loss is
not a criterion for moving back to the stabilization phase.

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EXERCISE C
Case 1 – Dendir
The following 24- hour intake chart and therapeutic section of the multi-chart excerpt summarizes
Dendir progress through the first two days of transition (Days 4 and 5). Dendir did not tolerate RUTF
during the test. On Day 4 and Day 5 he took all of every feed of 85 ml F-100. The column for Day 6
shows what the nurse wrote on the multi-chart in the morning of Dendir’s third day of transition.
*These figures show Dendir’s weight gain in grams per kilogram body weight. You will learn how to
calculate and interpret this gain later, in the module titled “Monitoring and Problem Solving.”
On Day 6 Dendir is on his 3rd day of transition. His 24-Hour Food Intake Chart for Day 4 and 5, through
the 24:00 feed, is shown on the next page. Study Dendir’s chart and answer the questions:
How much F-100 should Dendir be offered on day 6 at the 6:00 a.m. feed? Enter this amount in
the “Amount Offered” column of Dendir’s chart.
Dendir leaves 10 ml of the F-100 offered at 2:00 p.m and 6 p.m feeding. He has had no vomiting
or diarrhoea since the last feed. Complete the rest of Dendir’s therapeutic section of the multi-
chart for Day 6, including the totals.
Name: Dendir

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Case 2: Petros
You may remember that Petros was a reluctant eater on Days 1 and 2. On Day 3 his appetite increased,
and he took eight (3- hourly) feeds of 80 ml F-75. He took all of the F-75 offered at each feed. On Day 4
Petros took six 4-hourly feeds of 105 ml F-75. He ate greedily and still wanted more at the end of each
feed.
On Day 5 Petros began transition and refused to eat RUTF during the test. He was then given F-100. He
eagerly took six 4-hourly feeds of 105ml.
a. Should Petros be given larger feeds of F-100 on Day 6?
b. What should the nurse explain to Petros’s mother?
Case 3 – Rosa
You may remember that Rosa was admitted with severe edema and had to be fed by NG tube for
several days because she refused to eat.
By Day 6 Rosa was feeding much better, and she had lost most of her edema.
Her weight had decreased from 6.4 kg to 5.4 kg because of loss of edema fluid. Since Rosa’s starting
amount of F-75 was taken from the chart for severely edematous children, the staff continues to use
that chart and her starting weight to determine the amount of F-75 to give. On Day 4 Rosa was given six
feeds of 105 ml. She eagerly took all of the F-75 offered.
a . On Day 7 Rosa’s edema appears to be gone and she weighs 5.2 kg. During the acceptance test to
RUTF, she ate less than 30 g RUTF.
Is Rosa ready for transition? Why or why not?
b. Enter instructions for Rosa’s feeding plan for Day 7 on the following excerpt from the 24-Hour
Food Intake Chart:
DATE: ____ TYPE OF FEED: GIVE: ______ feeds of_____ ml
c. Rosa takes her feeds on Day 7 well and shows no danger signs. Enter instructions for Rosa’s feeding
plan for Day 8:
DATE: ___ TYPE OF FEED: ________ GIVE: ____ feeds of_______ ml
d. Rosa takes her feeds on Day 8 well and shows no danger signs. Enter instructions for Rosa feeding
plan for Day 9:
DATE: ___ TYPE OF FEED: ________ GIVE:____ feeds of_______ ml
When you have finished this exercise, please discuss your answers with a
facilitator.

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Rehabilitation Phase (Feed freely with F-100 or RUTF)

Criteria to move from transition phase to Rehabilitation phase feeding in OTP
Transition takes 3 days. After transition, the child is in the rehabilitation phase. A child is ready for
Rehabilitation Phase if:
• A good appetite: Passes the appetite test and takes the entire amount of the daily RUTF ration.
• Edema reduced to moderate (++) or mild (+). If wasting with bilateral pitting edema, edema
should completely disappear.
• Medical complications are resolved.
• Clinically well and alert.
Criteria to move from the transition phase to the rehabilitation phase in SC

Note: these are a few exceptions that cannot transition to RUTF
• A good appetite: Takes all the F-100 prescribed for the transition phase (150 kcal/kg/day).
• Edema reduced to moderate (++) or mild (+). If wasting with bilateral pitting edema, Edema
should completely disappear.
• Medical complications are resolved
Adjust feeding plan as necessary during rehabilitation

There are two options for Rehabilitation Phase:

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If no possible referral for outpatient care, feed freely with F-100 during rehabilitation
During rehabilitation phase, a child can feed freely on F-100 to an upper limit of 220 kcal/kg/day (This is
equal to 220 ml/kg/day.). Most children will consume at least 150 kcal/kg/day; any amount less than this
indicates that the child is not being fed freely or is unwell. There is F-100 reference table that shows the
amount to give for children of different weights
A severely malnourished child may equally be transitioned to RUTF while he or she remains in hospital
until discharge from program after attaining ≥-2 weight-for-height.
Encourage the child to eat freely at each feed

During the rehabilitation phase, encourage the child to eat as much as he wants at each feed, within the
range shown on the F-100 Reference Card. Continue to feed every 4 hours within this range. Sit with the
child and actively encourage eating. Never leave the child alone to feed.
If the child’s weight is between the weights given on the F-100 Reference Card, use the range for the
next lower weight.
If you need to calculate the acceptable range yourself (for example, if the child weighs more than 10 kg),
multiply the child’s weight by 150 ml (minimum) and 220 ml (maximum); then divide each result by 6
(for 6 feeds per day).
An easier method may be to add together the feed volumes for an appropriate combination of
children’s weights from the card. For example, if a child weighs 13.2 kg, add the volumes shown for a
10.0 kg child plus a 3.2 kg child.
Examples
• Meryam weighs 6.2 kg. According to the F-100 Reference Card, her feeds of F-100 may be in the
range of 155 - 230 ml.
• Loza weighs 4.5 kg. Using the range for the next lower weight, 4.4 kg, Loza’s feeds may be in the
range of 110 - 160 ml.
• Desta weighs 12 kg. Calculate the acceptable range of volumes of F-100 for her as follows:
• Minimum: 12 kg x 150 ml = 1800 ml per day
• 1800 ml ÷ 6 = 300 ml per feed
• Maximum: 12 kg x 220 ml = 2640 ml per day
• 2640 ml ÷ 6 = 440 ml per feed
• Alternative method for Delia = Add volumes for a 10.0 kg child plus a 2.0 kg child:
• Minimum: 250 ml + 50 ml = 300 ml per feed
• Maximum: 365 ml + 75 ml = 440 ml per feed
Due to rounding of the figures on the F-100 Reference Card, the volumes may be slightly different using this
alternative method.

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Record intake/output; determine if intake is acceptable

Record each feed on therapeutic diet part of the Multi-Chart. To determine if daily intake is acceptable,
compare the volume taken to the range given on the table on the F-100 Reference Card. If the child is
not taking the minimum amount, there may be a problem such as an infection, or the child may need
more encouragement to eat. In general, if the child is gaining weight rapidly, he is doing well.
If the child has diarrhea but is still gaining weight, there is no need for concern, and no change is
needed in the diet.
If diarrhea occurs so that the child loses weight, he/she needs to be moved back to Stabilization Phase.
If a major illness occurs during Rehabilitation Phase, the patient should be put back to Stabilization
Phase and given F-75 as in Stabilization Phase.
By week 3 or 4, if the child is doing well, there is no need to continue using the 24-Hour Food Intake
follow up. If the child is doing well and gaining weight rapidly, you may assume that he is doing well.
Monitoring for danger signs is no longer needed.
Criteria to move back from rehabilitation phase to stabilization phase
A child who has any one of the following should be returned to stabilization Phase:
• Develops any signs of a complication
• Increase/development of edema
• Development of refeeding diarrhea sufficient to lead to weight loss.
• Weight loss for 2 consecutive weighing
• Static weight for 3 consecutive weighing
• Fulfilling any of the criteria of “failure to respond to treatment” (further details in session 6)

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EXERCISE D
Case 1 – Dendir
You may remember that Dendir began transition on Day 4. On Day 5 he was given 85 ml F-100 per feed.
On Day 6 Dendir increased to 125ml by the last feed of the day. On day 7, he began free feeding on
F-100 and his weight is 4.1 Kg.
a. What amount of F-100 should he be offered on Day 7?
b. On Day 8 Dendir’s weight is 4.2 kg. What is the range of volumes of F-100 that is appropriate for
Dendir for each 4-hourly feed?
c. What should be the starting amount of F-100 given on Day 8?
d. Write the instruction, that should be written on the therapeutic section of the multi-chart
concerning the amount of F-100 to offer at subsequent feeds on Day 8? Assume that Dendir
leaves some amount from day 7 feed (i.e. from 135ml feed).
e. On Day 8 Dendir reached the maximum volume per feed and still wanted more. The nurse gave
him no more than the maximum allowed. On Day 9 Dendir’s weight is up to 4.4 kg. What should
be the starting amount of F-100 on Day 9? Should this amount be increased during the day?
Case 2 – Petros
Day 7 was Petros’s third day of transition. He started leaving food at 125 ml of F-100. On Day 8 he began
feeding at 125 ml and gradually increased to 145 ml, and he easily finishes his feed. On Day 9 his weight
was 5.05 kg. His 24-Hour Food Intake Chart for Day 9 is is on next page.
a. What is an appropriate range of daily volume of F-100 for Petros on Day 9?
b. Did Petros take a total volume of F-100 in this range?

Following is an excerpt from Petros’s multi-chart. On the fourth row Petro’s weight gain per day is
shown in grams per kilogram of his body weight. A weight gain of 10 or more g/kg/day is considered
good. A gain of 5 up to 10 g/kg/day is considered moderate. Less than 5 g/kg/day is poor. You will
learn to calculate daily weight gain and to keep a graph of weights in later modules.

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Name: Petros
1 2 1 2 3 34 45 56 67 7 8 8 9 910 1011 11
05/12/2010 0 60/51/21/22/021001 0 0 6 /0172//1220/1200 1 0 0078/ /1122/ /22001100 0089/ /1122/ /22001100 0190/ /1122/ /22001100 1101/ /1122/ /22001100 1 1 / 11 22 // 12 20 /1200 1 0 1 2 / 11 23 // 21 02 1/ 20 0 1 0 1134/ /1122/ /22001100 1145/ /1122/ /22001100 15/12/2010
Date Date
72 72
Height/Length Height/Length
(cm) (cm)
Anthropometric
Anthropometric
4 .8 44 .7
.8 5 4 4.7.75 5 4 4.7.85 44.8.8 44.8.8 44.8.8 5 4 .8 54 .9 4 .95 55.0 5 55.0.155 5 .1 5
Weight (kg) Weight (kg)
Chart
Chart
<- 3 <- 3
WFH/WFL z-score
WFH/WFL z-score
1 1 .2 1 1 .2
MUAC (cm) MUAC (cm)
Bilateral pittingBilateral
oedemapitting
(0, +, ++,
oedema 0
+++)(0, +, ++, +++) 00 00 00 00 00 00 0 0 00 00 00 0
Wt gain (g/kg/day)
Wt gain (g/kg/day) 1 0 .4 1 0 1.40 .3 1 02.3
0 .4 2 01 .4
0 190.9 9 .9
1 2 3 4 5 6 7 8 9 10 11
6 .5
WEIGHT CHART
6 .0
5 .5
5 .0
4 .5
4 .0

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690 -870
c. Look at Petros Multi-Chart. Notice that Petros ate the same amount per feed on Day 9 without
increasing. Is there any apparent reason for concern? Why or why not?
d. Enter instructions for Pedro’s feeding plan for Day 10 on the following excerpt from the 24-Hour Food
Intake Chart:
DATE:____ TYPE OF FEED: GIVE:______ feeds of_____ ml
Case 3 – Rosa
Day 9 was Rosa’s third day of transition. On Day 9 she started at 115 ml feeds of F-100. She took all of her
feeds well and progressed to 145 ml by the 10:00 am feed. On Day 10 Rosa weighed 5.2 kg and began
feeding freely on F-100. Her 24-Hour Food Intake excerpt for Day 10 is on the next page.

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3a. What should be the total volume of F-100 to be taken by Rosa over 24 hours on Day 10.
3b. Looking back at Rosa’s Monitoring Record for Day 10, the head nurse noticed that Rosa’s
temperature has increased to 38.50C axillary just before the 10:00pm feed. What does this suggest
about the cause of Rosa’s eating less?
3c. Which of the following should the head nurse do? (Tick)
____ Alert the doctor that Rosa has a problem and needs to be checked carefully
____ Plan feeding for Day 11 to start at 145 ml F-100 again
____ Both of the above
Name: Rosa Hospital ID: 453 Admission weight (kg): 6.4 kg Today’s weight: 5.2 kg

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4.3 Feeding Infants less than 6 months

Malnourished infants less than 6 months should always be treated in inpatient facilities. The
management of complication is the same as children 6-59 months. The feeding of infants is different
from older children and it is also different for infants on breast feeding or with a caretaker willing to
breast feed and for infants who cannot be breast-fed. RUTF is not suitable for them, as the reflex of
swallowing is not present yet.
There are important physiological and pathological differences between young infants and older
children that justify the separate consideration of the management of SAM in this specific age group.
Before 6 months of age, physiological processes including thermoregulation, renal and gastrointestinal
functions are relatively immature and may require modified management approaches or clinical
interventions. Clinical signs of infection and dehydration may also be more difficult to identify and
interpret.
Diagnostic criteria:
• Any grade of bilateral pitting edema (+, ++ or +++)
OR
• WFL < -3 z score
Note5: -Recent weight loss or failure to gain weight, or, Ineffective feeding (attachment, positioning and
suckling) directly observed for 15-20 minutes, ideally in supervised separate area, or, any medical or social
issue needing more detailed assessment or intensive support (e.g. disability, depression of caregiver, or other
adverse social circumstances), this infants need nutritional counseling, special attention and follow up. And
even need admission if no response to nutritional advice on follow up or based on the clinical judgment of
the treating health professional.
• Severely malnourished young infants need:

• Treatment with antibiotics
• Warmth to treat and prevent hypothermia.
• Nutritional support for breastfeeding which may require supplemental suckling techniques.
• Continuous monitoring of weight and feed intake.
• Psychological support to the mother or caretaker plus health and breastfeeding
counseling to reduce the risk of her infant becoming malnourished
• Keeping mothers and infants together must be a priority for a successful recovery of the infant
(Separating mothers from their children endangers breastfeeding, care and warmth for the
infant).
5 Note visible severe wasting is no longer recommended as Diagnostic criteria of SAM, due to its subjective
nature, but can be used during community screening, so as to refer to health facility for further evaluation.
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Outline for the management of severely malnourished infants less than six months of age

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4.4 Infants below six months with possibility of breast feeding

Infants who are malnourished are weak and do not suckle strongly enough to stimulate adequate
production of breast milk. The mother often thinks that she has insufficient milk and is apprehensive
about her ability to adequately feed her child. The objective of treatment of these children is to return
them to full exclusive breastfeeding.
Feeding
Stabilization:
The main objective is to supplement the child while stimulating production of breast milk. This is to
restore exclusive breastfeeding by supporting mothers and encouraging breastfeeding.
• The infant should be breastfed as frequently as possible; Breastfeed on demand or offer breast
milk every three hours for at least 20 minutes (more if the child cries or demands more)
During the initial phase of treatment, breastfeeding must be supplemented as follows:
• Between 30-60 minutes after a normal breastfeeding session, give maintenance amounts of milk
supplement as shown in the reference chart, distributed across eight feeds per day providing
100 kcal/kg per day. Two hourly feeding can be followed if the infant is having problems taking
the milk.
• Infants without edema should be supplemented with expressed breast milk, or, if this is not
possible give diluted F-100.6
• Infants with edema should be supplemented with expressed breast milk or, if this not possible,
F-75 until the edema has resolved.
When infant can suckle: The supplement is given in a cup through a thin tube along the nipple
(Supplementary Suckling technique).
When infant is too weak to suckle: Show
the mother how to express breast milk and
stimulate her breasts to make more milk.
Expressed breast milk should be used in
addition to the therapeutic milk given.
Preparation of F-100 diluted using the Tin

Formulation
1. Boil water to make it safe for drinking.
2. Ensure that the water temperature is not
below 70°C (i.e., cooled for not less than 3 – 5
minutes after boiling).
3. Add water to F-100 therapeutic milk. See
Table 6.
Figure 15: supplementary suckling technique
4. Whisk the mixture vigorously until the powder dissolves in the water.
5. Cool the prepared milk to feeding temperature before administering.
6. Give the feed based on the child’s body weight. See Annex 12a, 12b,12c
6 Undiluted F-100 should never be given to infants aged less than 6 months with SAM, because of the high renal solute
load and risk of hypernatraemic dehydration.

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- F-100-Diluted is prepared by adding 30% of the water, which was added to prepare the full-
strength F-100
Table 6 : Preparation of F-100 diluted feeds using the tin formulation
Blue scoop of f-100 Water (ml) volume of f-100 diluted (ml)
1 33 38
2 65 75
3 98 113
4 130 152
5 163 189
6 195 226
7 228 264
8 260 304
9 293 339
10 325 377
20 650 754
1 TIN (400G) 2405 2806

2 TINS (800G) 4810 5612
Supplementary suckling technique

The mother holds a cup with the F-100 diluted. The end of a NG tube (size nº8) is put in the cup, and the
tip of the tube on the breast, at the nipple. The infant is offered the breast in the usual way. The cup is
placed 5 – 10 cm below the level of the nipple for easy suckling. When the child suckles more strongly it
can lowered to up to 30 cm (see Figure 15 below)
Transition;
Monitor the progress of the infant in inpatient care by daily weighing.
• Decrease supplementary milk feeds by half when the child has gained at least 20g per day for 3
consecutive days and completely stop the milk when the child maintains a 10g per day weight
gain and continue on breast milk alone
• If weight gain is not satisfactory when reducing the volume of milk supplement, increase the
volume to the previous level for 2 days and try again.
Rehabilitation:
During this phase, the child does not receive any more milk supplement and is gaining weight by being
exclusively breastfed. Observe feedings in order to ensure that the infant is feeding well, and as often.
Breastfeeding must be at least 20 minutes. Continue to encourage the mother.

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Care for the mothers

• Check nutritional status of the mother (MUAC and edema).
• Assess the mother’s nutritional status using MUAC, if < 23.0 cm, admit in the TSFP.
• Explain the treatment and discourage self-criticism for the lack of breast milk.
• She should drink at least 2 liters of water per day and eat about 2500 kcal/day.
• From the beginning of rehabilitation, the mother must be prepared to feed the baby after
discharge.
• The mother should be counseled strongly on exclusive breast feeding.
Note: If the mother or the wet nurse is HIV positive, refer her to a specialist adviser on HIV and infant
feeding.
Discharge when the following criteria have been met:

• Successful re-lactation and effective breastfeeding has been achieved.
• Gaining weight on exclusive breastfeeding (i.e., more than 5 g/kg/day for at least 3 successive
days).
• No bilateral pitting oedema.
• Infant has been checked for immunization and other routine interventions.
• Mothers or caregivers have been linked with community-based follow-up and support.

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4.5 Infants below six months with no prospect to breast-fed

The following only applies to malnourished infants for whom there is no prospect of being breast-fed
(e.g. no mother, no wet-nurse) and are less than 6 months of age.
Feeding
Stabilization phase
Appropriate replacement feeding should be given such as F-75 (for edematous) or diluted F-100 (for
non-edematous) with relevant support to enable safe preparation and use.
Give F75 or F-100 diluted using a cup and spoon distributed. Amount is based on the child’s weight as
described in Annex 12a, 12b, 12c.
• If the infant is not taking sufficient amounts of milk orally, a nasogastric tube can be used
(drip, using gravity not pumping). A nasogastric tube should not be used for more than 3 days
and should only be used in the initial phase when the infant is still being treated for medical
conditions and/or doesn’t have appetite.
Substantial weight gain is not expected during stabilization.
Transition
This phase should continue for 4-5 days.
When the infant shows the signs of recovery and is F-100 diluted:
1. Increase the volume by 30%
2. Monitor the infant’s weight. Weigh every day and use appropriate scales.
When the infant shows the signs of recovery and is taking F-75(oedematous):
1. Give F-100-Diluted provided at 150–170 mL/kg per day, or increased by one third over the initial
amount given, providing 110–130 kcal/kg per day.
The criteria for further increasing the amount of feed given to the child are as follows.
• A good appetite: the child is taking at least 90% of the infant formula (F-100-Diluted)
prescribed
• Complete loss of bilateral pitting edema; or
• The child has been taking these amounts for at least 2 days;
• No other medical problem
Rehabilitation During rehabilitation, infants should be fed using a cup and a saucer; the mother or
caregiver will have to be sensitized to properly feed the infant at home after discharge.
• After 4-5 days, increase the volume of milk rations for another 30%.
• If the infant is still hungry after finishing the ration, give him more. Increase the rations of 5 ml
per meal.
The infant’s caregiver must prepare and provide meals under supervision while the infant is in the
malnutrition ward.

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Discharge criteria:
For an infant who is not breastfed, the planning and preparation for discharge is especially important.
Children under 6 months of age with SAM with no prospect of breastfeeding can be discharged when
they meet the following criteria:
• Infant is feeding well with the replacement feed.
• Has adequate weight gain and has a WFL ≥ -2 z-score.
• No bilateral pitting edema.
• Infant has been checked for immunization and other routine interventions.
• Mothers or caregivers have been linked with community-based follow-up and support

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4.6 Micronutrient supplementation

The infant should receive the following micronutrients supplements:
Vitamin A:
Give a dose of 50,000 IU on Day 1 and Day 2, Day 15 if:
• The child has visible clinical signs of vitamin A deficiency (Bitot’s spots, corneal clouding, or
corneal ulceration)
• The child has signs of eye infection (pus, inflammation)
• The child has measles now or has had measles in the past 3 months
• The child has persistent diarrhea
Iron:
Iron supplement should be given when the infant starts to gain on weight. Give 3 mg/kg/day into two
divided doses until discharge (if in tablet form, crush the tablet and dilute it in the milk).
Dose of Iron syrup

Weight of child Dose of Iron syrup
Ferrous fumarate 100mg/5ml (20 mg elemental
iron per ml)
3 up to 6 kg 0.5 ml
6 up to 10 kg 0.75 ml
10 up to 15 kg 1 ml

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EXERCISE E
Case 1: Almaz
You are in charge of 10 babies below 6 months in Zewditu Hospital. On August 1st, Almaz was admitted
to a SC. She is 5 months old, weighs 2.9kg and her length is 55cm. She is being breastfed. Her mother
says that her pregnancy lasted 9 months. Her mother is 22 years old, she has had 4 pregnancies but has
only 2 children alive. The father is absent.
1. Answer the following questions based on the previous and the additional information given below:
2. She was admitted to in-patient because her Weight for length is < -3 Z-score? True/False
3. What feed should be given to Almaz daily using the SS technique?
TYPE OF FEED: ___________ GIVE: ________ feeds of _______ ml
4. When she gains weight at 20 g/d the volume of F100 diluted should be one third? True/False
5. After satisfactory weight gain her SS diet is reduced by one third, it should now be stopped if
she gains at least 20g per day? True/False
6. The SS technique has been successful and she is gaining weight at 30gm/d on breast milk
alone. She will complete treatment and can be discharged when she has reached -2 Z-score
weight for height for two successive weights? True/False

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4.7 Plan feeding for the ward

Until this point, this session has focused on planning feeding for the individual child. It is also important
to plan to feed for the ward as a whole, so that the staffs know how much food to prepare, how much
food to put in cups at each feed, etc.
Determine a schedule for feeding and related activities in the ward
The ward schedule should include times for the following activities:
• Preparing feeds (as often as necessary to ensure freshness)
• Reviewing patient charts and planning feeding for the day
• Feeding according to 2-hourly, 3-hourly and 4-hourly plans
• Weighing
• Bathing
• Shift changes
Once these activities are scheduled, you will see where time for organized play and educational
activities most conveniently fit in.
In general, monitoring activities (such as measuring temperature and pulse and respirations) will take
place every four hours on an individual basis, before a child feeds. There is no need to include these
activities on the written schedule for the ward. Individual treatments and drugs will also be given on an
individual basis.
Time for preparing feeds

It is recommended to prepare for each feed and storage is not recommended especially in our situation
where refrigeration is poor and storage facilities are not good.
As for RUTF, it requires no preparation, no cold storage. When RUTF is indicated during transition, the
required amount can be given to the mother for the day, while also explaining how the food should be
given to the child during the day.
Time for review and planning
Select a time of day to review each child’s past 24-Hour Food Intake Chart; plan feeding for each child (if
this has not already been done during physician rounds); and compile feeding plans for each child onto
a feeding chart for the entire ward. This daily ward feed chart is used in the kitchen so that staff knows
how much F-75 and F-100 to prepare and which amount of RUTF to give.
Feeding times
Select a time of day that each “feeding day (24 hours)” will start. This is usually in the morning after
totals have been done from the previous day, and a Daily Ward Feed Chart has been prepared for the
new day. The time selected should be after staff have arrived and had time to prepare the food.
Plan times for 2-hourly, 3- hourly, and 4-hourly feeds. At almost every hour, some children will have
feeds. Ensure that no feeds occur at times of shift changes. For example, if shift changes are on the hour,
plan for feeds to occur on the half-hour.
Keep in mind that a few children, for example, those with hypoglycemia or continued vomiting, may be
on a special half-hourly or hourly feeding schedule. Those children will need special attention to ensure
the more frequent feeds are provided outside the normal schedule.

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Weighing and bathing

Daily weighing will need to occur at about the same time each day, preferably one hour before or after
a feed.
Since the children are undressed for weighing, this is also a good time for bathing. Generally children on
2-hourly feeding schedules are new to the ward and are likely to be too ill to be bathed. Children on 3
hourly and 4-hourly schedules may be bathed when they are weighed if this is convenient.
Shift changes
Shift changes may already be fixed for your hospital, and you may need to work around them in
planning your schedule. Often there are three shifts per day, with the night shift being the longest. Keep
in mind that no feeding should be scheduled during a shift change. It is best for shifts to overlap slightly
so that instructions may be communicated from one shift to the next.
Prepare a Daily Ward Feed Chart to use in preparing feeds

An example of a Daily Ward Feed Chart is on the next page. To prepare a Daily Ward Feed Chart:
• Enter the name of each child in the ward in the first column.
• Looking at each child’s individual daily intake on the 24-Hour Food Intake chart and on the multi-
chart for the coming day, transfer:
• the number of feeds planned for the child for the day
• the amount of F-75 or F-100 needed per feed (Note: if a child may be increasing the size of feeds
during the day, enter the amount of the largest feed that you expect him to take. To ensure that
there is enough food, it is better to estimate high.), as well as amount of RUTF needed per day.
• Determine the total amount of F-75 and F-100 needed for each child by multiplying the number of
feeds by the amount per feed.
• Add the individual totals to determine the total amount of F-75, F-100, and RUFT to be prepared
during each feeding.
• Plan to prepare some extra feed. The extra amount will be used for new admissions, etc. Enter the
amount to prepare in the appropriate space on the chart.

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Example
DAILY WARD FEED CHART
DATE: 14/03/01 WARD: SC
F-75 F-100
Amount/ Amount/
Number feed Number feed
Name of Child feeds (ml) Total (ml) feeds (ml) Total (ml)
Muleta 6 90 540
Elisabeth
6 300 1800
Feven
6 180 1080
Leila
6 110 660
Amanuel
Yosef
6 95 570
Genet
6 200 1200
Hailu
6 270 1620
Meriem
6 95 570
Kebre
6 150 900
Kendu
6 210 1260
Jemila
6 150 900
Jemberu
Total 590 3540 1,260 7560
RUTF
Child’s name RUTF amount / day (g) Number of sachets of 92 g
RUTF for 12 hours (g)

RUTF for 24 hours (Number of
sachets)

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EXERCISE F
In this exercise, you will finish completing a Daily Ward Feed Chart and determine how much F-75 and
F-100 to prepare for the ward. Use the partially completed Daily Ward Feed Chart on the next page in
this exercise.
1. Paulos is the tenth child in the ward. It is his fourth day in the ward and he is still on F-75. His feeding
plan for the day is below. Add Paulos’s feeding plan to the Daily Ward Feed Chart.
2. Fatuma is the eleventh child in the ward. She is starting her second day of transition, so her planned
amount of F-100 should not be increased during the day. Fatuma’s feeding plan for the day is
below. Add her feeding plan to the Daily Ward Feed Chart.
3. Samuel is the last child in the ward. Samuel’s feeding plan is below. Samuel ate eagerly yesterday,
and he is likely to reach his maximum amount today. Add Samuel’s feeding plan to the Daily Ward
Feed Chart.
DATE: 17/5/01 TYPE OF FEED: F-100 GIVE: 6 feeds of 170 ml Do not exceed 190 ml
4. Feeds are prepared every 4 hours at this hospital. Complete the Daily Ward Feed Chart to determine
how much to prepare every 4 hours.
When you have finished this exercise, please discuss your answers with afacilitator.

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Use in Exercise F
DAILY WARD FEED CHART
DATE: 17/05/01 WARD: Severe Malnutrition

F-75 F-100
Amount/ Amount/
Number feed Total ml Number feed Total ml
Name of Child feeds (ml) feeds (ml)
Menen 6 240 1440
Taye 6 70
Abdu 6 180 1080
Mame 6 160 960
Netsanet 6 65
Kiflu 6 200 1200
Hagos 6 220 1320
Belisa 6 120
Lemi 6 200 1200
Total F-75 needed for 24 F-100total ml needed

hours for 24 hrs
Amount needed for ___ Amount needed for
hours __hours
Amount to prepare (round Amount to prepare
up to whole liter) (round up to whole liter

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4.8 Plan staff assignments related to feeding children

The major tasks involved in feeding are:
• Preparing F-75, F-100, Diluted F-100, Formula milk and ReSoMal
• Ensure adequate stocks of RUTF
• Measuring Out Feeds In Amounts Prescribed For Each Child
• Feeding Children
• Recording feeds taken, vomiting and diarrhea episodes on intake chart
• Planning feeding schedule for an individual child for the next day
• Preparing the daily ward feed chart
Each of these tasks is extremely important. Each task requires different skills. For example, preparing
feeds requires the ability to follow a recipe and measure carefully. Feeding children requires patience
and the ability to encourage a child in a loving way. Appropriate staff, with the necessary skills or the
ability to learn them, must be assigned to each of these tasks.
Prepare staff to do assigned feeding tasks
If staffs do not know how to do the tasks that you plan to assign them, you will need to provide some
training. Training need not be lengthy or formal but may be done through staff meetings or on the job.
Good training includes information, examples, and practice.
Example: Think about a time when you learned a new skill, such as riding a bicycle, tying your shoe, or
cooking rice. If you had a good teacher, that person probably:
• First told you how (information)
• Then showed you how (example); and
• Then helped you practice until you could do it yourself.
These simple components of good teaching can be used in training staff to do feeding tasks or other
tasks on the ward.
Information: Staff must be told (and preferably informed in a written job description) what tasks are
expected. They must also be given instructions about how to do the tasks. Instructions may be in the
form of a “job-aid”, such as a poster on the wall with recipes for F-75, F-100, and ReSoMal. The F-75,
F-100, and RUTF Reference Cards used in this course are job-aids. Information may also be given orally,
for example, in a staff meeting about how to complete patient records.
Example: Staff must be shown how to do the tasks. For demonstration of preparing feeds or feeding a
very weak child. completed 24-Hour Food Intake Chart.
example, they may watch a They may look at a correctly
Practice: Practice is the most important element of training. In order to learn a task, staff must do the
task themselves, at first receiving careful supervision and feedback as needed to improve performance.
For example, staff must actually prepare feeds with supervision until they can do it correctly. They must
also practice reading a Daily Ward Feed Chart and measuring out appropriate amounts of feed. Staff
who will feed children need to practice holding them and encouraging them to eat.
Of course, training will not solve every problem in the ward. For example, staff may not want to do
a task because it is unpleasant, or they may be unable to do a task because they lack the time or
equipment. Training will not solve these problems, and other solutions will need to be considered.
Training is appropriate when staff:
• do not know what to do; or

• do not know how to do a task.

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EXERCISE G
In this exercise you will discuss various ways in which information, examples, and practice can be
provided for feeding-related tasks.
First answer the questions below. Be prepared to discuss your answers with the group.
List one feeding-related task that staff in your hospital do not know how to do correctly.
In training staff to do this task, how could you provide information cheaply, quickly, and realistically?
How could you provide examples cheaply, quickly, and realistically?
How could you provide practice cheaply, quickly, and realistically?
Tell a facilitator when you are ready for the group disc

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ANSWERS TO SHORT ANSWER EXERCISE

Answers, page 104
Child 1: 110 ml F-75
Child 2: 185 ml F-75 (When the weight is not on the feeding table, use the next lower weight. Use the
regular feeding table for a child with mild oedema.)
Child 3: 45 ml F-75 (Use feeding table for children with severe oedema.)
Child 4: 15 ml F-75 every half hour (Divide 2-hourly amount for severely oedematous child by 4.)
Child 5: 210 ml F-75 (Use regular table since child has only moderate oedema.)
Answers, page 109
1. 12 times
2. Mattios was offered 35 ml each time.
3. No, 20 ml is only about 75% of 35 ml.
4. He refused most of the feed and vomited the small amount that he took.
5. He was fed by NG tube. The staff realized that he had not taken enough by mouth for 3
successive feeds. (Note: They could have started the NG after 2 poor feeds.)
6. He was fed as much as he would take orally; then he was given the rest by NG tube.
7. No, the NG tube should not be removed. Although he took almost all of the last two feeds by
mouth, it is night time.

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SESSION 5: DAILY CARE

S-5 Daily Care
Introduction
Attentive and consistent daily care will make the difference in a severely malnourished child’s recovery.
The routine of daily care in a severe malnutrition ward includes such tasks as feeding, bathing,
weighing, giving antibiotics, and monitoring and recording each child’s progress. Throughout a very
busy day, and through the night, the staff must be patient and caring with both the children and their
parents.
Feeding tasks were described in the Feeding Session. Weighing and measuring tasks were described in
Principles of Care. This Session will describe other aspects of daily care. You will practice tasks related to
daily care during ward visits. Written practice in the session will focus on completing and interpreting
the sections relevant for daily Care and Weight Chart of the multi-chart and the surveillance Chart.
Learning Objectives
This Session and related clinical sessions will describe and allow you to practice the following skills:
• Handling a child with SAM appropriately
• Caring for the skin and bathing a child with SAM.
• Giving routine medicines and other prescribed antibiotics, medications and supplements
• Caring for the eyes
• Monitoring pulse, respirations, and temperature and watching for danger signs
• Completing and interpreting the sections of the multi-chart relevant for daily Care and
Monitoring Record, Preparing and maintaining a weight chart (graph)

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5.1 Handle the child gently

Children with SAM must be handled very gently, especially at the beginning of their care. The body of
a child with SAM is fragile and bruises easily. The child needs all his energy to recover, so he must stay
calm and not become upset. It is important to speak quietly and handle children as little as possible at
first. Hold and touch children with loving care when feeding, bathing, weighing, and caring for them.
Through calm voice, gentle manner, and caring attitude, nurses will set a good example for the mothers
of providing tender, loving care. They will also win the trust of the mothers and make them more likely
to stay with their children in the hospital for the necessary length of time. It is critical for mothers to
stay with their children in the hospital. The number of other adults interacting with each child should
be limited, and the most skilled staff available should perform medical procedures, preferably out of
earshot and sight of the other children. Nurses can set a good example by:
• Removing the child’s clothes gently

• Bathing the child gently
• Talking softly to the child while giving treatments
• Holding the child close while feeding
• Encouraging a mother who is helping to provide care
• Comforting a child after a painful procedure
As the child recovers, stimulation of the child should increase. Play, physical activities, and mental and
emotional stimulation become very important to the child’s complete recovery. There will be more
information on these activities in session 7- Involving Mothers in care.

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Tick all of the appropriate responses or actions in the situations described below.
1. A child is crying after having an intramuscular injection. The mother appears upset and uncertain
what to do.
____ a. Leave the child alone until he calms down.
____ b. Hold and comfort the child.
____ c. Explain to the mother why the procedure was necessary and how it will help the child.
____ d. Show the mother how to hold the child gently without rubbing the site of the injection.
2. A mother pays little attention while her child is bathed by a nurse. The mother sits quietly, does not
participate, and is hesitant to touch the child.
____ a. Look at the mother directly and explain the bathing procedure.
____ b. Reassure the mother that she will not hurt her child by bathing and holding her gently.
____ c. Show the mother how to bathe and hold the child gently.
____ d. Leave the mother alone with the child, assuming she will figure out how to finish the bath.
_____e. Watch and help while having the mother dress and warm the child after the bath.
3. A mother falls asleep and does not finish feeding her child F-75 during the night.
_____ a. Let the mother sleep while you feed the child yourself.
_____ b. Gently wake the mother and ask, “Can you finish the feed?”
____ c. Wake the mother and tell her that the child could die if not fed every three hours.
____ d. Suggest that the mother take turns sleeping and giving feeds with another woman whose
child is nearby.
Check your own answers by comparing them to the answers given at the end of the module.

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Example of sections of Therapeutic-treatment multi-chart relevant for Daily care.

The next page shows an example of completed sections of multi-chart relevant for daily Care of
severe malnutrition. When daily care tasks are performed, the nursing staff should record their
initials on these pages.
Tell a facilitator when you have reached this point of the session. When everyone is ready, your
facilitator will present a brief demonstration on how to use the multi-chart for daily care. In the
meantime, you may continue reading.
Name:- Birke Abera

1 2 2 4 5 6 7 8 9
08/01/11 09/01/11 10/01/11 11/01/11 12/01/11 13/1/2011 14/1/2011 15/1/2011 16/1/2011
Date
90
Height/Length (cm)
Anthropometric
8 .8 8 .8 8 .7 5 8 .8 8 .8 8.8 8.9 8.9 9

Weight (kg)
Chart
<- 3
WFH/WFL z-score
11
MUAC (cm)
Bilateral pitting oedema (0, +, ++, +++) 0
Wt gain (g/kg/day)
None Lethargic/unconsious Cold hand Slow capillary refill(>3 seconds) Weak/fast pulse If diarrhoea,other signs present;
Watery diarrhoea? Yes No
Lethargic Yes No
SIGNS OF Skin picnch goes back slowly Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give DIARRHOEA Dry mouth/tongue Yes No
SHOCK IV glucose as described under Blood Glucose (left). Then give IV fluids:
Blood in stool? Yes No
Restless/Irritable Yes No Thirsty Yes No
Vomiting? Yes No Sunken eyes Yes No No tears Yes No
Amount IV fluids per hour: 15 ml x kg (child’s wt) = ml If diarrhoea and/or vomiting, give ReSoMal. Every 30 minutes for first 2 hours, monitor and give:* For up to 10 hours, give ReSoMal and F-75 in alternate hours.
Start: Monitor every 10 minutes *2nd hr Monitor every 10 minutes Monitor every hour. Amount of ReSoMal to offer:*
Time *
INITIAL MANAGEMENT
5 ml x kg (child’s wt) = ml ReSoMal 5 to 10 ml X kg (child’s wt) = to ml ReSoMal
Resp. rate * Time Start:
Pulse rate * Resp. rate
*If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in right part of chart below. If
Pulse rate
no improvement on IV fluids, transfuse whole fresh blood.
Weight
TEMPERATURE:- 3 5 .5 °C Rectal axillary
If rectal <35.5°C (95.9°F), or axillary<35°C (95°F), actively warm child. Check temperature every 30 minutes. Passed urine? Y / N
Oral doses vitamin A: Number stools

MEASLES Yes No
If corneal clouding or ulceration, give vitamin A & atropine immediately.
EYE SIGNS None Left Right Record on Special Medicine section. Number vomits
EYE CARE
<6 months 50,000 IU Hydration signs

Bitots' spot
100,000 IU Amount taken (ml) F-75 F-75 F-75 F-75 F-75
6-11months
*Stop ReSomal if: Increase in pulse,& resp.rates, Jugular veins engorged, increasing oedema eg. Puffy eyes, weight gain exceeds th weight before diarrhoae or is above 5% of the weight before rehydration
Pus/inflammation
X 200,000 IU BLOOD GLUCOSE (mg/dl): 7 8 m g/ dl HAEMOGLOBIN (Hb) (g/dl): 9 .5 g/ dl Blood type:
Corneal clouding
≥ 12 months If <54mg/dl and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG). If <54mg/dl If Hb <4g/dl or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg
Corneal ulceration and lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s packed cells) slowly over 3 hours. Amount: Time started:
wt) = ml Then give 50 ml bolus NG. Time glucose given: Oral NG Ended:
IV

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Pulse rate
no improvement on IV fluids, transfuse whole fresh blood.
INITIAL MANA
Weight
TEMPERATURE:- 35.5 °C Rectal axillary

MEASLES Yes No If corneal clouding or ulceration, give vitamin A & atropine immediately.
EYE SIGNS Record on Special Medicine section.
S-5 Daily Care
None Left Right Number vomits
EYE CARE
Bitots' spot
100,000 IU Amount taken (ml)
6-11months
Pus/inflammation *Stop ReSomal if: Increase in pulse,& resp.rates, Jugular veins
X 200,000 IU BLOOD GLUCOSE (mg/dl): 78mg/dl

Corneal clouding
≥ 12 months If <54mg/dl and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG).
Corneal ulceration lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x
Then give 50 ml bolus NG. Time glucose given: Oral NG
1 2 3 4 5 6 7 8 9 10 11 12
11
10.5
WEIGHT CHART
10.0
9.5
9.0
8.5
8.0
7.5
1 2 3 4 5 6 7 8 9 10 11 12
Date 08/01/11 09/01/11 10/01/11 11/01/11 12/01/11 13/1/2011 14/1/2011 15/1/2011 16/1/2011
Phase I I I I I TR TR II II
Diet Name F-75 F-75 F-75 F-75 F-75 F-100 F-100 F-100 F-100
ml/feed 95 95 145 190 190 190 190 225 225
#/feed/day 11 12 8 6 6 6 6 6 6
Total ml offered per day 1049 1144 1144 1144 1144 1144 1144 1320 1350
Total ml taken per day 920 1105 1110 950 1090 1092 1144 1220 1280

6:00 X X X X X X X X X X X X X X X X
1 6:00 am 6:00 am
A= Absent
am X R X R X X X X X X X X X X X X
V= Vomit 9:00 X X X X X X X X X X X X X X X X X X
2 8:00 am 10:00 AM
R= Refuse
am
X R X X X X X X X X X X X X X X X X
NG = NG
X X X X X R X X X X X X X X X X X X
THERAPEUTIC DIET
Tube 3 10:00 12:00

2:00 pm
IV = IV am pm
Fluid X X X X X X X X X X X X X X X X X X
3:00 X X X X X X X X X X X X X X X X X X
4 12:00pm 6:00 pm
pm
X X X X X X X X X X X X X X X X
6:00 X X X X X X R R X X X X X X X X X X
5 2:00 pm 10:00 PM
>80% pm X R X X X X X R X X R X X X X X X X
9:00 X X X X X X X X X X X X X X X X X X
6 4:00 pm 2:00 am
pm
75% X X X X X X X R R X X X X X X X X X
X X
X 12:00 X X X X X X
7 6:00 pm
50%
X
am X X X X X X
X
3:00 X X X X X X
8 8:00 pm
25%
X
am
X X X X X X
9 10:00 X X X X
pm
X R X X
10 12:00 X X X X
am
X X X X
11 2:00 X X X X
am
X X X R
12 4:00 X X X X
am
X X X X
Porridge
Family Meal
Other

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1 2 3 4 5 6 7 8 9
08/01/11 09/01/11 10/01/11 11/01/11 12/01/11 13/1/2011 14/1/2011 15/1/2011 16/1/2011
Date
Diarrhoea (Tally) //// /// // N N N N N N
Vomit (Tally) N N N N N N N N N
SURVEILANCE CHART
Dehydration (Y/N) N N N N N N N N N
Cough (Y/N) N N N N N N N N N
Septic Shock (Y/N) N N N N N N N N N
Respiratory Rate 35 36 35 37 34 34 36 37 37
Palmer pallor (Y/N) Y Y Y Y Y Y Y Y Y
Temp. AM Ax/Rect 3 5 .5 3 6 .3 3 6 .8 3 7 .3 3 6 .9 3 7 .2 3 6 .8 3 6 .7 3 6 .6
Temp. PM Ax/Rect 36 3 6 .5 37 3 7 .4 3 6 .9 37 3 7 .1 3 6 .3 37
Deramtosis( 0, +, ++, +++) +++ +++ ++ ++ ++ ++ + 0 0
Liver Size (cm) 0 0 0 0 0 0 0 0 0
Failure to Respond N
1 2 3 4 5 6 7 8 9
08/01/11 09/01/11 10/01/11 11/01/11 12/01/11 13/1/2011 14/1/2011 15/1/2011 16/1/2011
Date
Antibiotics-1 Time : 6 :0 0 A M AS AS AS AS AS
A m ox ci l l i n 2 5 0 m g 6 :0 0 P M BT BT BT BT BT
ROUTINE MEDICINE
BAntibiotic
ID P O 2: Time 6 :0 0 A M AS AS
A m pi ci l l i n 4 4 0 m g IV 1 2 :0 0 P M AS AS
Q ID 6 :0 0 P M BT BT
1 2 :0 0 A M BT BT
Antibiotic 3: Time 6 :0 0 A M AS AS BT BT BT FH FH
G en ta m y ci n 4 0 m g IV
OD BT
Deworming in phase 2

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5.2 Give Routine medicines and other medications

The nurse checks the multi-chart for severe malnutrition and gives the child any medication needed at
that time. In addition, she may monitor respirations, pulse, and temperature; give eye drops, etc.
Give antibiotics as prescribed

Note: The prescription of appropriate antibiotics has already been discussed in the Initial Management
session. This section is about administering them.
When antibiotics are prescribed, enter the name, the dose and the route of administration in the routine
medicine section under antibiotic I if it is the first line drug; and any additional antibiotics in the special
medicine box under antibiotic II and III. The nurse should sign in the box when the antibiotic is given. If
the prescription changes, be sure to update the multi-chart.
Look at the example of the routine and special medicines sections of the multi-chart. Notice how the
Antibiotics section is set up and completed.
It is assumed that nursing staff know how to measure and administer oral doses, so that will not be
discussed here. However, giving antibiotics by IM injection may be difficult in a child with SAM and
requires special care and attention.
Possible sites for IM injections are the thighs. Carefully select the site for an injection:
• Choose a site with enough muscle.
• Change the site when it becomes sore.
Give Folic acid

Folic acid is a vitamin B complex important for treating and preventing anemia and repairing the
damaged gut. Each child who has clinical anaemia (severe anaemia), except infants aged less than
6 months, should be given a large dose (5 mg) on Day 1 ; there is sufficient folic acid in commercially
manufactured F-75, F-100 and RUTF to treat mild folate deficiency. CMV should be added if locally
prepared F75 and F-100 is used.
Commercial F-75 and F-100 contain folic acid; therefore folic acid in addition to the feeds is not needed.
Give vitamin A
Vitamin A doses are given on Day 1 and Day 2, Day 15 if:
• The child has visible clinical signs of vitamin A deficiency (Bitot’s spots, corneal clouding, or
corneal ulceration)
• The child has signs of eye infection (pus, inflammation)
• The child has measles now or has had measles in the past 3 months
• The child has persistent diarrhea
Severely malnourished children are at high risk of blindness due to vitamin A deficiency. Severely
malnourished children are at high risk of blindness due to vitamin A deficiency. Thus, vitamin A
should be given to all severely malnourished children at the end of rehabilitation when the child stops
receiving therapeutic food, unless there is definite evidence that a dose has been given in the past
month.

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Timing and oral dosages of vitamin A:

If the child has an active case of measles or has had measles recently (in the past 3 months), or eye signs give
a high dose of vitamin A on days 1, 2, and 15 (with or without edema).
Oral treatment with vitamin A is standard

Enter the dose in the multi-chart when vitamin A is given. Sometimes the first dose is given immediately
when the child arrives at the hospital for emergency treatment of corneal ulceration. If so, be sure that
this dose is entered on the multi-chart, so that a duplicate dose is not given on Day 1. It shades out the
boxes for Day 1, Day 2 and Day 15, for vitamin A, if these doses are not needed (child has no eye signs
and no recent measles).
Age Vitamin A dose

< 6 months 50, 000 IU
6 - 11 months 100, 000 IU
≥ 12 months 200, 000 IU
Give Measles Vaccine

All children from 9 months who are not vaccinated should be given measles vaccine both on admission
and discharge after Rehabilitation Phase. The first measles dose often does not give a protective
antibody response. It is given because it ameliorates the severity of incubating measles and partially
protects from nosocomial measles. The second dose is given to provoke protective antibodies.

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1. Look again at the example of the multi chart for Birke (page 153). Birke is 2 years old and was
admitted with corneal clouding. Should she be given a dose of vitamin A? If yes, what is the dose?
2. Another severely malnourished child without edema, Neway, is admitted with no signs of vitamin A
deficiency or eye infection. Neway is 12 months old and has never had measles. He has no record of
previous doses of vitamin A. Should Neway be given a high dose of vitamin A? why?
3. Germew is 3 years old and has severe edema. He has Bitot spots and there is no evidence that he
has had a dose of vitamin A in the past months.
a. Should vitamin A be given to him?
b. What is the dose?
4. Dasash (age 20 months) was referred from a health centre where she was given 200 000IU vitamin A
yesterday. She has no edema. She has corneal clouding.
a. Should she be given another dose today day 1 at the hospital?

b. Should she be given a dose on Day 2?
c. When is the next dose of vitamin A?
Check your own answers to this exercise by comparing them to

those given at the end of the module.

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Give Deworming tablets

Worms are common in older children who play outside, and they can be a problem in severely
malnourished children. They can cause dysentery and anemia
Albendazole or Mebendazole is given at the start of Rehabilitation phase for children greater than 2 year
that will remain as in-patient. For those transferred to outpatient Albendazole or Mebendazole is given
at the second outpatient visit (after 7 days). Write the drug, dose (see table below) and put on the drug
for worm row initials on the day the drug is given on routine medicines section of the multi-chart.
Table 6: Dose of deworming Give a single dose if child is ≥ 2 years and didn’t get within
tablets the previous 6 months
Age Mebendazole Albendazole
500 mg tablet,
or 5 tablets of Syrup, Syrup,
2 - 5 years 100 mg 100mg/5ml 400mg Tablet 100mg/5ml
Give Iron
Even if the child is anemic, he/she should not be given iron until he is recovering, and he/she is on F-100
for two days. If given earlier, iron can have toxic effects and reduce resistance to infection.
Calculate and administer the amount needed: Always give iron orally, never by injection. Preferably
give iron between meals using a liquid preparation.
Give: 3 mg elemental Fe/kg/day in 2 divided doses.

See the therapeutic diet section of the multi-chart. Continue giving iron throughout the hospital stay if
the child is on F-100.
Don’t give iron to a child who is taking RUTF because it already has the required amount of iron.
See the therapeutic diet section of the multi-chart. Continue giving iron throughout the hospital stay if
the child is on F-100.

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5.3 Care for skin and bathe the child

Bathe children daily unless they are very sick. If a child is very sick, wait until the child is recovering to
bathe her/him.
If the child does not have skin problems, or has only mild or moderate dermatosis, use regular soap for
bathing.
If the child has severe (+++) dermatosis, bathe for 10-15 min/day in 0.01% potassium permanganate
solution. Sponge the solution onto affected areas while the child is sitting in a basin. This dries the
lesions, helps to prevent loss of serum and inhibits infection. Note it on the special medicine section under
“others”, when the bath is done.
If potassium permanganate solution is not available, affected areas may be dabbed with gentian violet.
If the child has severe dermatosis but is too sick to be bathed, dab 0.01% potassium permanganate
solution on the affected areas, and dress oozing areas with gauze to keep them clean.
Apply barrier cream to raw areas. Useful ointments are zinc and castor oil ointment, petroleum jelly,
or paraffin gauze dressing. These help to relieve pain and prevent infection. Use a different tube
of ointment for each child to avoid spreading infection. If the diaper area becomes colonized with
Candida, use nystatin ointment or cream after bathing. (Candidiasis is also treated with oral nystatin as
described in the manual.)
Leave off diapers (nappies) so the affected area can dry. Be sure to dry the child well after a bath and
wrap the child warmly.
5.4 Care for the eyes

Tetracycline, or Gentamycin eye drops are given for eye infection or possible eye infection. Atropine eye
drops are used to relax the eye when there is corneal involvement (i.e., corneal clouding or ulceration).
In some cases, both types of eye drops may be needed.
Doses are as follows. Instill drops into the affected eye(s):
• Gentamycin (0.3%), tetracycline (1%): 1 drop/ointment , 3-4 times daily for 7 to 10 days
• Atropine (0.1%): 1 drop, 3 times daily for 3 to 5 days.
Here is a summary of the eye drops needed for the eye signs discussed in this course:

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Some severely malnourished children sleep with their eyes open. Nurses should gently close the child’s
eyes while sleeping to prevent abrasion.
Register on the multi-chart when eye drops are given.

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EXERCISE A
In this exercise you will decide on treatment for children with various eye signs. For some of the cases,
you will refer to the Photographs booklet. For each child pictured or described, determine how many
doses of vitamin A are needed and what kind of eye drops are needed.
1. Photo 8 – It was necessary to clean and open this child’s eyes to examine them. Pus and
inflammation were the eye signs found. The child has not had a dose of vitamin A in the last
month. On what days should this child receive vitamin A? What eye drops should be given, if any?
2. Photo 9 - This child has corneal clouding. He has not had a dose of vitamin A in the last month.
• On what days should this child receive vitamin A?
• What eye drops should be given, if any?
3. Photo 10 - This child has a Bitot’s spot and inflammation. He has not had a dose of vitamin A in
the last 6 months.
4. Photo 12 - This child has corneal ulceration. He has not had a dose of vitamin A in the past 6
months.
5. Photo 15 – The child has +++ dermatosis. What treatment should this child get?
When you have completed this exercise, please discuss your answers with a
facilitator.

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EXERCISE B
This exercise will be done as a group. Your facilitator will prompt you as you set up the multi-chart.
Obtain a blank multi-chart to use in this exercise. (There should be a supply in your classroom.) When
you have completed this exercise, save the filled multi-chart for later use in Exercise C.
Case – Lelisse
Lelisse is an 18-month-old girl with severe wasting and edema of both feet. She is acutely sick and has
severe dermatosis, corneal clouding, and pus draining from her left ear. Lelissa does not seem to have
worms.
Nurses take the nursing trolley around the ward to give antibiotics, eye drops etc. at the following times:
06:00am, 12:00pm, 06:00pm, 12:00 pm

Use the information on Lelisse’s initial management page, and the above information on nursing
rounds, to set up Lelisse’s Daily care page. Your facilitator will prompt you to include the necessary
information.
When the group has completed this exercise, please discuss your answers with
a facilitator

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5.6 Monitor pulse, respirations, and temperature, and watch for

danger signs
Measure Pulse and respiratory rate and take temperature
Measure pulse, count respirations and measure temperature every 4 hours, before feeding. This
monitoring is very important because an increase in pulse rate or respiratory rate can signal a problem
such as an infection, or heart failure from over hydration due to feeding or rehydrating too fast. An
increase or decrease in temperature to above or below normal can indicate infection.
It is critical to monitor the child closely (every four hours) during initial treatment and during transition
to free feeding on F-100. After the child is stable and feeding freely on F-100, you may decrease
monitoring of pulse, respirations, and temperature to once a day as long as the child is gaining weight.
If there is no weight gain, or if the child loses weight, resume monitoring every four hours.
Record results of monitoring on the surveillance section of the multi-chart that allows you to record
only two records of temperature and one reading of pulse and RR per day. However, a child with
medical complications like, shock, dehydration, heart failure, hypoglycemia, hypothermia needs close
follow up; thus use the monitoring record chart for pulse, respiration and temperature with 6 readings
per day (Annex 16).
Page 159 shows an example of a completed Monitoring Record. Tell a facilitator when you have
reached this point in the module. When everyone is ready, your facilitator will present a brief
demonstration of how to use the Monitoring Record. In the meantime, you may continue reading.
Recognize danger signs

Changes in pulse, respirations, temperature
The following increases in pulse and respiratory rate should be confirmed in order to determine if there
is problem:
• If pulse increases by 25 or more beats per minute from the last measurement, confirm in 30
minutes*
• If respiratory rate increases by 5 or more breaths per minute from the last measurement, confirm
in 30 minutes*
* If on IV fluids, confirm in 10 minutes and watch closely.
If the above increases in pulse AND respiratory rates are BOTH confirmed, they are a danger sign.
Together, these increases suggest an infection, or heart failure from over hydration due to feeding or
rehydrating too fast. Call a doctor for help. Stop feeds and ReSoMal, and slow fluids until a doctor has
checked the child.

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If only the respiratory rate increases, determine if the child has fast breathing, which may indicate
pneumonia. If the child is from 2 up to 11 months old, a rate of 50 breaths per minute or more is
considered fast. If the child is 12 months up to 5 years old, a rate of 40 breaths per minute or more is
considered fast.
If only the pulse increases, there is no cause for concern, as the pulse may increase for many reasons,
such as fear or crying.
If a child’s axillary temperature drops below 35 0C, the child is hypothermic and needs re-warming.
Have the mother hold the child next to her skin, or use a heater or lamp with caution. Be sure the room
is warm (28 – 32 0C if possible) and the child is covered. Hypothermia may be a sign of infection. If the
temperature drops suddenly, call a physician.
Increases in temperature can also indicate infections. Call a physician for help if there is a sudden
increase or decrease in temperature. Changes in temperature can easily be seen on the temperature
graph of on the monitoring record for pulse, RR, and temperature. Notice the changes in temperature
on the example of the monitoring record of SAM on page 159.
Summary of Danger Signs Related to Pulse, respirations and temperature

Danger signs Suggests
Other danger signs

Carefully watch any child with an infection such as pneumonia or sepsis, ear infection, or UTI. If possible,
Keep children with infections near the nurses’ station so that they can be easily watched. If a child has
diarrhea or a rash, keep the child separate from the other children, if possible. For example, isolate the
child behind a screen or in a separate area. Take special care with hand washing after handling these
children.
Medical intervention is required when these danger signs appear.

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In addition to watching for increasing pulse or respirations and changes in temperature, watch for the
following danger signs and alert a physician if any of these danger signs appear.
• anorexia (loss of appetite)
• change in mental state (e.g., becomes lethargic)
• jaundice (yellowish skin or eyes)
• cyanosis (tongue/lips turning blue from lack of oxygen)
• difficult breathing
• difficulty feeding or waking (drowsy)
• abdominal distention
• new edema
• large weight changes
• increased vomiting
• petechiae (bruising)
5.7 Provide continuing care at night

Many deaths in severely malnourished children occur at night because a feed is omitted or the child
becomes uncovered and cold. It is extremely important that enough staff are assigned to work at night,
and that they are properly trained. Night staff must:
• Keep each child covered to prevent hypothermia.
• Feed each child according to schedule during the night (at first this will be every 2 hours). This will
involve gently waking the child to feed.
• Take 4-hourly measurements of pulse, respirations, and temperature.
• Watch carefully for danger signs and call a physician if necessary.

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Name: Birke Age:- 2 years

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The following questions relate to the example of the monitoring Record of Birke on the previous page.
The child monitored is 2 years old.
1. What were the child’s temperature, respiratory rate, and pulse rate at 02:00 pm on Day 2?
_____0C ______ beats/minute _____ breaths/minute
2. What is the trend for the child’s temperature over Days 1 through 3? (Tick one answer.)
____ a. There are sharp increases in temperature.
____ b. The temperature rises slowly and steadily.
_____ c. The temperature stays below normal.
3. Has there been any significant change in the child’s pulse rate? If so, when?
4. Has there been any significant change in the child’s respiratory rate? If so, when?
5. At 10:00pm the nurse finds that the child has rectal temperature of 38.00C, a pulse rate of
100 beats per minute, and a respiratory rate of 45 breaths per minute (confirmed after 30
minutes). Enter this information on the Monitoring Record.
6. Is there a danger sign(s)? If so, what is the danger sign(s)? Should the nurse call a physician?
module.

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EXERCISE C
In this exercise, you will make entries on a Daily Care part of the in-patient multi-chart and Monitoring
Record for severe malnutrition. You will use the Daily Care that you set up for Lelisse in Exercise BA
blank Monitoring Record and 24-Hour intake Chart below
Pretend that you are the nurse who cares for Lelisse on her first day in the ward. At the following times
you give Lelisse her medications or monitor her progress. Make appropriate entries on the multi-chart
and Monitoring Record; for example, enter your initials or record results of monitoring. Additional
information about feeding is provided in italics.
Day 1
8:00am Lelisse is given her first feed of F-75. It is recorded on the therapeutic diet section.
• You give Lelisse1.75 ml Ampicillin and 1.3 ml Gentamicin through her Heparinised IV
cannula.
• You also give her 5 mg folic acid and 200 000 IU vitamin A.
• You put one drop of tetracycline and one drop of atropine in her left eye.
• Her ear is draining, and you gently wick it with a clean cloth.
• Since Lelisse is very ill, you do not bathe her, but you dab potassium permanganate solution
on the worst patches of dermatosis, and you cover the raw areas with ointment and gauze.
09:00am You check Lelisse’s pulse, respiratory rate, and temperature. Her pulse rate is 100 beats per
minute, her respiratory rate is 35 breaths per minute, and her axillary temperature is 380c.
10:00 am Lelisse is given her second feed of F-75. It is recorded on the therapeutic diet section of the
multi-chart.
12:00pm Lelisse is given her third feed of F-75. It is recorded on the therapeutic diet section of the
multi-chart.
01:00pm You check Lelisse’s pulse, respiratory rate, and temperature. Her pulse rate is 105 beats per
minute, her respiratory rate is 35 breaths per minute, and her rectal temperature is 380c.
02:00pm Lelisse is given her four feed of F-75. It is recorded on the multi-Chart
• You give Lelisse1.7 ml Ampicillin IV.
• You give Lelisse her multivitamin (which is needed since F-75 is not prepared with CMV at
this hospital).
• You put one drop of tetracycline.
03:00pm The shift changes. Now pretend that you are the nurse on the next shift.
04:00 pm Lelisse is given her fifth feed of F-75. It is recorded on the therapeutic diet section of the
multi-chart. And one drop of atropine in her left eye
05:00pm You check Lelisse’s pulse, respiratory rate, and temperature. Her pulse rate is 110 beats per
minute, her respiratory rate is 35 breaths per minute, and her rectal temperature is 37.80C.
06:00pm Lelisse is given her sixth feed of F-75. It is recorded on the therapeutic diet sectiomultichart.
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Answer the following questions:
1. At 08:00pm Lelisse will be fed again. At that time what else should be given to Lelisse?
2. When should Lelisse’s respiratory rate, pulse rate, and temperature next be monitored?
3. What should be done for Lelisse at 2:00 a.m.?
When you have finished this exercise, there will be group discussion.

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Blank Monitoring Chart

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EXERCISE D
In this exercise, you will review several Monitoring Records and identify any danger signs.
Case 1 – Lelisse
You will remember that Lelisse was admitted with an ear infection and fever. You began Lelisse’s
Monitoring Record in the last exercise. Lelisse’s continuing monitoring Record for the first two days is on
the next page. Review her Monitoring Record; then answer the questions below.
1. What happens to Lelisse’s temperature at 5:00 a.m. on Day 3?
2. Is this temperature change a danger sign? Why or why not?
3. What might be a cause of the temperature change?
4. Do Lelisse’s pulse and respiratory rates indicate any danger signs?

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MONITORING RECORD Monitor respiratory rate, pulse rate, and temperature 4-hourly until after transition to F-100 and patient is stable. Then monitoring may be less frequent (e.g., twice daaily).
Respiratory rate
Breaths/ 35 35 35 35 30 35 35 32 35 32 35 35
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minute
Pulse rate
Beats/
minute
100 100 105 110 100 105 102 105 105 100 105 105
Name ;- Lelisse Abera
Temperature
39.0
38.5
38.0

37.5
Age :- 18 months
37.0
36.5
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36.0
35.5
35.0
34.5
10Am 1Pm 5Pm 11Pm 1AM 5Am 3Am 1Pm 5Pm 11PM 1Am 5Am
Date/time: Day 1 Day 2
Danger Signs: Watch for increasing pulse and respirations, fast or difficult breathing, sudden increase or decrease in temperature, rectal temperature below 35.5°C, and other changes in
condition. See Danger Signs listed on back of F-100 Reference Card. Normal ranges of pulse and respiratory rates are also listed on back of F-100 Reference Card.
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Case 2 – Chaltu
Chaltu is 2 years old and was admitted with diarrhea. She took ReSoMal orally for 2 hours. Then she
began taking ReSoMal and F-75 in alternate hours. She did not take enough F-75 by mouth, so now she
is being fed by NG tube. She still has some diarrhea and is given ReSoMal after each loose stool. Her
temperature is steady and normal on day 1 and 2.
Review Chaltu’s Monitoring Record without temperature below and answer the following questions.
1. Does Chaltu’s pulse and respiratory rates indicate any potential danger sign? If yes, what is the
danger sign?
2. What should be done in 30 minutes?
3. In 30 minutes Chaltu’s pulse rate is 125 and her respiratory rate is 45. What should the nurse do?
4. What is a possible reason for the increase in Chaltu’s pulse and respiratory rates?
Monitoring Record for Respiratory rate, pulse rate (4hourly)
Name: Chaltu
Respiratory Rate (breath/minute)
Give a single dose if child is ≥ 2 years

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Case 3 – Bulto
Bulto is 2 years old. He is severely wasted but has no obvious complications or infections on admission.
He is prescribed a routine course of Amoxicillin for 5 days.
Review Bulto’s Monitoring Record and answer the questions below:
1. What happens to Bulto’s temperature during the night of Day 2 and morning of Day 3? Does this
indicate a danger sign?
2. Does the record of Bulto’s pulse rates suggest any danger sign? Why or why not?
3. Does the record of Bulto’s respiratory rates suggest any problem? Why or why not?
4. Is medical intervention required? Should the physician be alerted?
5. The nurse notes that Bulto has chest indrawing. What could be the problem? What treatment
should be given to Bulto?
facilitator

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MONITORING RECORD Monitor respiratory rate, pulse rate, and temperature 4-hourly until after transition to F-100 and patient is stable. Then monitoring may be less frequent (e.g., twice daaily).
Respiratory rate
Breaths/ 35 30 32 35 35 35 35 38 35 40 40 45 50
minute
Pulse rate
Beats/
minute
90 86 90 92 90 90 90 92 90 90 96 100 110
Temperature
39.0
38.5
38.0
Name :- Bulto Age: 2 years
37.5
37.0
36.5
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36.0
35.5
35.0
34.5
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10Am 2Pm 6Pm 10Pm 2AM 6Am 10Am 2Pm 6Pm 10PM 2Am 6Am 10Am
Date/time: Day 1 Day 2 Day 3
Danger Signs: Watch for increasing pulse and respirations, fast or difficult breathing, sudden increase or decrease in temperature, rectal temperature below 35.5°C, and other changes in
condition. See Danger Signs listed on back of F-100 Reference Card. Normal ranges of pulse and respiratory rates are also listed on back of F-100 Reference Card.

S-5 Daily Care
5.8 Weigh the child daily and maintain weight chart

How to weigh the child was described in Principles of Care. Remember to weigh the child at about the
same time each day, about one hour before or after a feed.
After weighing the child each day, record the child’s weight on the Anthropometric section of the Multi-
chart. Then plot the child’s weight on the Weight Chart included in the Multi-chart. The Weight Chart
will visually show the child’s progress towards discharge weight, any loss of weight due to edema, or
failure to improve.
An example of a completed weight chart is shown on the next page. Study the example as you read the
instructions below for preparing and maintaining a Weight Chart:
1. Label the vertical axis of the graph with a range of weights that includes the child’s starting
weight and desired discharge weight and allows for some weight loss as well as weight gain. Each
horizontal line on the graph should represent a difference of 0.1 kg.
• If the child has no edema, label the axis so that the starting weight will be near the bottom, but
allow a little space (1 kg) below for possible weight loss.
• If the child has edema, allow more space for weight loss (up to 30%) by placing the starting
weight higher on the axis. As a general guideline, allow for up to:
1 kg weight loss if mild (+) or moderate (++) edema
2 kg weight loss if severe (+++) edema and child is ≤ 7 kg
3 kg weight loss if severe (+++) edema and child is > 7 kg
2. Use the weight for height reference card or table (Presented on session 2 Annex B) to determine the
child’s desired discharge weight (i.e. –2 SD, discharge criteria when there is no outpatient program
on management of severe acute malnutrition). to reach. Mark the desired discharge weight with a
horizontal line across the chart.
3. Each day, plot the child’s weight on the chart. Plot the starting weight on Day 1, the next day on Day
2, etc. Mark each point with an X or large dot so that it shows up clearly.
4. Connect the points for the daily weights to see the child’s progress.
5. To highlight the day that F-100 is begun (the first day of transition), draw and label an arrow
pointing to the weight for that day.

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Example of weight chart for a boy with no edema

Starting weight: 6.0 kg Length: 71 cm. Desired discharge weight (> -2 z-score weight for height): 7.4 kg
The chart above shows a child who lost a little weight during the first few days on F-75 but then began
to gain steadily after transition to F-100.

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S-5 Daily Care
An example of a partially completed weight chart for a girl with mild (+) edema is on the next page. The
child’s starting weight is 5.4 kg. Since she has mild edema, space should be allowed for a 1 kg weight
loss. To allow for this loss, the vertical axis is labeled so that 4.0 kg is at the bottom.
a. Look up the desired discharge weight for the child whose weight chart is shown on the next
page. Enter the desired discharge weight above the chart, and mark it with a bold line on the
chart.
b. Plot the weights for the next several days on the chart and connect them with a line:
Day 11 weight: 5.1 kg
c. What was the child’s lowest weight? On what day did this occur?
d. Why did the child lose weight?
e. Has the child made progress?
Check your answers of this exercise by comparing them to those given at the end of this of the module.

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S-5 Daily Care
Example of weight chart for a girl with mild edema (+)
Starting weight: 5.4 kg, Length: 67cm

WEIGHT CHART
5 .5
4 .5
4
1 2 3 4 5 6 7 8 9 10 11 12 13

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S-5 Daily Care
5.9 Discharge Criteria

The discharge criteria differ for children age 6-59 months and less than 6 months.
Children age 6-59 months
Discharged after Full Recovery (CURED) in SC:
Note: The same anthropometric indicator that is used to identify and confirm SAM on admission should be
used to determine recovery and discharge from treatment.
If admitted with bilateral pitting edema, discharge cured when:
• No bilateral pitting edema for 2 weeks
• AND MUAC ≥ 12.5 cm or WFH/WFL ≥ -2 z-score
• AND Clinically well and alert
If admitted with MUAC discharge as cured when:
• MUAC ≥ 12.5 cm
• AND No bilateral pitting edema
If admitted based on WFH/WFL, discharge cured when:
• WFH/WFL ≥ -2 z-score
• AND No bilateral pitting edema
Children age less than 6 months

Discharge from in-patient care if they fulfill the following criteria:
Table 7 : discharge criteria for infants less than 6 months

<6 months with prospect to  Successful re-lactation and effective breastfeeding has been
breastfeed or with caregiver achieved.
willing to breastfeed  Gaining weight on exclusive breastfeeding (i.e., more than 5 g/
kg/day for at least 3 successive days).
 No bilateral pitting oedema.
 Clinically well and alert.
 Infant has been checked for immunization and other routine
interventions.
 Mothers or caregivers have been linked with community-based
follow-up and support.
< 6 months with no  Infant is feeding well with the replacement feed.
prospect of breastfeeding  Has adequate weight gain and has a WFL ≥ -2 z-score.
 No bilateral pitting oedema.
 Clinically well and alert.
 Infant has been checked for immunization and other routine
interventions.
 Mothers or caregivers have been linked with community-based
follow-up and support
If early discharge is necessary, many preparations must be made to ensure that the parents can
continue care at home. Follow-up visits are essential.

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ANSWERS TO SHORT ANSWER EXERCISES

Answers, page 152
1. Answers b, c, and d should be ticked.

2. No
3. Answer b should be ticked. Answers a and d may be appropriate in certain circumstances. If the
mother is extremely tired, it may be best to let her sleep and feed the child yourself. If several mothers
can be trusted to take turns feeding and sleeping, then answer d may be appropriate.
Answer c would make the mother feel guilty and afraid, and would never be appropriate
Answers page 158

1. Yes, the child should be given a dose of 200 000 IU on Day 15.
2. Yes, day 1, 2 and 15.
3. a) Yes, Day 1 give 200 000 IU, oral dose. b) Give the second dose on Day 2 and 3rd dose on day 15.
4. a) Yes, Dasashe should be given a dose on Day 1 at the hospital since she has corneal clouding.
b) No, she should not be given a dose on Day 2 because that would be the third day in a row to
receive vitamin A.
c) Yes, she should be given a dose on Day 15.
If you have any questions about the vitamin A schedule, please see a facilitator.
Answers, page 168
1. 36.4ºC 86beats/minute 35 breaths/minute

2. Answer b should be ticked.
3. There has been no significant change in the child’s pulse rate.
4. Yes, the respiratory rate increased from 35 to 40 beats per minute between 2pm and 6 pm on
Day 4.
5. A temperature of 38ºC, pulse rate of 100 beats/minute, and respiratory rate of 45 breaths/
minute should be entered on the Monitoring Record.
6. Yes, there is a danger sign. There is a sudden increase in temperature. Also, the respiratory rate
has again increased by 5 breaths/minute and is at 45, which is considered fast breathing for a
2-year-old. The physician should be called.
In this case, there is no possible referral for management of severe acute malnutrition through
outpatient care.

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S-5 Daily Care
Answers, short answer exercise-Page 171

A.
WEIGHT CHART
5 .5
4 .5
4
1 2 3 4 5 6 7 8 9 10 11 12 13
B. 4.8 Kg; On day 5,6, and 7

C. Because the child has lost his Edema.
D. Yes, the child has made progress since the edema has decreased and he is satisfactorily gaining weight

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S-6
Monitoring
and Problem
Solving
SESSION 6: MONITORING AND PROBLEM SOLVING
S-6 Monitoring and Problem Solving
Introduction
Many types of problems may occur in a severe malnutrition ward/ inpatient care. There may be
problems with an individual patient’s progress or care, such as failure to gain weight or treat an
infection. There may also be problems that affect the entire ward, such as problems with staff
performance, food preparation, or ward procedures or equipment. All of these problems require
attention to prevent patient deaths.
This session teaches a process for identifying and solving problems that may occur on the ward.
The process includes:
• Identifying problems through monitoring
• Determining solutions
• Implementing solutions
This process can be used in solving problems with individual patients or problems that may affect the
entire ward.
This session also describes the multi-chart relevant for monitoring and the monthly Reporting formats.
Learning Objectives
This session will describe and allow you to practice the following skills:
• Identifying problems by monitoring:

• Individual patient progress, weight gain and care
• Overall weight gain on the ward
• Patient outcomes (such as recovery, referral, death)
• Case-fatality rate for the ward
• Food preparation, ward procedures, and hygiene
• Determining solutions appropriate for causes
• Conducting a problem-solving session with a group.

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6.1 Use a process to identify and solve problems

Identify problems
Identify problems by monitoring. By monitoring individual patient progress, weight gain and care, you
may identify problems such as the following:
• A patient’s appetite has not returned
• A patient has failed to gain weight for several days while taking F-100
• A mother wants to take her child home before the child has reached the discharge weight
• A child seems to have an unrecognized infection
By monitoring overall weight gain on the ward, patient outcomes, and the case-fatality rate, you may
identify problems such as the following:
• 20% of children in the ward have poor weight gain
• 75% of mothers leave with their children before they reach the desired discharge weight
• The case-fatality rate in the ward was ≥ 15 % during the previous month.
By monitoring case management practices, food preparation, ward procedures, and hygiene, you may
identify additional problems, which may in fact be causes of poor weight gain or adverse outcomes. For
example, you may identify problems such as the following:
• IV fluids are given routinely by certain physicians
• Children are not fed every 2 hours through the night
• Staff do not consistently wash their hands with soap
• Preparation of milk is not correct.
When a problem is identified, describe it in as much detail as possible
Figure 16: Nurse identifying possible problems on the ward

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To describe the problem, state when, where, and with whom the problem is occurring. Also try to
determine when the problem began. Knowing the details will help you find the cause, or causes, of the
problem.
Read each pair of problem descriptions below. Tick the problem description that is more detailed and
therefore more useful.
1. _____a. There has been an increase in the number of deaths on the ward.
_____b. Four deaths have occurred at night in the past month.
2. ____a. Tarekegne is not gaining weight.
____ b. After gaining 10 g/kg/day for four days, Tarekegne has stayed the same weight for the last
three days.
3. ____a. Dr Petros prescribes a diuretic for severe edema, but no other doctors do this.
_____b. Diuretics are sometimes prescribed for edema.
4. _____a. Weight gain of some children on the ward is poor.
____ b. Weight gain is poor for most children who are taking adapted home foods instead of F-100.

answers given at the end of the module.

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Investigate causes of problems

It is critical to find the cause(s) of a problem before trying to solve it. Different causes require different
solutions.
Investigation of causes may involve doing laboratory tests for a patient, observing and asking questions
of staff, reviewing patient records, and/or monitoring food preparation and ward procedures.
Determine solutions
Solutions will depend on the causes of the problems. For example, if staff do not know how to do a new
procedure, a solution may be training. On the other hand, if the cause is a lack of equipment or supplies,
a different solution is needed. Solutions should:
• remove the cause of the problem (or reduce its effects)
• be feasible (affordable, practical, realistic); and
• not create another problem.
Figure 17: Nurse investigating possible solutions

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Example of problem-solving process
Problem: Weight gain in the inpatient care is not as good as it was several months ago. Instead of good
weight gain for most children on RUTF OR F-100 (that is, 10 g/kg/day or more), the typical weight gain is
now less than 10g/kg/day.
The senior nurse decides to investigate by monitoring ward procedures and food preparation.
Following are some possible causes that she might find, along with an appropriate solution for each.
By investigating the cause of a problem, one can avoid wasting money and time on the wrong
solutions.
Possible Cause: Possible Solution:

 Staff add too much water when making  Explain the preparation to staff
F-100 or Add less F-100 powder when
making F-100
 There are more children on the ward, and  Invest time in teaching mothers to feed
staff numbers have not increased. Nurses and care for the children.
cannot spend as much time feeding each
child.
 Incorrect recording: Inaccurate weighing  Check the weighing scale according to the
scale or Failure to complete the Multi- standard randomly check the multi-chart
chart correctly

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Implement solutions
Implementing a solution may be relatively simple (such as speaking with an individual staff member, or
changing a child’s feeding plan) or quite complex (such as changing staff assignments throughout the
ward). Good communication with staff is important whenever any change is made.
To promote good communication when solving problems:

• Hold regular staff meetings, during which positive feedback is given and any problems, causes,
and solutions are discussed.
• Provide staff with job descriptions, which list their assigned tasks.
• Provide clear instructions whenever any change is made.
• Provide “job-aids” such as checklists or posted instructions for any complex tasks (E.g. laminated
F-75 and F-100 reference cards.)
Follow up to determine if a solution is implemented as intended. Then continue monitoring to
determine whether the problem is solved. Give feedback to staff that includes praise for work done
well, along with any instructions for improvement.

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6.2 Monitor and solve problems with an individual patient

Monitor individual patient progress and care
Nursing staff should monitor certain signs (such as pulse rate, respiratory rate, and temperature)
repeatedly during the day, especially during initial treatment. If there are danger signs (such as
increasing pulse and respiratory rate, or a sudden drop in temperature), the staff should immediately
respond as described in Initial Management and Daily Care. Otherwise, information is simply recorded
on the Multi-chart, where it is reviewed by a clinician during rounds.
Clinicians should do a ward round at least once every day. During rounds, a clinician should:
• Observe the child and question the mother and nurse
• Is child more alert? smiling? sitting up? able to play?
• Has the child lost edema?
• Is there less diarrhea?
• Has dermatosis improved?
• How is the child’s appetite?
• Review the child’s weight chart
• Is the child gaining weight according to the weight chart?
• If there is a loss, is it due to decreasing edema?
• Check for edema daily
• Review the multi-chart and the food intake chart
• Is the child getting the recommended feeds?
• Is prescribed care (such as antibiotics) being given?
• Are there any danger signs recorded on the multi-chart:
• Increased pulse rate, respiratory rate, or temperature?
Daily, after a child is in taking F-100, a clinician should calculate the child’s weight gain in grams per
kilogram body weight (g/kg/day) and judge whether weight gain is sufficient:

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To calculate daily weight gain

a. Subtract the child’s weight yesterday (W1) from the child’s weight today (W2). Note: Do this even if
the child has lost weight. If the child has lost weight, the result will be negative. Express the difference as
grams (kg x 1000). This is the total amount of weight gained during the day.
• W2 – W1 = _ _ kg
• _ _ kg x 1000 = ____ grams gained
b. Divide the grams gained (from step “a”) by the child’s weight yesterday. The result is the weight gain
in g/kg/day.
Weight gain in grams ÷ W1 = ____ g/kg/day
If the child has lost weight during the past day, the “weight gain” for that day will be negative.
Note: This calculation is not useful until the child is on F-100, as the child is not expected to gain weight on
F-75. In fact, weight may be lost on F-75 due to decreasing edema.
Remember that this calculation will be most useful if the child is weighed at about the same time each
day.
Example
Ketema began taking F-100 on Day 4 in the in the SC. By Day 6 he began to gain weight. On Day 6
Ketema weighed 7.32 kg. On Day 7 he weighed 7.4 kg. His weight gain in g/kg/day can be calculated as
follows:
• 7.4 kg – 7.32 kg = 0.08 kg 0.08 kg x 1000 = 80 grams gained

• 80 grams ÷ 7.32 = 10.9 g/kg/day
A gain of 10.9 g/kg/day is considered a good weight gain.

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Calculate the daily weight gain for the children described below. Assume that the weights were taken at
about the same time each day.
1. Mussa weighed 7.25 kg on Day 10. He weighed 7.30 kg on Day 11. What was his
weight gain in g/kg/day? What is your assessment of the weight gain?
2. Kefel weighed 6.22 kg on Day 8. She weighed 6.25 kg on Day 9. What was her weight
gain in g/kg/day? What is your assessment of the weight gain?
3. Girum weighed 7.6 kg on Day 9. He weighed 7.5 kg on Day 10. What was his weight gain
in g/kg/day? (Note: Since Girum lost weight, the answer will be negative.)

answers given onat the end of the module.

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6.3 Identify the child who is failing to respond

A child is failing to respond if he or she:
• does not improve initially (primary failure); or
• Deteriorates/Levels off.
Some criteria for failure to respond are listed below as a guide:
Failure to respond is a “diagnosis” in its own right. It should be recorded on the chart as such and the
child then seen by more senior and experienced staff.
Table 8: Criteria for failure to respond in SC

Criteria Approximate time after admission
• Failure to regain appetite Day 4
• Failure to start to lose edema Day 4
• Edema still present Day 10
• Failure to gain at least 5 g/kg/day for 3
successive days after feeding freely on
F-100 After feeding freely on F-100
Note: the day of admission is counted as day 0

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EXERCISE A
In this exercise you will review information about two cases to determine if they are making progress or
if they are failing to respond.
Case 1 – Sara
Sara was admitted five days ago with moderate edema and wt for height of<- 3 z-score.
Parts of her Multi-chart and her feeding on the therapeutic Diet section of the multi-chart for Day 5
are provided on the next four pages. Sara’s pulse rate has remained at about 90 over the five days, and
her breathing rate has remained at about 35. She had measles in the last three months
Study the information about Sara and answer the questions below.

1a. Is Sara making progress? If so, describe her progress.
1b. Are there problems? If so, describe the problems.

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Exercise A, continued
Case 2 – Lemma
Lemma was admitted ten days ago with mild edema (both feet), dysentery, a fever, and Z- score of
less than -2. Lemma was given Amoxicillin for5 days. After 5 days he was still sickly and had fever. He
also had a deep, persistent cough and some difficulty of breathing. The physician suspected possible
pneumonia and prescribed Ampicillin and Gentamicin, which has been given for 5 days.
Study parts of Lemma’s MULTI-CHART and his most recent 24- food intake chart, which are given on the
next pages. Then answer the questions below.
2a. What is Lemma’s weight gain in g/kg/day from Day 10 to Day 11?
2b. Is Lemma making progress? If so, describe his progress.
2c. Are there problems? If so, describe the problems.
facilitator

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PARTICIPANT MODULE
Lethargic Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give IV DIARRHOEA Dry mouth/tongue Yes No
SHOCK Blood in stool? Yes No
glucose as described under Blood Glucose (left). Then give IV fluids: Restless/Irritable Yes No Thirsty Yes No
Time * 5 ml x kg (child’s wt) = ml ReSoMal 5 to 10 ml X kg (child’s wt) = to ml ReSoMal

*If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in right part of chart below. If no
improvement on IV fluids, transfuse whole fresh blood.
Pulse rate
Weight
TEMPERATURE:- Rectal axillary

MEASLES Yes No
INITIAL MANAGEMENT
Bitots' spot
6-11 months
Pus/inflammation
EYE CARE
200,000 IU BLOOD GLUCOSE (mg/dl): 59 HAEMOGLOBIN (Hb) (g/dl): 9 .3 Blood type:
Corneal clouding
≥ 12 months If <54mg/dl and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG). If <54mg/dl and If Hb <4g/dl or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg
Corneal ulceration lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s wt) = packed cells) slowly over 3 hours. Amount: Time started:
ml Then give 50 ml bolus NG. Time glucose given: Oral NG IV Ended:
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Determine cause(s) of failure to respond

When a child fails to respond then the common causes must be investigated and treated appropriately
according to the standard protocol. The causes of a child’s failure to respond may be related to
procedures, staff, equipment, or the environment throughout the ward, or they may be related only to
the individual child. If many children are failing to respond, look for causes that affect the entire ward,
such as incorrect feeding practices or poor hygiene; these types of causes will be discussed. If your
investigation is focused on one child, consider such possible causes as the following:
• Insufficient food given

• Has the feeding plan been adjusted as the child gains weight?
• Is the correct feed being given?
• Is the correct amount offered at the required times?
• Is the child being fed adequately at night?
• Is the child being held and encouraged to eat?
• Are leftovers recorded so the child’s recorded intake is accurate?
• Insufficient attention given to child

• Do staffs pay less attention to this child for some reason (for example, because they believe he is
“beyond help”)?
• Is the mother present to assist in feeding and care of the child?
• Rumination- The child regurgitates food from the stomach to the mouth, then vomits part of it and
swallows the rest. This usually happens when the child is not observed.
• -Is the child eating well but failing to gain weight?
• -Does the child smell of vomit or have vomit-stained clothes or bedding?
• -Does the child seem unusually alert and suspicious?
• -Does the child make stereotyped chewing movements?
• Unrecognized infection – Infections most commonly overlooked include pneumonia, urinary tract
infection, ear infection, and tuberculosis. Others include malaria, viral hepatitis B, and HIV infection.
• Serious underlying disease (such as congenital abnormalities, cancer, immunological diseases).

Remember that there may be multiple causes of failure to respond. For example, a child may have an
infection plus a vitamin deficiency. Try to find all of the causes.

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Identify and implement solutions for the individual child
In some cases, the cause of a problem may require a specific medical solution. If the child has an
infection, a clinician will need to prescribe appropriate treatment as described in daily care session.
In many cases the solution to a problem may seem apparent through “common sense”. For example, if
the child is not being fed according to schedule, he must be fed according to schedule. However, there
may be underlying causes that are also important. Continue to ask “Why?” until you reach the “root
causes” of problems. The solutions to problems must address the root causes.
Solutions: To solve this problem, it will be necessary to address all of the causes. Possible solutions
include getting more night staff or finding a time and place for mothers to rest during the day. Night
staff could also be asked to wake up the mothers and supervise night feeds, or help those mothers
whose children require 2-hourly feeds.

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EXERCISE B
In this exercise, you will discuss causes and solutions to problems affecting Sara and Lemma, two cases
presented previously in Exercise A.
Case 1 – Sara
You remember that Sara was failing to respond on Day 5. She had not lost her edema and was not
eating well. She had not progressed to F-100. You may wish to review the information about Sara on
pages 197.
Write answers to the following questions as preparation for a group discussion:
a. What are some possible causes of Sara’s failure to respond? (List at least 3 possible causes.)
b. How could you find out the real cause(s)? List several possible ways to investigate.
c. While observing feeding in the ward, the senior nurse found that the staff paid very close attention
to the children with IV drips and NG tubes. They paid much less attention to the children feeding
orally. Sara did not appear as sick as many of the other children, and the nurses did not spend time
with her encouraging her to eat.
• Based on the senior nurse’s observations, what is a possible cause of Sara’s failure to respond?
d. What is a possible solution appropriate for the cause identified in question 1c above?

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Case 2 – Lemma
You remember that Lemma was failing to respond on Day 10. He had a deep, persistent cough and
some difficulty breathing. The physician had been treating Lemma for pneumonia with Ampicillin and
Gentamicin, which had been given for 5 days.
Since Lemma was not improving on Ampicillin and Gentamicin, the physician did a complete
examination. He obtained a chest x-ray, which showed a shadow on the lungs. The physician also
learned that a relative who lives in Lemma’s household has tuberculosis.
1. Lemma’s MULTICHART shows no weight gain (page 203). Has Lemma been taking enough F-100?
2. What is a possible cause of Lemma’s failure to respond? (Hint: See antibiotic reference chart for
management of severe acute malnutrition with medical complications.)
Tell a facilitator when you are ready for the group discussion.

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6.4 Monitor overall weight gain in the inpatient Care/ward

Section 6.2 discussed problem-solving for individual patients. The remaining sections will discuss
identifying and solving problems for the ward.
Compile data on weight gain in the inpatient care
Once a month, review records for the TFU or inpatient care ward for a given week (for example, the first
week of the month) and compile data on an average Weight Gain Tally Sheet for the Ward. Average
Weight Gain is useful to show the quality of feeding
To complete the tally sheet:
• Identify the children who were on phase 2 for the entire week. (Only children in phase 2 are
expected to gain weight.)
• Calculate the average daily weight gain for each of these children: (see the example below, how
to calculate it)
• Add the daily weight gains recorded on the child’s Multi-chart for the 7 days of the week being
reviewed. Divide the total by 7
Eg. Chaltu has been admitted to ward, today is her 12th day in the ward. To calculate the average daily
weight gain in the week, study the following tables and steps:
Multi-Chart - Chaltu
The week, Day 0 to 7
0 1 2 3 4 5 6 7
Date 1 2 3 4 5 6 7 8 9 10 11 12
Weight (Kg) 4.6 4.5 4.55 4.6 4.63 4.65 4.7 4.8 4.85 4.9 5.0 5.1
• Determine if the child’s average daily weight gain was poor, moderate, or good during that
week.
• Record the child’s name in the appropriate column of the tally sheet.
• When the process is complete for each child on F-100, total the columns.
• Determine what percentage of the children on F-100 had poor, moderate, or good weight gain.
Compare the results to tally sheets from similar weeks in other months. Use the tally sheets as a
basis for discussion and problem solving with staff. If you cannot complete this review process
every month, try to do it at least four times a year.

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Determine if there is a problem with weight gain on the ward

If the weight gain of 10% or more of the children on F-100 is poor, there is a problem that must be
investigated. If there is a negative change as compared to previous months, there may also be a
problem. For example, if the percentage of children in the “moderate” column increases and the
percentage in the “excellent” column decrease, investigate the reasons for this change.
Example weight gain tally sheet for ward
Week of: Good weight gain Moderate weight gain Poor weight gain
9/2/18 (10 g/kg/day) (5 up to 10 g/kg/day) (< 5 g/kg/day)
Number of Jallele Ebrhaim Fantu

children on
Ishac Babu Abdrahamn
F-100 for
entire week: Nanu Fares
Amiet Sehen
12 Gadisa
Mohammed
Totals 4 6 2
% of children 33% 50% 17%
on
F-100 in ward
State the problem specifically

Describe the problem as completely and specifically as possible. Determine if the children who are not
gaining weight adequately have certain things in common. For example:
• How long have they been on the TFU or ward?
• What are their ages?
• Are they located in a certain area of the ward?
• Are they cared for by certain staff?
• Are they receiving food or drinks that interfere with prescribed feeds?
You may think of other questions to ask to determine common factors. If there are no apparent
common factors, then assume that the problem is throughout the SCor ward.
After determining common factors, state the problem specifically, for example, “4 out of 5 children
whose mothers are not staying in the SC have poor weight gain”. If the problem is occurring throughout
the ward, say so, for example, “25% of children throughout the ward have poor weight gain”.
Stating the problem specifically will help you look for the cause(s). Investigating causes by monitoring
ward procedures, food preparation, etc. will be discussed in section 6.6

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EXERCISE C
In this exercise, you will review information on children who have been on F-100 for the past seven
days. You will use a tally sheet to determine whether there is a problem with weight gain on the ward.
There will then be a group discussion.
Information for the exercise

Twenty children on the ward have been in phase 2 for the past seven days. For seventeen of these
children, the average daily weight gain for the past seven days has been calculated.
These children’s names have already been entered on the tally sheet on the next page.
MULTl-CHART excerpts for the three children are given on page 214, 215 and 216. Follow the
instructions given below to complete the tally sheet. Check your tally sheet given below. Then answer
the questions on page 217.
Instructions to complete tally sheet
For each child whose multi-chart excerpt is given below:
1. Calculate the average daily weight gain:
Add the daily weight gains recorded on the child’s multi-chart for the 7 days of the week being
reviewed (dates: 13/4/10 – 19/4/10). Divide the total by 7.
2. Determine if the child’s average daily weight gain was poor, moderate, or good during that
week.
3. Add the child’s name to the appropriate column of the tally sheet.
When you have added all three children to the tally sheet:
4. Total the columns on the tally sheet.
5. Determine what percentage of the children on F-100 had poor, moderate, or good weight gain.
To do this:
• Divide total in each column by the total children on F-100.
• Express the result as a percentage.

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WEIGHT GAIN TALLY SHEET FOR WARD
Week of: Good weight Poor weight gain:

13/4/10 gain: Moderate weight gain: 5 <5
10 g/kg/day up to 10 g/kg/day g/kg/day
Number of Amir Lukman Samson
children in phase
2 for entire week: Wondwossen Rahemeto Marima
20 children Sulayman Zenieba Lulit
Fate Taye
Keste Adem
Shimeles Alemayhew
Edris
Kibrom
Totals
% of children in
phase 2 in ward

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Multi-Chart Excerpt
1. Aron
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Height (cm) 64
Weight (Kg) 4.6 4.5 4.55 4.6 4.63 4.65 4.7 4.8 4.85 4.9 5.0 5.0
Wt for Ht (Z-score) <-3SD
MUAC (cm)
Edema (0 to +++)
Weight gain (g/ Calculate daily after on 6.5 4.3 10.7 21.3 10.4 10.3 20.4 0
Anthropometric Chart
kg/day) F-100 or RUTF
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2. Keflom
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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Height (cm) 64
Weight (Kg) 5.9 5.8 5.9 5.9 6.0 6.0 6.0 6.0 6.10 6.15 6.10 6.20 6.25 6.20
Wt for Ht (Z-score) <-3SD
MUAC (cm)
Edema (0 to +++)

Weight gain (g/ Calculate daily after on -- -- -- 0 16 8.2 8.1 16.4 8.1 8
Anthropometric Chart
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3. Saba
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Height (cm) 64
Weight (Kg) 7.7 7.7 7.7 7.8 7.8 8.0 8.1 8.15 8.22 8.2 8.3 8.3 8.3 8.35
Wt for Ht <-3SD
(Z-score)
MUAC (cm)
Edema (0 to +++)
Weight gain (g/ Calculate daily after on -- 25.6 12.5 6.17 8.6 - 2.4 12.2 0 6.0
nthropometric Chart
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Questions to answer and discuss:

1. Does the tally sheet show that there is a problem with weight gain on the ward?
2 . The senior nurse decided to look for common factors among the children who had poor weight
gain. She found the following information:
Samson – Arrived 21 days ago, age 2 years, orphan (no caregiver at the hospital), cared for by
Nurse Rahel
Marima – Arrived 18 days ago, age 19 months, no mother at hospital (aunt comes to visit), cared
for by Nurse Aman
Lulit– Arrived 12 days ago, age 22 months, was on IV at admission and then NG but now takes
feeds orally, moved yesterday to Nurse Rahel’s area, mother is present
Keflom – Arrived 14 days ago, age 18 months, cared for by Nurse Aman, orphan (parents died
and a neighbour left Keflom at hospital)
What common factor(s), if any, are there among these children?
3. State the problem as specifically as possible using the information from the tally sheet and the
information gathered by the senior nurse.
4. Do the common factors among the children with poor weight gain suggest a possible cause
of the problem? If so, what is a possible cause? What further investigation may need to be done
to investigate causes?

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6.5 Monitor patient outcomes

Record each patient’s outcome on the MULTI-CHART
On front page and at the right upper corner of the MULTI-CHART, there is discharge box for recording
patient outcomes. Record the outcome for the patient whether it is successful or not. Record any
relevant comments, such as circumstances and causes of adverse outcomes. Record the discharge
outcomes in the outcome column and the reasons for any discharge outcomes, and within how many
hours the death occurs in remark column of the Registration book too.
Discharge Outcomes
1. Cured:- Has reached the discharge criteria for SAM treatment
2. Died: - Dies while receiving treatment in the SC.
3. Defaulted Absent for two consecutive days in the SC. Default should be confirmed.
4. Non-responder: - Patient who remained in treatment in the SC does not reach the SAM discharge
criteria after 16 weeks (4 months) in treatment.
5. Stabilized; - Condition has stabilized and referred to continue treatment in OTP.
6. Transferred-out :- Moved to another facility for further medical care or moved out to receive care
in another SC

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Tag adverse outcomes on the multi-chart

Use a colored tag or some other means to indicate records with adverse outcomes (that is, death,
defaulter or referrals). The tag will make these records easy to find in the files when you are doing a
review.
Review patient records for common factors in adverse outcomes

Periodically and whenever there is a death, review patient records. Note common factors that would
suggest areas where case management practices or ward procedures may need to be carefully
examined and improved.
For example, note whether recent deaths have occurred within the first 2 days after admission or later.
Deaths that occur within the first 2 days are often due to hypoglycemia, over hydration, unrecognized
or mismanaged septic shock, or other serious infection. Deaths that occur after 2 days are often due to
heart failure; check to see if deaths are occurring during transition to F-100.
An increase in deaths occurring during the night or early morning, or on weekends, suggests that care
of children at these times should be monitored and improved. For example, if there are many early
morning deaths, it is possible that children are not being adequately covered and fed during the night.
If many mothers are choosing to take their children home after only a few days, look for common
reasons. Are the mothers unable to leave other children at home? Is the ward uncomfortable for them?
Is the staff unfriendly? Early departures also suggest a need to monitor and improve ward conditions
and procedures.
Review of patient records for adverse outcomes can provide a basis for staff to discuss and solve
problems.

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EXERCISE D
In this exercise, you will review excerpts from the MULTI-CHARTs of three children who died. You will
review the circumstances of the deaths and determine whether there are common factors.
Ketema had watery diarrhea, recent sunkening of eyes and he is lethargic. He was given normal saline IV
at OPD due to low plasma sodium. The IV fluid continued for rehydration until 4:00 pm.
Betre was given IV plasma and a diuretic for low albumin and edema at the emergency room. Lulit has
diarrhea and vomiting.
Study the MULTI-CHART excerpts for Ketema, Betre, and Lulit on the following pages and answer the
following questions:
1. What are the circumstances of each child’s death?
Ketema–
Betre –
Lulit –
2. Are there common factors among any of the three deaths? If so what are they?
3. What areas of case management practices or ward procedures need to be monitored to find
related problems and causes?

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Health facility MRN .................................................... Referred from:. C h a k a H P Major Problems Date of admission(EC) (DD/MM/YY): 14/06/11 Date of Discharge (DD/MM/YY): 14/06/11 at 9:00pm
324
Registration # ............................................................. Age (d/m/y specify):. 1 5 m on th s 1 N on Oed em a tou s SA M Time: 10:00 AM /PM Cured Causes
Sex:..M 2 . C or n ea l u l cer a ti on Re-admission (Y/N): N Died X
Full Name: K etem a D a n a N (Relapse or Returned defaulter: circle type of readmission)

Breastfeeding (Y/N):.......................................................... Defaulted
Complementary feeding (Y/N): N
Un k n ow n
From:.................................................................... Non-responder
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Address (Kebele, Woreda, Region): D i ch o, B / sh or e Old registration #:................................................. Stablized To:.......................................... .........................................................
SN N P R Transferred-out
Followed up by:.......................................................................................................................
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date 14/06/1
71
Height/Length (cm)
6 .3
Weight (kg)
-3
WFH/WFL z-score
Chart
1 0 .9
MUAC (cm)
Anthropometric
Bilateral pitting oedema (0, +, ++, +++) 0
Wt gain (g/kg/day)

Lethargic Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. DIARRHOEA Dry mouth/tongue Yes No
Give IV glucose as described under Blood Glucose (left). Then give IV fluids: Restless/Irritable Yes No Thirsty Yes No
*If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in right part of chart
Pulse rate
below. If no improvement on IV fluids, transfuse whole fresh blood.
Weight
TEMPERATURE:- 36 °C Rectal axillary

MEASLES Yes No
INITIAL MANAGEMENT
Bitots' spot
6-11 months
Pus/inflammation
EYE CARE
200,000 IU BLOOD GLUCOSE (mg/dl): 7 2 m g/ d l HAEMOGLOBIN (Hb) (g/dl): 9 .0 g/ d l Blood type:
Corneal clouding
Corneal ulceration X lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s wt) = packed cells) slowly over 3 hours. Amount: Time started:
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1 2 3 4 5
Date 14/06/1
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Phase 1
F- 7 5
Diet Name
70
ml/feed
12
#/feed/day
806
Total ml offered per day
Total ml taken per day

1 6 :0 0 a m
A= Absent
V= Vomit 2 8 :0 0 a m
R= Refuse
NG = NG
X X
Tube 3 1 0 :0 0
IV = IV am
X X
Fluid
X X
4 1 2 :0 0 pm
X X
X X
5 2 :0 0 pm
>80% R R
R R
6 4 :0 0 pm
75% R R
X X
X R R
7 6 :0 0 pm
THERAPEUTIC DIET
50% R R
X
X R R
8 8 :0 0 pm
25% R R
X
9 1 0 :0 0
pm
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1 0 1 2 :0 0
am
1 1 2 :0 0
am
1 2 4 :0 0
am
Porridge
Family Meal
Other

1 2 3 4 5
14/06/1
Date
Diarrhoea (Tally) Y
PARTICIPANT MODULE
Vomit (Tally) N
Dehydration (Y/N) Y
Cough (Y/N) N
Septic Shock (Y/N) N
Respiratory Rate 35

Palmer pallor (Y/N) Y
Temp. AM Ax/Rect 36
Temp. PM Ax/Rect 36
Deramtosis( 0, +, ++, +++) +
SURVEILANCE CHART
Liver Size (cm) 0
Failure to Respond
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1 2
14/06/1
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Date
6 : 0 0PO,
Antibiotics-1 Time : Amoxicillin 250 mg A M BID BT
6 :0 0 P M
Antibiotic 2: Time
Antibiotic 3: Time
ROUTINE MEDICINE
Antibiotics-4 Time :
ReSoMal (ml)
IV Fluids
Blood
NG Tube
BT
Vitamin A
Drugs for eye problems
Tetracycline 1 drop 4 X daily
SPECIAL MEDICINE
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Atropine 1 drop 3 X daily
Others

1 2 3 4 5 6 7 8 9 10
Date 14/06/1
Hemoglobin (g/dl) 9
Glucose Test (mg/dl) 72
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Malaria Test
TEST
TB Test
RESULTS
HIV Test
OBSERVATION:
IV fluids begun in emergency room and
continued for dehydration until 4:00 pm

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Monitoring Record for Respiratory rate, pulse rate and temperature (4 hourly)
Name: Ketema

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Health facility MRN .................................................... Referred from:. C h a k a H P Major Problems Date of admission(EC) (DD/MM/YY): 0 5 / 1 0 / 2 0 1 1 Date of Discharge (DD/MM/YY):...06/10/2011 at 7:00 am ..
756
Registration # ............................................................. Age (d/m/y specify):. 24 months 1 . O ed em a tou s SA M Time: 2:45 AM /PM Cured Causes
Sex:.. M 2 . C or n ea l cl ou d i n g Re-admission (Y/N): N Died X L ow P ota ssi u m
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Full Name: B etr e Y oh a n n es N
Breastfeeding (Y/N):.......................................................... (Relapse or Returned defaulter: circle type of readmission) Defaulted H i gh A l b u m i n
Complementary feeding (Y/N): N From:.................................................................... Non-responder O ed em a +++
Address (Kebele, Woreda, Region): k ol i sh o, H u l l a , Old registration #:................................................. Stablized To:.......................................... .........................................................
SN N P R Transferred-out
Followed up by:.......................................................................................................................
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date 5/10/11 6/10/11
78 78
Height/Length (cm)
8 .1 8 .1
Weight (kg)
<-3 <-3
WFH/WFL z-score
Chart
1 1 .5
MUAC (cm)
Anthropometric
Bilateral pitting oedema (0, +, ++, +++) +++ +++
Wt gain (g/kg/day)

Lethargic Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. DIARRHOEA Dry mouth/tongue Yes No
Give IV glucose as described under Blood Glucose (left). Then give IV fluids: Restless/Irritable Yes No Thirsty Yes No
*If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in right part of chart
Pulse rate
below. If no improvement on IV fluids, transfuse whole fresh blood.
Weight
TEMPERATURE:- 3 5 .5 ° C Rectal axillary

MEASLES Yes No
INITIAL MANAGEMENT
Bitots' spot
6-11 months
Pus/inflammation
EYE CARE
X 200,000 IU BLOOD GLUCOSE (mg/dl): HAEMOGLOBIN (Hb) (g/dl): Blood type:
Corneal clouding

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1 2 3
8 .5
8 .0
WEIGHT CHART
7 .5
7 .0
6 .5
6 .0
5 .5

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1 2 3 4 5
Date 5/10/11 6/10/11
Phase 1 1
F- 7 5 F- 7 5
Diet Name
65 65
ml/feed
12 12
#/feed/day
800 800

R R
1 6 :0 0 a m
A= Absent
R R
V= Vomit 2 8 :0 0 a m
R= Refuse
NG = NG
THERAPEUTIC DIET
Tube 3 1 0 :0 0
IV = IV am
Fluid
4 1 2 :0 0 p m
5 2 :0 0 p m
>80%
x x
6 4 :0 0 p m
75% x R
X X
X x x
7 6 :0 0 p m
50% R R
X
X x x
8 8 :0 0 p m
25% x R
X
9 1 0 :0 0 x x
pm
R R
1 0 1 2 :0 0 R x
am
R R
1 1 2 :0 0 R R
am
x R
1 2 4 :0 0 x x
am
x R
Porridge
Family Meal
Other

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1 2 3 4
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5/10/11
Date
Diarrhoea (Tally) N
Vomit (Tally) N
Dehydration (Y/N) N
Cough (Y/N) N
Septic Shock (Y/N) N
Respiratory Rate 34
Palmer pallor (Y/N) N
Temp. AM Ax/Rect 3 5 .5
Temp. PM Ax/Rect 36
Deramtosis( 0, +, ++, +++) 0
SURVEILANCE CHART
Liver Size (cm) 0
Failure to Respond
1 2 3 4
5/10/11
Date
Antibiotics-1 Time : 6 :0 0 A M KS
A m ox ci l l i n 2 5 0 m g 6 :0 0 P M
B
Antibiotic
ID P O 2: Time
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Antibiotic 3: Time
ROUTINE MEDICINE

Date of Discharge (DD/MM/YY):…
PARTICIPANT MODULE
Lethargic Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give DIARRHOEA Dry mouth/tongue Yes No

IV glucose as described under Blood Glucose (left). Then give IV fluids: Restless/Irritable Yes No Thirsty Yes No
Time * 5 ml x 6 .8 kg (child’s wt) = 3 4 ml ReSoMal 5 to 10 ml X 6 .8 kg (child’s wt) = 3 4 to 68 ml ReSoMal
Resp. rate * Time Start: 9:30 10:00 10:30 11:00 11:30 12:30 13:30 14:30 15:30 16:30 17:30 18:30
Pulse rate * Resp. rate 35 35 35 35 35 32 34 35 34 35 35 35
Pulse rate 95 95 95 95 95 94 95 98 95 90 95 95
Weight 6.8 6.8 6.8 6.8 6.81 6.81 6.81 6.8 6.8 6.8 6.8 6.8

If rectal <35.5°C (95.9°F), or axillary<35°C (95°F), actively warm child. Check temperature every 30 minutes. Passed urine? Y / N N N N N Y N N N Y N N
Oral doses vitamin A: Number stools 1 0 1 1 1 0 1 0 0 0 0

MEASLES Yes No
EYE SIGNS None Left Right Record on Special Medicine section. Number vomits 1 0 0 0 0 0 0 1 0 0 0
INITIAL MANAGEMENT
<6 months 50,000 IU Hydration signs _ _ _
Bitots' spot
100,000 IU Amount taken (ml) 34 34 34 65 F-75 60 F-75 65 F-75 55 F-75 F-75
6-11 months
Pus/inflammation
EYE CARE
200,000 IU BLOOD GLUCOSE (mg/dl): A ssu m ed < 5 4 m g/ dl HAEMOGLOBIN (Hb) (g/dl): 9 .5 g/ dl Blood type:
Corneal clouding
Corneal ulceration lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x kg (child’s wt) = ml packed cells) slowly over 3 hours. Amount: Time started:
Then give 50 ml bolus NG. Time glucose given: Oral NG IV Ended:
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Name: - Lulit Aschalew (first day monitoring Chart records)
Page 232 (After Shuffling the previous pages)

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6.6 Monitor practices and procedures

As needed, you may monitor the following practices and procedures periodically to investigate causes
of problems:

• Food preparation
• Ward procedures, and/or
• Hygiene
Suggestions for monitoring are provided in this section. Monitoring Checklists for use during ward visits
are provided in Annex 16. Any “NO” answer to a question on the checklist indicates a problem that
needs to be corrected.
Monitor case management practices

Deaths during initial case management are often the result of well-intentioned but incorrect practice.
Monitor to ensure that all clinicians are following the case management practices described in the
module and national protocol, particularly during initial treatment. Ensure that emergency room
personnel are also following appropriate practices for severely malnourished children. No checklist
is given for monitoring case management, as it would be too lengthy. However, some examples of
common incorrect practices to look for are described below:
Common Incorrect Practices in Initial

Treatment – These cause deaths: Correct Practice
• Child not fed at night During initial treatment ensure that the child
is fed
every 2 hours at night.
• IV fluids given even though child is Give IV only if signs of shock (cold hand plus
not in shock slow
capillary refill or weak/fast pulse).
• Diuretics given to treat edema Do not give these. Edema will resolve with
correct
initial treatment using therapeutic feeds
• High protein diet given immediately Give F-75 until the child stabilizes; then start
F-100/RTUF.
• Antibiotics not given because no Presume infection and give antibiotics to all
clinical signs of infection severely
malnourished children as described in the
manual.
• Standard ORS used instead of Give ReSoMal to severely malnourished
ReSoMal children with
diarrhea.
• Child left uncovered at night Provide blanket and ensure the child is
covered at night.
• Anemia treated with iron from admission Wait to start iron until the child has been on
F-100 for 2 days.

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Monitor feed preparation

Problems such as poor weight gain on the ward may be due to problems with food preparation.
Periodically, or whenever you suspect that there is a problem, carefully observe preparation of feeds
using the monitoring checklist in annex 16. Monitor the following:
• Are ingredients for the recipes for F-75, or F-100 are available?
• Is the correct recipe used for the ingredients that are available?
• Are ingredients stored appropriately and discarded at appropriate times?
• Are containers and utensils kept clean?
• Do kitchen staffs (or those preparing feeds) wash their hands with soap before preparing food?
• Are the recipes for F-75 and F-100 followed exactly? (If changes are made due to lack of
ingredients, are these changes appropriate?)
• Are measurements made exactly with proper measuring utensils (e.g., correct scoops)?
• Are ingredients thoroughly mixed (and cooked, if necessary)?
• Is correct amount of water added to make up a liter of formula? (Staff should not add a liter of
water, but just enough to make a liter of formula.)
• Is food served at an appropriate temperature?
• Is the food consistently mixed when served (i.e., oil is mixed in, not separated)?
Monitor ward procedures
Problems such as inadequate weight gain on the ward, early departures, or even deaths may be
due to inadequate ward procedures. Whenever you suspect that there is a problem related to ward
procedures, observe staff as they do those procedures, or review relevant records (use the ward
procedure monitoring record in annex 16. Procedures to monitor include:
Feeding
• Are correct feeds served in correct amounts?
• Are feeds given at the prescribed times, even on nights and weekends?
• Are children held and encouraged to eat (never left alone to feed)?
• Are children fed with a cup(never a bottle)?
• Is food intake (and any vomiting/diarrhea) recorded correctly after each feed?
• Are leftovers recorded accurately?
• Are amounts of F-75 kept the same throughout the initial phase, even if weight is lost?
• After transition, are amounts of F-100 given freely and increased as the child gains weight?
Warming
• Is the room kept between 28-32°C (to the extent possible)?
• Are blankets provided and children kept covered at night?
• Are safe measures used for re-warming children?
• Are temperatures taken and recorded correctly?

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Weighing
• Are scales functioning correctly?
• Are they standardized weekly? (Check scales as described in Daily Care.)
• Are children weighed at about the same time each day, one hour before a feed (to the extent
possible)?
• Do staff adjust the scale to zero before weighing children?
• Are children consistently weighed without clothes?
• Do staff correctly read weight to the nearest division of the scale?
• Do staff immediately record weights on the child’s MULTICHART?
• Are weights correctly plotted on the Weight Chart?
Giving antibiotics and other medications and supplements
• Are antibiotics given as prescribed (correct dose at correct time)?
• When antibiotics are given, do staff immediately make a notation on the MULTICHART?
• Is vitamin A given according to schedule?
• After children are on F-100 for 2 days, is the correct dose of iron given daily and recorded on the
MULTICHART?
Ward environment
• Are there separate rooms for each phase (Phase 1, and 2)?
• Are the children sleeping under ITN in malarious area?
• Are surroundings welcoming and cheerful?
• Are mothers offered a place to sit and sleep?
• Are mothers taught and encouraged to be involved in care?
• Are staff consistently courteous?
• As children recover, are they stimulated and encouraged to move and play?
Monitor hygiene
Good hygiene is extremely important because children with severe malnutrition are highly susceptible
to infection. Whenever you suspect that a problem may be related to hygiene, or periodically, visually
inspect hygiene in the ward using the Hygiene monitoring checklist in annex 16. Monitor such items as
the following:
Hand washing
• Are there working hand washing facilities in the ward?
• Do staff consistently wash hands thoroughly with soap?
• Are their nails clean?
• Do they wash hands before handling food?
• Do they wash hands between each patient?
Mothers’ cleanliness
• Do mothers have a place to bathe, and do they use it?
• Do mothers wash hands with soap after using the toilet or changing diapers?
• Do mothers wash hands before feeding children?

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Bedding and laundry

• Is bedding changed every day or when soiled/wet?
• Are diapers, soiled towels and rags, etc. stored in bag, then
washed or disposed of properly?
• Is there a place for mothers to do laundry?
• Is laundry done in hot water?

Laundry in Line
General maintenance
• Are floors swept?
• Is trash disposed of properly?
• Is the ward kept as free as possible of insects and rodents?
Trash bins and broom
Food storage
• Are ingredients and food kept covered and stored at the proper
temperature?
• Are leftovers discarded?
Covered bowels in refrigerator
Dishwashing
• Are dishes washed after each meal?
• Are they washed in hot water with soap?
Basin with sudsy water
Toys
• Are toys washable?

• Are toys washed regularly, and after each child uses them?

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6.7 Solve problems

Some problems require individual solutions and should be handled privately. For example, if you find
that a particular staff member is doing a procedure incorrectly or dangerously, correct that person
privately.
On the other hand, some problems may be solved by working with staff members as a group to discuss
the causes and possible solutions. Some examples of problems that could be reviewed as a group might
include:
• A diarrhea outbreak in the ward

• An increasing case fatality rate; or
• Procedural problems involving all or many of the staff.

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Staff may have useful information to contribute on the causes of problems and creative ideas for
solutions. They are also more likely to work together towards a solution if they are involved in decision
making that affects them.
Process for problem-solving in a group

1. When conducting a problem-solving session with a group, use the following process as a guide:
2. Welcome everyone to the meeting and explain the purpose. Be careful not to sound like you are
threatening or blaming anyone. Stress that you need their ideas to understand the causes of the
problem and how to solve it.
3. State the facts of the problem as clearly and completely as possible. Include when, where, and with
whom the problem is occurring.
4. Discuss causes of the problem that you have discovered through monitoring. Ask the staff if they
know of other causes. Ask questions to try to find the “root” causes of the problem. Causes may
include:
• obstacles (such as lack of time, insufficient staff, or lack of equipment)
• lack of motivation (for some reason, staff are not motivated to do a task correctly)
• lack of skill or information (staff do not know what to do or how to do it)
5. The group must avoid blaming particular staff or having the discussion degenerate into a complaint
session.
6. It may be helpful to write down causes identified on a flipchart or large paper.
7. Ask the staff to help you think of solutions appropriate for the causes. Different causes require
different solutions. For example, if there is a problem due to lack of supplies, a solution is to obtain
more supplies. If a task is done poorly because staff members do not enjoy it, a solution may be to
rotate that task so that everyone takes a turn, but no one has to do it too often. If staff forget how to
do a certain task, the solution may be to make a job aid and post it on the wall.
Ask staff to think of solutions that they believe will work. Discuss the steps needed to implement the
solutions, i.e., who will do what after the meeting.
8. Thank the staff for their ideas. Review what was decided in the meeting. After the meeting it is
important to implement the solutions as quickly as possible. Be sure to give feedback to staff on
how the solutions are working. They will want to know if the problem is decreasing or is solved.

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EXERCISE E
This exercise will be a role play of a problem-solving session in a severe malnutrition ward. Your
facilitator will assign you a role such as one of the following:
Physician in charge
Senior nurse on duty in the morning (Matron)
Senior nurse on duty in the afternoon
Night nurse
Junior auxiliary nurse
Hospital administrator
You will be given a card describing your knowledge and attitude about the situation being discussed.
One participant (the “physician in charge”) will lead the discussion using the process described in the
module. Another will assist by recording on the flipchart. Others will participate in the discussion
according to their assigned roles.
The objective is to describe the problem clearly, discuss possible causes and identify the most likely
causes, and identify possible solutions.

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ANSWERS TO SHORT ANSWER EXERCISES

Answers, page 188
1. b
2. b
3. a
4. b
Answers, page 194
1. 7.30 kg – 7.25 kg = 0.05 kg 0.05 kg × 1000 = 50 grams gained
50 grams ÷ 7.25 = 6.90 g/kg/day
2. 6.25 kg – 6.22 kg = 0.03 kg 0.03 kg × 1000 = 30 grams gained
30 grams ÷ 6.22 = 4.8 g/kg/day
3. 7.5 kg – 7.6 kg = – 0.1 kg
– 0.1 kg × 1000 = –100 grams gained (or 100 grams lost)
–100 grams ÷ 7.6 = –13.16 g/kg/day

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S-7 Involving
Mothers in
Care
SESSION 7: INVOLVING MOTHERS (CAREGIVERS)
IN CARE
S-7 Involving Mothers in Care
Introduction
It is essential for the mother (or other caregiver) to be with her severely malnourished child in the
hospital. For the following reasons, she must be encouraged to feed, hold, comfort, and play with her
child as much as possible. Some of the reasons to involve mothers in this critical moment are:
• Emotional and physical stimulation are crucial for the child’s recovery and can reduce the risk of
developmental and emotional problems.
• The child’s mother can provide more continuous stimulation and loving attention than busy staff.
• When mothers are involved in care at the hospital, they learn how to continue care for their children
at home
• Mothers can make a valuable contribution and reduce the workload of staff by helping with activities
such as bathing and feeding children.
Learning Objectives
This Session will describe and allow you to discuss and observe:
• ways to encourage involvement of mothers in hospital care; and
• ways to prepare mothers to continue good care at home, including proper feeding of the child
and stimulation using play.
• On the ward or in role-plays, this Session will allow you to practice:
• teaching a mother to bathe or feed a child; and
• giving complete discharge instructions.

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7.1 Organize facility routine to encourage mothers’ involvement

There are many ways to encourage mothers’ involvement in hospital care. Mothers can be taught to:
• prepare food
• feed children
• bathe and change children; and
• play with children, supervise play sessions, and make toys.
The staff must be friendly and treat mothers as partners in the care of the children. A mother should
never be scolded or blamed for her child’s problems or made to feel unwelcome. Teaching, counseling
and befriending the mother are essential to long-term treatment of the child.
Mothers should have a place to sit and sleep (preferably sleep with their children) in the SC or ward.
They also need washing facilities and a toilet, and a way to obtain food for them. Some mothers may
need medical attention themselves if they are sick or anemic.
The staff should also make other family members feel welcome. All family members are important to
the health and well-being of the child. When possible, fathers should be involved in discussions of
the child’s treatment and how it should be continued at home. Fathers must be kept informed and
encouraged to support mothers’ efforts in care of the children.

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EXERCISE A
The group will discuss ways that facilities encourage mothers and other family members to be involved,
as well as things that may hinder involvement. You may discuss examples from your own facilities and
from the ward that you have visited during this training course.
Prepare for the discussion by listing a few ideas below.
Ways to encourage mothers and other family members to be involved:
Things that hinder involvement of mothers and other family members:

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7.2 Involve mothers in comforting, feeding, and bathing children

Staff should informally teach each individual mother certain skills. First, they may need to show the
mother how to hold her child gently and quietly, with loving care. Immediately after any unpleasant
procedure, staff should encourage the mother to hold and comfort her child.
When teaching tasks such as feeding or bathing, staff should:
• First, show the mother how to do the task, explaining each step.
• Let the mother try the task, assisting and encouraging her as she tries.
• Ask checking questions to make sure the mother understands what to do. For example, if you
have just explained how to feed the child, ask the mother such questions as:
• What will you feed your child?
• How often will you feed him?
• How much will you give him for a serving?
• Observe when the mother does the task independently the first time.
• Give positive feedback, that is, tell the mother what she did well. Make suggestions for
improvements without discouraging the mother. For example, say “Let’s try together to do it this
way…”.
At all times staff must communicate clearly with mothers in a way that builds their confidence in their
ability to take care of their children. For example, when a clinician examines the child, he should explain
what is happening and show the mother how to hold the child during the exam. Staff must treat the
mothers as partners in helping the child to health.
Tell a facilitator when you have reached this point in the module.

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EXERCISE B
This exercise will include two role-plays of situations in which a nurse is teaching a mother to bathe or
feed a child. Your facilitator may assign you the role of a nurse or a mother; if so, you will be given some
information to help you prepare for your role. If you are an observer of the role play, you will take notes
below.
Role Play 1
How would you feel if you were the mother in this situation?
How did the nurse encourage or discourage the mother?
Role Play 2
How would you feel if you were the mother in this situation?
How did the nurse encourage or discourage the mother?

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7.3 Teach mothers about feeding and care

Teach groups of mothers about preparing feeding
There are many topics that can efficiently be presented to groups of mothers and other interested
family members. Group teaching sessions may be held on topics such as nutrition and feeding, hygiene,
making ORS to treat diarrhea, family planning, etc.
Staff members with good communication skills should be assigned to teach these group sessions. There
may be several staff members who can take turns presenting different topics. The selected staff must
know the important information to cover on a topic and be able to:
• communicate clearly in a way that mothers understand
• prepare and use suitable visual aids such as posters, real foods, etc.
• demonstrate skills when necessary (e.g., cooking procedures, hand washing, making ORS)
• lead a discussion in which mothers can ask questions and contribute ideas.
The sessions should not be limited to lecture but should include demonstrations and practice whenever
possible. Encourage questions from the mothers so that the session is interactive.
Example outline of teaching session

On the following page is an outline of a teaching session that could be used with parents of
malnourished children. The purpose of the training session is to teach parents how to prepare a
nutritious food at home. Different types of food can be prepared depending on the available local
foods that would be appropriate for children of ages 6 to 24 months when they have recovered and are
eating at home (refer FMOH 2016 Adolescent, maternal, infant and young child nutrition guide). For this
session, the recipes given on the next page is selected which provides 295 kcal and 7.3 g protein.
The outline contains information, examples and visual aids, and practice. It also includes opportunities
for parents to ask questions and contribute ideas.

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Teaching Session: Preparing Home-Based Nutritious Food

Preparation: Before the teaching session, prepare a display tray with ingredients for the selected food
recipe.
I. What is this recipe?

• Information: this recipe is a nutritious home-based food for children. It will help children continue to
recover at home. This food should definitely be given to the child in addition to breast milk. However,
if the rest of the family like this food too, prepare enough for the whole family.
• Example: Display the following ingredients on a tray. Call attention to the amount of each.
Ingredient Amount Amount in gram

Cereals (teff, maize etc)
flour half cup of coffee 45 gm
Legumes (eg peas,
chickpea, lentils, beans) 1 Third of coffee cup 15gm
Tomato 1 35 gm
Carrot One small 20 gm
Milk 1 cup of coffee 75 ml
Oil One and half teaspoon 7 ml
water Four and half cup of coffee 315 ml
Iodized salt For taste
• Discussion: Ask the parents why they think these ingredients are good for children and all family
members. In discussion, explain that:
• Oil, Teff (or other staple such as Barley, Enset) are needed to give energy
• milk is needed to build and grow the body
• Leafy green and orange-colored vegetables like the tomato and carrot are needed to give
strength and good health and also to prevent blindness.
II. How to make the recipe
• Information and example: Describe the recipe, pointing to each ingredient on the tray as you talk. If
the parents can read, the recipe may be given to them in writing. If not, a picture recipe may be used.
Tell parents what you have already done to begin the cooking.
• Wash hands before preparing food
• Blend the teff with milk and water in a pot. Add salt and boil to make porridge
• Peel the carrot and boil. When it is cooked, smash it
• Boil the tomato and peel off the cover. Then chop it into small pieces
• Add the tomato, smashed carrot, and oil into the porridge and mix until it is cooked
• Practice: When it is time to add the carrot, tomato, and oil, have a parent boil, peel, chop and add
them to the pot.

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III. Amount to serve

• Information and example: Children should be fed 5 times daily. Explain that the amount in the
pot is enough for one meal for a one-year-old child. Give also as snack (‘Mekses’) a quarter of
Papaya or one banana. They can use different recipe for other meal.
• Remind parents to wash hands before serving food and keep food covered. Do not store too
long or the food may spoil.
• Focus on giving this food to the discharged child until he is better. Then the child can shift to
other nutritious family foods.
• Practice: Ask a parent to wash hands and serve two portions of food from the pot. Show parents
that this is the correct serving size for a one-year-old. Show and describe the portion in relation
to the size of the bowl or plate. Let parents (and children, if present) taste the food.
IV. Discussion and review

• Discussion: Ask parents questions about how they can prepare this recipe at home. Encourage them
to ask questions as well. Include in the discussion:
• Will they be willing to buy ingredients for their child to prepare recipe like this?
• How much do you think this recipe costs? Estimate the price for this recipe including firewood.
• Review: What are the reasons to serve nutritious foods like this for children? To prevent and treat
malnutrition, prevent blindness, and ensure strong and good health.
• How often should you feed your child this recipe or other types? ___ times per day.
• How much will you give at each meal? Show serving size (it depends the age of the child).
• Review the ingredients and recipe.

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7.4 Prepare for feeding the child at home

For children who will be referred for rehabilitation in outpatient sites (health centers and community):
Children in transition with the following conditions:

• Eat entire amount of the proposed daily amount of RUTF
• Medical complications were treated
• Minimal oedema
• Alert
Should be referred for outpatient care (health centers and community monitoring) when a health
center accessible from the family home has the ability to perform this type of management. More
details of outpatient care and their integration into health care services are provided in Module 8.
In this case, food from home during rehabilitation will consist of RUTF at first and then, as a second step,
RUTF in alternated with meals based on locally available foods, nutrient rich and varied.
(See section Give general discharge instructions).
The mother or caretaker of the child must receive appropriate information at the health centers and
community about feeding the child at home after discharge from care on an outpatient basis.
For children receiving inpatient care (severe malnutrition ward) during rehabilitation:
After the child recovers and reaches ≥ -2SD weight-for-height, the child should be fed at home
according to national Integrated management of childhood illness (IMCI) recommendations or other
national guidelines from the Ministry of Health. For a child age 2 years or older, this means giving the
child 3 meals plus 2 snacks each day, with nutritious food.
Before returning home, the child must become accustomed to eating family meals based on locally
available foods. During rehabilitation, while the child is on the ward, gradually reduce and eventually
stop the feeds of
RUTF/F-100, while adding or increasing the mixed diet of home foods, until the child is eating as he or
she will eat at home.
Appropriate mixed diets are the same as those recommended for a healthy child. They should provide
enough calories, vitamins, and minerals to support continued growth. Home foods should be consistent
with the guidelines below:
• The mother should continue breastfeeding as often as the child wants.

• If the child is no longer breastfeeding, animal milk is an important source of energy, protein,
minerals and vitamins.
• Solid foods should include a well-cooked staple cereal. To enrich the energy content, add
vegetable oil (5-10 ml for each 100 g serving) or butter. The cereal should be soft and mashed;
for infants use a thick pap.
• Give a variety of well-cooked vegetables, including orange and dark-green leafy ones. If possible,
include fruit in the diet as well.

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• If possible, include meat, fish, or eggs in the diet. Pulses and beans are also good sources of
protein.
• Give extra food between meals (healthy snacks).
• Give an adequate serving size (large enough that the child leaves some).
Examples of healthy snacks that are high in energy and nutrients include:
• Bread with butter, or margarine (‘Yedabo kebe’)
• Biscuits
• Yoghurt, milk,
• Ripe banana, papaya, avocado, mango, other fruits
• Cooked potatoes
To prepare the mother to continue appropriate feeding at home:

• Discuss with the mother (and other family members, if possible) the child’s previous diet and the
foods that are available at home.
• Discuss practical ways to address specific problems in the child’s past diet.
• Be sure to involve the mother as a partner in deciding what to feed the child, so that the
decisions will be practical.
• Explain how to use or adapt available foods for a healthy diet that will meet the criteria on the
previous page.
• Summarize what to feed the child, how much to give at each meal, and how many meals and
snacks to give. Write it down or give the mother a prepared card with feeding instructions. Use
pictures for mothers who cannot read.
• Remind the mother to sit with the child and encourage the child to eat.
• Before discharge, when the child is adjusting to home foods under health facilities supervision,
have the mother practice preparing recommended foods and feeding them to her child.
• Review instructions before discharge and ask the mother checking questions to be sure she
understands what to do, for example:
• What will you feed your child? Where will you get the ingredients to prepare foods at home as
you have done it here?
• How many meals and snacks will you feed your child each day?
• How much will you feed your child at each meal or snack?
• Provide additional information and instruction if the mother needs it.
Tell a facilitator when you have reached this point in the module. There will be a brief videos showing an
educational session about preparing home food.

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EXERCISE C
This exercise will be a group discussion of how hospitals can successfully prepare mothers to continue
proper feeding at home. To prepare for the discussion, consider the questions below.
1. In your hospital, what will mothers be taught about feeding children at home?
a. What mixtures of foods will make good meals in your area?
b. What will be the main messages taught about feeding?
c. Will you need more information before deciding what to teach?
d. What information is needed and how will you get it?
2. Who will teach mothers about home foods and how will they teach?
a. Who is most suited to teaching mothers about feeding?
b. How will demonstrations or examples be given in teaching sessions?
c. How can mothers practice make home foods in the hospital?
d. How can transition to home foods be supervised in the hospital?
e. How can nurses work with mothers to ensure that advice about home feeding is practical and
will be followed?
A group discussion of these questions will follow the video on preparing

home food.

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7.5 Teach mothers the importance of stimulation

Severely malnourished children have delayed mental and behavioral development. As the child
recovers, he or she needs increasing emotional and physical stimulation through play. Play programs
that begin during rehabilitation and continue after discharge can greatly reduce the risk of permanent
mental retardation and emotional problems.
Create a stimulating environment in the centers, provide opportunities for play activities with toys and
interaction between children and with their mothers or careers. Promote physical activity of children
that can move and passive mobilization of limbs for those that cannot. Avoid wrapping the child: the
child should be able to move freely.
A comprehensive emotional and physical stimulation program should be set up in each centre, led
by a person from the health staff. The hospital can provide stimulation through the environment, by
decorating in bright colors, hanging colorful mobiles over cots, and having toys available.
Mothers should be taught to play with their children using simple, homemade toys. It is important to
play with each child individually at least 15-30 minutes per day, in addition to informal group play.
Emotional and physical stimulation

Severely malnourished children have delayed mental and behavioral development, which, if not
treated, can become the most serious long-term result of malnutrition. Emotional and physical
stimulation through play programs that start during rehabilitation and continue after discharge can
substantially reduce the risk of permanent mental retardation and emotional impairment.
Rehabilitation
Care must be taken to avoid sensory deprivation. The child’s face must not be covered; the child must
be able to see and hear what is happening around him or her. The child should never be wrapped or
tied to prevent him or her moving around in the cot.
It is essential that the mother (or caregiver) be with her child in hospital and at the nutrition
rehabilitation center, and that she be encouraged to feed, hold, comfort and play with her child
as much as possible. The number of other adults who interact with the child should be as few as
possible. Each adult should talk, smile and show affection towards the child. Medical procedures, such
as venipuncture, should be done by the most skilled person available, preferably out of earshot and
sight of the other children. Immediately after any unpleasant procedure the child should be held and
comforted.

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7.6 Give general discharge instructions

• In addition to feeding instructions, mothers will need to be taught:
• How to continue any needed medications (except the antibiotic treatment that will be fully
given in the severe acute malnutrition ward), vitamins (based on the indications), folic acid, (if
indicated), and iron (for 1 month) at home if RUTF is not provided to the child
Signs to bring the child back for immediate care:
• Not able to drink or breastfeed
• Stops feeding
• Develops a fever
• Has fast or difficult breathing
• Has a convulsion
• Has diarrhea for more than a day, or blood in stool
• Has edema (swelling in feet, legs, hands, or arms).
In addition to feeding instructions, mothers will need to be taught:
• When and where to go for planned follow-up at OTP or out-patient follow up of a hospital: at
2 weeks, 1 month, 3 months, and 6 months; then twice-yearly visits until the child is at least 3
years old.
• Any currently needed immunizations should be given in the hospital. When to return for next
immunization.
• When to go to the health center for vitamin A (every 6 months);
• How to continue stimulating the child at home with play activities.

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If early discharge is unavoidable, make special arrangements for follow-up

If a child must be discharged before reaching weight for length or weight for height > -2 SD and there
is no program for outpatient, it is critical to make arrangements for follow-up of the child (for example,
special visits by a health worker to the child’s home, or outpatient care at a health facility or nutritional
rehabilitation centre). Mothers will need special training to prepare feeds and give iron, folic acid, and
multivitamins at home.
In no case should a child be discharged until the following conditions are met:
• The child is in phase 2 (is feeding on RUTF or freely on F-100);

• Antibiotic treatment is finished;
• The child is eating well;
• The child is gaining weight;
• The mother has been thoroughly trained on how to feed the child at home and give the
remaining basic medication and supplements
• Arrangements have been made for support and follow-up (e.g., home visits, or visits to an
outpatient facility).
* If a program on outpatient management of severe malnutrition is in place, early discharge means before
the reduction of edema or regaining appetite. If no program is in place, early discharge means before
reaching Weight/Height equal to ≥-2SD.

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S- 8 OTP
SESSION 8: OUT-PATIENT THERAPEUTIC PROGRAM
(OTP)
S-8 OTP
Introduction
Most of severe acute malnutrition cases, around 85%, are treated in the outpatient therapeutic
component of Therapeutic Feeding program (TFP). This session will teach participants the skills and
knowledge specifically needed for outpatient care for management of children with SAM in health
centers and health posts.
This session introduces participants to the concepts and protocols used in outpatient care for children
with severe acute malnutrition. It provides an overview of admission and discharge processes, medical
treatment and nutrition rehabilitation in outpatient care. Emphasis is placed on the use of an action
protocol, which helps health care providers determine which children require referral to inpatient care
and which children require follow-up at home.
OTP for children runs every week; exceptions can be made for individual cases living in very remote
areas, where they can be seen on fortnightly basis. Cases’ regular attendance is precondition for a
successful result.
The session also includes a clinical session where participants will practice assessing, admitting and
treating children with SAM to OTP. Participants will also have the opportunity during this clinical session
to practice the skills covered in session 1 of recognizing signs of severe acute malnutrition, assessing
and classifying SAM.
Learning objectives
By the end of the session, the participants will be able to:
• Explain the principles of outpatient management of severe acute malnutrition:
• community mobilization
• timely detection and treatment
• integration with inpatient care
• linkages with other programmes
• Explain the admission procedures of OTP
• Manage children in OTP
• Routine medicines
• Nutritional rehabilitation with RUTF
• key Messages for Mothers/Caregivers Used in Outpatient Care
• Emotional and psychosocial stimulation
• Follow up a child with SAM as outpatient.
• Fill child information in OTP card.
• Describe Discharge Criteria and Procedures
• Mobilize community and ensure early identification of cases

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S-8 OTP
8.1 Principles of outpatient management of severe acute malnutrition

In some contexts, outpatient management of severe acute malnutrition can benefit from the
involvement of the community in identifying and preventing severe acute malnutrition.
The components of outpatient management of acute malnutrition are:
• community mobilization and case-finding;
• outpatient therapeutic care for severe acute malnutrition without complications;
• alignment and integration with inpatient therapeutic care for severe acute malnutrition;
• Inclusion of management of moderate acute malnutrition where in place.
Internal coordination between the different components is essential. Linkages with the community
ensure the adequate referral of children to outpatient care services; the follow-up of cases enrolled in
those services; simplified management of cases at health centre level; and treatment that is integrated
into routine health services.
Efficient tracing systems are fundamental for the continuity of care for children moving between
inpatient and outpatient care services.
Community mobilization
Community mobilization aims to sensitize, inform and educate the community on nutrition matters to
promote and encourage their active participation in the activities for the prevention of malnutrition. It
allows early detection and referral of cases to appropriate nutrition or health services and their follow-
up. Where community mobilization is well implemented, self-referral and passive case-finding also
occur.
Timely detection of cases
Active case-finding is done in the communities by Health extension worker. They detect wasting using
mid-upper arm circumference (MUAC) and the presence of oedema in children aged under 5 years and
refer suspected cases of severe acute malnutrition to inpatient or outpatient care.
Integration
Integration into health care services implies the recognition by the ministry of health of the importance
of the prevention and treatment of severe acute malnutrition and its relevance for morbidity and
mortality rates in the country, especially for children aged under 5 years.
An integrated approach between inpatient and outpatient services can reduce costs and be more
effective in the management of severe acute malnutrition.

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S-8 OTP
Linkages with other programmes

The linkages established between management of severe acute malnutrition activities or programmes
and other health and nutrition-related activities are key to prevention of new cases or relapse, and
promotion of better nutrition.
Examples of programmes and strategies to which management of severe acute malnutrition
programmes could connect include the following.
• Nutrition: infant and young child feeding, growth monitoring, and essential nutrition actions,
including micronutrient supplementation;
• Health: Integrated community Management of neonatal and Childhood Illness (ICMNCI),
expanded programme of immunization, HIV/AIDS and tuberculosis treatment programmes,
diarrhoeal disease and malaria control, national child survival or immunization days;
• Others related to: water, sanitation and hygiene, food security, social welfare, emergency
preparedness or response plans, education.

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S-8 OTP
8.2 Case-finding and triage for severe acute malnutrition

In the absence of disease outbreaks (such as measles, cholera or malaria), less than 15% of all cases with
severe acute malnutrition will need hospitalization. If community mobilization, and the active case-
finding and referral system within the community, are adequately performed so that cases are identified
in a timely manner.
Levels of case finding

Community level
In some programmes, the identification of children with severe acute malnutrition is carried out at the
community level. The same procedures described in session 2 on principles of care should be applied –
weighing, measuring and screening for medical complications.
There are different ways the community can mobilize to identify severe acute malnutrition cases.
• Active case-finding refers to the identification of acutely malnourished children by health
extension workers or volunteers in communities.
• Passive case-finding refers to the identification of acutely malnourished children by health
workers after presenting during routine child visits or general consultation at the health facility
or hospital.
• Self-referral can become a significant means of case identification when management of severe
acute malnutrition activities has been long established in an area and communities have been
adequately mobilized. In such circumstances, most cases will arrive spontaneously at health
facilities for screening and treatment.
Health facility level
Health staff should screen all children for their nutritional status. This should be done during routine
primary health care services (for example, expanded programme of immunization, growth monitoring),
or when children attend any other consultation. If any signs of severe acute malnutrition are detected,
the patient should be referred to the appropriate nutrition service.

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S-8 OTP
8.3 Admission procedure to out-patient therapeutic care

You have used the admission procedure and assessment table in session 2 of the module. You can
review to better identify the children with SAM who need OTP
Appetite test
It is not necessary to conduct the appetite test if the child is very ill, for example with pneumonia,
persistent diarrhoea, dysentery, measles or malaria, or any of the general danger signs. This child should
be immediately referred to inpatient care.
The appetite test is performed to evaluate if the child will be able to eat RUTF and can be treated at
home.
How to conduct the appetite test

The appetite is tested by giving the child a packet (sachet) of RUTF and observing how they eat it. It can
be done while the health worker starts the medical history with the caregiver, but it is generally better
to leave the child with the mother alone in a calm and quiet place. This will prevent the child becoming
afraid of the environment or health facility staff and refusing to eat.
• Leave the child with the caregiver in a separate and quiet place.
• Explain to the caregiver the reason for the test and how it is going to be carried out.
• Verify with the caregiver how long since the child ate or drank before the appetite test to ensure
that a failed appetite test is not due to the child just having eaten.
• The caregiver should wash their hands and the child’s hands and face before the test starts.
• The caregiver should be comfortably seated with the child before offering the sachet or pot of
RUTF for the child to eat.
• If the child refuses to eat, the caregiver should continue to gently encourage the child to eat.
However, the child should not be forced.
• Provide clean water for the child to drink while eating the RUTF.
• Observe the child eating the RUTF for 30 minutes and decide if the child passes or fails the test.
Table 9: RUTF Appetite Test Results

Pass Appetite Test Fail Appetite Test
The child eats some of the RUTF within 30
The child refuses to eat the RUTF after 30 minutes.
minutes.

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SHORT ANSWER EXERCISE

In this exercise, you will be given some information for several children. You will then answer questions
about whether the child has SAM. You will also determine whether in-patient, OTP or TSFP treatment is
needed and why? Use the Assessment and Classification Algorithm table given on the previous page
Case 1: Chaltu
Chaltu is 24 months old female child who has a MUAC of 10.9 cm and has been referred by the Health
Development Army (HDA) to the health post. On admission, she refuses to eat RUTF during the appetite
test. You ask her mother to move to a quiet area and try again. After a half-hour Chaltu still refuses to eat
the RUTF and also the HEW ask the mother if she is eating or not and the mother said that she can’t eat
and breast feed starting from the previous day .
a. Does Chaltu have SAM? Why?

b. Does she need OTP or inpatient care, why?
c. What action is needed?
Case 2: Abera
Abera is 17 months old boy. He lives in Dera woreda and mekit kebele. The mother brought him directly
from his community because he has had watery diarrhea for the past week. He does not vomit. She
reports no other problems but says he has been getting thinner for some time. Abera has edema. He
weighs 8.2kg, and MUAC is 11.2 cm. He has a rectal temperature of 36.9 °C and has 38 respirations per
minute, and there are no chest retractions. He has no clinical signs of dehydration. He has no other
pertinent clinical findings
a. Does Abera have SAM? Why?

b. Does he need OTP or SC care, why?

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Case 3: Guluma
Guluma is 28 months old and presented at the health post with bilateral pitting oedema + and a MUAC
of 11.7 cm and his weight is 12kg. He has good appetite and no other signs of medical complications.
a. Does Guluma have SAM? Why?

b. Does Guluma need OTP, SC or TSFP? Why?
Case 4: Alemitu
Alemitu is a 4 months old girl. She has bilateral pitting oedema + and weighs 3.6 kg. She has good
appetite and no other signs of medical complications.
a.Does Alemitu have SAM? Why?

b. Does Alemitu need OTP, SC or TSFP? Why?
Case 5. Mulu
Mulu is a 36 months old girl. She lives in Bolososore woreda and came from Achura kebele and referred
to the HP by the HDA. The HEW took her MUAC and measured 11.7 cm. She has no oedema and weigh
13 kg and she has good appetite.
a. Does Mulu has malnutrition?

b. Where will she be admitted and treated?
c. Why?

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Case 6. Abdulaziz
Abdelaziz is 12 months old boy. He lives in kebridehar woreda. His mother Kedija brought him for
treatment because he has cough for the past three days. He does not vomit. And breast feeding well.
The HEW has done medical assessment and he doesn’t have pneumonia and she want to check his
nutritional status and she took his weight and he weighs 9.2 kg, MUAC 12.0cm and he doesn’t have
edema.
a. Does Abdelaziz have malnutrition? Why?

b. What action is needed for Abdelaziz and for his mother Kedija.?
When you completed working on the exercises, please check for the answers at the back of your
participants` manual.

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8.2 Admission Procedure

STEP 1: Triage
The word triage means “sorting”. Triage is the sorting out of clients into priority groups according to
their need.
• Conduct triage and fast-track seriously ill clients.
• Identify referred clients from the community, SC, or SF programme.
• Give glucose 10% (10g or 2 teas spoon of sugar per 100 ml of water) to any clients with SAM,
suspected to be at risk of hypoglycaemia.
• Conduct nutrition education to clients not seriously ill or those attending for follow-up.
STEP 2: Assess for nutritional status

• Determine age of an infant based on recall of the caregiver in the absence of a health card or
birth certificate.
• Measure MUAC for children 6-59 months, pregnant women or clients who cannot stand.
• Check for the presence of bilateral pitting edema.
• Take weight and height measurement.
• Determine the nutrition status and classify using the reference table 2.
• Refer to a health facility for further investigations, all infants under 6 months of age who meet
the criteria for SAM
• Admit clients who meet the criteria.
STEP 3: Clinical assessment

• Take the medical history and record.
• Conduct a physical examination and record.
• Determine the medical condition (presence or absence of medical complications).
• If possible, screen for HIV/TB.
Note: A medical assessment should take place before the appetite test as one of the steps to determine
whether a client should be enrolled in OTP or needs to be referred for SC. If severe medical complications are
identified, the client should be referred to SC.
STEP 4: Perform the appetite test with RUTF

• Clients who pass the appetite test should be considered for admission to OTP.

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STEP 5: Counseling in OTP and use of RUTF

• Explain to the client/caregiver reasons and purpose for admission to the OTP and expected
treatment, care and support.
• Link clients/caregivers to other primary health care services or initiatives.
• Counsel clients/caregivers on key messages.
STEP 6: Dispense medication and RUTF

• All new clients admitted to the OTP should receive routine and appropriate medication. Check
previous treatment of clients referred/transferred from other clinics to avoid overdose of routine
medicines. Ensure that they continue with the treatment started earlier.
• Clients on treatment for HIV/AIDS, TB should be counseled to continue with the medication.
Those diagnosed after admission to OTP should be referred to appropriate program/health
facility for treatment care and support.
Dietary therapy for clients in OTP

• RUTF is energy and nutrient dense pre-packed paste specially designed for the treatment of
acute malnutrition. Therefore, RUTF should be available at all OTP.
• RUTF provides approximately 500 kcal per 92g and the ration given to a client is based on the
need for an intake of between 150 to 220 kcal/kg/day and is calculated based on the weight of
the client.
• RUTF is dose-related and should be given on prescription.

• Counsel and support mothers whose children are still breastfeeding to continue to breastfeed
on demand while on treatment. Clients/caregivers should give safe drinking water after feeding
with RUTF in order to keep the client hydrated.
Benefits of using RUTF

• It is easy to calculate quantity required for each beneficiary.
• It does not require preparation or cooking.
• Client can just open sachet and eat directly.
• It reduces the need for SC admission.
• RUTF has a long shelf life.
• It does not require refrigeration.

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STEP 7: Follow Up in OTP

• Clients/caregivers should be encouraged/counseled to return for scheduled follow-up visits
to enable monitoring of progress. Depending on the OTP site’s schedule and the ability of the
client to return or caregiver to bring in the child, weekly or bi-weekly follow-on sessions should
be scheduled.
• The client or caregiver is asked to return for each OTP follow-on session, and the importance of
compliance with this is explained. Returning for outpatient care follow-on sessions is critical for
the client’s treatment as receiving the needed RUTF is vital for nutrition rehabilitation.
• Review of regularity of attendance and discussion with caregiver on reasons for any absences.
• Anthropometry: weight and MUAC are taken to assess progress. Static weight or weight loss
requires action (refer to action protocol table 11).
• Medical history and physical examination to investigate the presence of medical complications
and the need for referral to SC (refer the action protocol).
• The appetite test to identify any problems with feeding to assess the need for home visit or
referral to SC (refer the action protocol).
• Continuation of drug treatment protocol.
• Supply of RUTF.
• Individual counseling as well as group health and nutrition education.
• Assessment of readiness for discharge according to discharge criteria.
Ensure a steady flow of clients as well as organized provision of comprehensive health and nutrition
services.
Table 10. OTP Entry Categories

Category Definition
New admission New case who meets the admission criteria for OTP
Readmission Re-admitted for treatment in OTP due to relapse or a returned defaulter
who meets the admission criteria.
Relapse: Cured within the past 3 months and now meets the admission
criteria for OTP. Relapse cases require special attention, therefore conduct
home visit.
Returned defaulter: Defaulted within the past 3 months and has returned
to continue treatment in OTP. A returned defaulter should be re-admitted if
they meet the admission criteria.
Transfer-in Continuing treatment in OTP after stabilisation in SC or has moved in from
another facility where s/he was receiving OTP.

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Table 11: OTP Action Protocol

Sign Referral to SC Follow-Up Home Visit
Grade +++
Severe wasting with bilateral pitting
oedema
BILATERAL PITTING Bilateral pitting oedema still present by
OEDEMA Develops or increases in severity week 2
No reduction for 2 weeks
Not resolved after 3 weeks
No appetite or unable to eat, fail RUTF
APPETITE / Child eats < 75% of the RUTF a week by
appetite
ANOREXIA third visit
test.
VOMITING Intractable
Fever: axillary temperature > 38.5°C
TEMPERATURE
Hypothermia: axillary temperature < 35°C
≥ 60 respirations/
minute for under 2 months
≥ 50 respirations/
RESPIRATION RATE minute from 2 to 12 months
(RR) ≥ 40 respirations/minute from 1 year to 5

years
≥ 30 respirations/minute for over 5 years
Any chest in-drawing
General medical deterioration
Very pale (severe palmer pallor), difficulty
ANAEMIA
breathing
SUPERFICIAL Extensive infection requiring intravenous
INFECTION or intramuscular treatment
Very weak, apathetic, unconscious
ALERTNESS
Fitting/convulsions
Dehydration based primarily on recent
HYDRATION history of diarrhoea, vomiting, fever or
sweating and on recent appearance of
STATUS clinical signs of dehydration as reported
by the caregiver or patient
Below admission weight on week 3 (non-
Weight loss for 3 consecutive weighing oedematous children)
WEIGHT CHANGES (non-oedematous children) Weight loss for 2 consecutive weeks (non-
oedematous children)
Static weight for 5 consecutive weighing Static weight for 3 consecutive weeks
Returned from SC (first 2 weeks)
GENERAL Caregiver or patient requests SC
Refused referral to SC
Patient that is not responding to
NOT RESPONDING treatment is referred to SC for further
investigation

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Refer the patient who fails appetite test and has medical complications to the sc
If the child is 6-59 months old and has medical complications or fails the appetite test, start treatment of
the medical complications;
• Provide sugar water solution to avoid hypoglycaemia. Sugar water contains 10 g of sugar (2
teaspoons) dissolved in 100 ml of water.
• Refer the child to the closest SC.
• Record findings and the treatment given on the Referral Slip.
• Explain the following to the caregiver:
• Severity of the condition and the need for referral to SC
• Need to keep the child warm during transportation
• Need to give frequent, small amounts of 10 percent sugar water solution during
transportation
• If breastfeeding, need to frequently breastfeed the child
*NOTE: All infants 0-6 months of age with SAM with or without medical complications should be referred to
the SC.
Demonstrate how to fill OTP card
Below is all of the information needed to complete the Admission detail part of an OTP card. You should
fill all the information into the OTP card.
Registration number available is 002. The health facility code is AKT.
Halima brought her daughter Meriam Kemal to the nearest health post.
Halima lives in Asaita woreda , Aloyu Kebele. Meriam is 18 months old.
She has come directly from her community to the OTP.
She lives in a house with his 1 brother and 2 sisters and her mother and father. She is on breast feeding
and start complimentary food soon.
Admission anthropometry
• Weight - 8.0 kg
• MUAC - 10.8 cm
• Oedema –No
What is her admission criterion?
History
Meriam’s mother says that she has no diarrhea, doesn’t vomit, passes urine without
problem, occasionally has a cough, her appetite is generally good, she is breast feeding.
She reports no other problems but says she has been getting thinner for some time now.
Physical examination
Her respiration is 38 and there are no chest retractions, her temperature is 37.5 °C, no palmar pallor,
her eyes are wet and have no discharge, although her skin is saggy, she shows no apparent signs of
dehydration, her mouth is clear, there are no enlarged lymph glands, she has no apparent disabilities,
her skin is in good condition. She has good appetite.
Notes: Meriam’s mother has carried her Vaccination card – she was given all her vaccinations 9 months
ago, along with vitamin A.

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8.3 Medical treatment and care for children 6-59 months with SAM in
OTP
Children who have been transferred from stabilization centre for the management of severe acute
malnutrition should not receive routine medications that have already been administered during the
hospital stay. However, if any treatments received during inpatient care is incomplete (for example, for
clinical signs of severe vitamin A deficiency), this information should be included on referral documents
and the doses required to complete that treatment given during outpatient care.
Routine medications
On admission, routine medication should be given to the children attending outpatient care. Caregivers
should be advised on how to continue the treatment at home.
Antibiotics
Routine antibiotics are given to all children, due to the high prevalence of silent infection in severe
acute malnutrition. Amoxicillin should be used as a broad-spectrum antibiotic. If the patient continues
to present infectious symptoms, they should be referred to an inpatient service.
The first dose of amoxicillin should be taken during the admission process under the supervision of
the health care provider. An explanation should be given to the caregiver on how to complete the
treatment at home.
The recommended dosage for amoxicillin is 25 mg/kg every 12 hours for 5 days.
Give routine medicines as indicated in Table 12 below. Carefully check the records of patients who were
previously treated in SC or other OTP to avoid prescribing medicines that have already been given.

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Table 12: Routine Medication and Treatment in OTP

10% (2 tea spoon During referral All ages 50 ml Once, orally
sugar in 100 mil to SC to prevent
water) sugar water hypoglycaemia
solution
Amoxicillin On admission of All ages 25 mg/kg, every 12 Oral: 25 mg/
all SAM patients hours, for 5 days. kg, every 12
hours, for 5
days
Albendazole At the second ≥ 24 Albendazole 400 mg Single dose,
visit months orally
Or
for treatment in
Mebendazole OTP Mebendazole 500
mg
Measles vaccine On the fourth 9–59 Refer to the Refer to the
week if the months National Expanded National EPI,
child has not Programme on ICCM/ IMNCI
yet received the Immunisation (EPI) Guidelines
measles vaccine Guidelines
Other vaccines Update All ages Refer to the National Refer to the
vaccinations EPI Guidelines National EPI,
based on EPI ICCM/ IMNCI
schedule Guidelines
Vitamin A: Do not give an additional high dose of vitamin A to children with SAM who are receiving
RUTF
• A high dose (50,000 IU, 100,000 IU or 200,000 IU, depending on age) of vitamin A should be
given on admission only if the therapeutic foods given are not fortified as recommended in
WHO specifications and if vitamin A is not part of other daily supplements and was not given to
the child in the past one month. (Note: RUTF is fortified).
• All patients who show signs of vitamin A deficiency should be referred for treatment in SC.

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Specific treatments
Anaemia:
Children with severe acute malnutrition often have low iron stores, as they have reduced haemoglobin
synthesis and have lost iron-rich muscle. Iron supplementation, however, may be harmful to them, as
this may promote infection, increase severity of malaria in highly endemic areas, and lead to oxidative
stress. Therefore, if the child does not present with any signs of anaemia there is no need to provide
supplements, as RUTF already contains the daily required doses. Iron and folic acid should not be given
routinely to children in OTP as RUTF contains iron and folic acid.
If anaemia is suspected, a test must be done and appropriate treatment given.
If severe anaemia, refer for treatment in SC. Malaria testing and treatment should be done
Diarrhoea
Oral rehydration solution (ORS) should never be given to children with severe acute malnutrition
through outpatient care.
Children who have severe acute malnutrition and diarrhoea but no signs of dehydration or medical
complications, are clinically well and alert, can be treated as outpatients. ReSoMal should not be
provided for home preparation.
RUTF that complies with WHO specifications provides a daily supplementation of zinc.
Caregivers should be given information on feeding and hygiene and advised to return to the health
facility immediately if the child’s condition deteriorates.
MUAC or weight-for-height should be reassessed after children have been rehydrated.
HIV/AIDS and TB: If possible, offer HIV counselling and testing, and TB testing to all patients with SAM,
especially if readmitted or not responding to treatment. If the patient is HIV+ or HIV-exposed, give
Cotrimoxazole prophylaxis as well in addition o the selected antibiotic. Medical treatment and care
should follow the National Guidelines for Comprehensive HIV Prevention, Treatment and Care.

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8.4 Nutritional rehabilitation with RUTF (Plumpy’Nut)

The dietary management of cases in outpatient care is based on RUTF feeds
RUTF mainly Plumpy’nut is high-energy, nutrient-dense therapeutic food that is used to treat SAM in
OTP. It is similar in composition to F100 (except RUTF contains iron and is about five times more energy
nutrient dense). There are two types: soft lipid-based paste (Plumpy’nut®) or crushable nutrient bar
(BP100), which is available mainly during emergencies.
RUTF is provided at between 150 and 220 kcal/kg/day. A commonly practised dosage is 200 kcal/kg/
day. The following table 13 shows the amounts of RUTF to give based on the weight of the child.
RUTF presented in biscuit form (BP-100®) is not recommended by the manufacturer for children aged
under 2 years (less than 7 kg) as it is crumbly, and the child is at risk of swallowing incorrectly. For these
younger children, aged 6–24 months, the biscuits can be mixed with clean water to make porridge.
Special orientation will be required for the caregiver on how to do this. However, if the caregiver
prepares porridge, anything not eaten should be immediately discarded after the meal to avoid
contamination.
Amount of RUTF/ BP 100 to give

The number of packets of RUTF or BP100 given is based on the weight of children and the frequency of
follow up with enough amounts until the next visit. It continues to be taken regularly, until the child is
fully recovered.
Determine the amount of the RUTF or BP 100 using the RUTF or BP100 reference table for OTP (refer
table 14) and prescribe adequate amount until the next visit.
Table 13: Amount of RUTF to Give (92 g Sachet Containing 500 Kcal)
Weight of Child (kg) Sachets per Day Sachets per Week
3.5 - 3.9 1½ 11
4.0 – 5.4 2 14
5.5 – 6.9 2½ 18
7.0 – 8.4 3 21
8.5 – 9.4 3½ 25
9.5 – 10.4 4 28
10.5 – 11.9 4½ 32
≥ 12 5 35

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Table 14: Amount of BP 100 to Give

Weight of Child (kg) Bars per Day Bars per Week
3.0-3.5 2 14
3.5-4.9 21/2 18
5.0-6.9 4 28
7.0-9.9 5 35
10.0-14.9 7 49
15.0-20 9 63
Explain the following on the feeding procedure:
• Do not give RUTF to infants 0-6 months. They should be exclusively breastfed.
• If the child is 6-23 months, continue to breastfeed on demand. Mother’s milk is best for infants
and young children.
• Feed small amounts of RUTF until the allocated daily ration is finished, and before eating any
other food (apart from breast milk).
• Encourage the child to eat as often as possible (every 3 hours during the day).
• If the child is breastfeeding, offer breast milk on demand and before feeding RUTF.
• Offer plenty of safe drinking water while eating RUTF.
• Do not mix RUTF with liquids as this might cause bacterial growth.
2.7 Counsel on Key Messages for caregiver

There are key messages that should be given to mothers/caretakers with regard to:
• How to feed RUTF to the child
• When and how to give the medicines to the child
• When to return to outpatient care
• The child should be brought to the health facility immediately if his/her condition deteriorates

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Counsel the mother/caretaker on the following key messages how to feed the RUTF:
• RUTF is a food and medicine for malnourished children only. It should not be shared. Opened
packets of RUTF can be kept safely and eaten later – the other family members should not eat
any that is left over at a meal.
• RUTF is the only food the child needs to recover during his/her time in the program.
• Sick children often do not like to eat. Give small regular meals of RUTF and encourage the child
to eat often (if possible, eight meals per day). Leave time for the child to eat. RUTF can be left for
later if not finished and be eaten during the course of the day.
• Always offer plenty of clean water to drink while eating RUTF.
• For breast-fed children, always give breast milk before the RUTF and on demand
• Use soap and water to wash her/his hands before feeding
• Keep food clean and covered.
• Always keep the child covered and warm as sick children get cold quickly
• When a child has diarrhoea, never stop feeding. Give extra food and extra clean water.
• Return to the health facility whenever the child’s condition deteriorates or if the child is not
eating sufficiently
• As soon as the child is improving and has increased appetite, mothers/caregivers can start
giving the child other foods in addition to, but after breast milk and the RUTF.
NB: Check the mothers understanding using appropriate checking questions.
Emotional and physical stimulation

Severely malnourished children have delayed mental and behavioral development, which if not treated,
can become the most serious long-term result of malnutrition. Emotional and physical stimulation
through play programs from the start of treatment and after discharge can substantially reduce the risk
of permanent mental retardation and emotional impairment.
Teach mothers the importance of stimulation and how to make and use toys
Ensure that the child is stimulated by the mother. Create a stimulating environment in the centers and
at home, provide opportunities for play activities with toys and interaction between children and with
their mothers or careers.
Promote physical activity of children that can move and passive mobilization of limbs for those that
can’t. Avoid wrapping the child: the child should be able to move freely.
Mothers should be taught to play with their children using simple, homemade toys. It is important to
play with each child individually at least 15-30 minutes per day, in addition to informal group play. The
video will demonstrate to you how to teach mothers to play with children at home to stimulate their
mental development.

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EXERCISE A
1. Why should all severely malnourished children be given antibiotics?
2. What are the advantages of RUTF?
3. Sara is admitted at your OTP and her weight is 10.7kg
4. If you have Plumpy’nut determine the amount of ration to be given
GIVE: amount per day Amount for one week.
5. If you have BP100 determine the amount of ration to be given
GIVE: amount per day Amount for one week.
6. What important message will give to Sara care giver?
Tell the facilitator when you are ready to discuss these questions with
the group

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8.5 Follow up during treatment in OTP

Children treated in OTP are seen by a health worker/HEW every week. During weekly visits, the Health
worker/HEW assesses progress, monitors weight gain, and checks for associated complications requiring
referral to inpatient care or risks that need home visit. The patient receives drugs and RUTF supplies for
the week. Individual counselling and health and nutrition education in groups can also be provided
during these visits.
The health worker/HEW should assess for the following conditions during every follow up visit:
Ask about
• Unable to feed
• Vomiting everything
• Seizure
• Mental change
• Diarrhea, blood in stool
• Fever
• Cough
• Any other new complaint or problem
• the child is taking and finishing the prescribed RUTF
Look for and Do/Act:

• Check for medical complications
• Check temperature and RR
• Weigh the child, assess edema and measure MUAC at every visit. Write the information
down on the patient’s card.
• Do appetite test (Repeat the RUTF feeding procedure on every follow-up visit and ask
the caregiver to repeat back.)
• Inform the caregiver on the treatment progress.
• Conduct individual and/or group counselling on health, WASH, and IYCF.
• Indicate any necessary follow-up actions on the OTP Treatment and Follow-up Card, such as:
• Home visits for patients requiring special attention. (use checklist)
• Referral to the SC.

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Table 15: Summary of activities during weekly visits to outpatient therapeutic care
Activity Frequency
Weight Each week
MUAC Each week
Check for oedema Each week
Height or length Once a month
Medical history Each week
Physical examination (including
Each week
temperature and respiratory rate)
Appetite test Each week
Routine medical treatment According to treatment protocol
Home visit As needed according to action protocol
Vaccinations As needed according to immunization schedule
Evaluation of health and nutrition
Each week
status progress and counselling
Health and nutrition education Each week
Evaluation of RUTF consumption Each week
Provision of RUTF Each week
Decide on action to take

According to the outcomes of each visit, the health worker or HEW should take actions based on
result of the above follow up assessment and document on the OTP care and registration book. A
child might:
• Continue OTP without home visit if the progress is satisfactory
• Continue OTP with home visit support if there is progress but it is not satisfactory
• Be transferred to in-patient care if there are medical complications or failed the appetite test
• Referred to a higher-level referral hospital for other underlying medical complications.
Continue OTP without home visit

The child should continue the OTP without additional home visit if the child has no danger signs,
medical complications, pass appetite test, no other medical reason to refer, and the weight gain is
satisfactory. Most children fall in this category. The health worker/HEW should provide the following OTP
• Provide routine medicine based on the protocol and record on the OTP card
• Counsel on the progress of the child and OTP key messages
• Provide the amount of RUTF needed until the next visit
• Provide emotional and psychosocial stimulation
• Inform the when the next visit

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Continue OTP with home visit support

Some children may need to be monitored through visits by HEWs or volunteers (HDA) at their homes.
The HEWs or HDA can discuss issues with the career, assess home environment and adapt messages
to improve treatment. Their OTP follow up visit at facility should be every week. This may be necessary
when
• There is an unexplained lack of weight gain.

• Eats < 75% of the RUTF a week by second visit
• Returned from inpatient care (first 2 weeks)
• Refused referral to inpatient care
Transfer to and from in-patient care

Children on OTP care and who develop any danger sign or sign of medical complications, should be
referred to the in-patient facility for management of their condition, until they are fit to return and
continue in OTP care. Likewise, if the patient is being treated as an out-patient and develops any of the
following s/he should be referred to the in- patient care facility.
Referral to SC Based on the Action Protocol (Refer table for action protocol)
• Refer patients with a poor appetite, deteriorating nutritional status, and/or a medical
complication.
• Issue a Referral Slip to the patient referred for treatment in the SC.
Failure to Respond to Treatment

If a child requires in-patient care, all anthropometric measurements, medical history and physical
findings are recorded in the OTP card and the child is classified as transfer. The card is filed in the
discharge folder until s/he comes back after the severe medical complications have been treated.
Explain to the mother/caregiver that her child requires in-patient care and ask, if she is willing to go.
Explain to her also, that once the child is discharged from the inpatient care, she should bring her child
back to OTP. If you are referring to other health facility, clearly fill in the referral form and send
to the nearest health facility providing inpatient care. Many care givers refuse transfer to in-
patient due to distance, cost of travel, unwilling to leave other kids at home, etc. The health worker/
HEW should try to persuade the care taker. If this fails, the child should be treated in OTP; it should be
recorded as ‘refused transfer’.
When a child returns from in-patient care, look at the referral form to see what has happened there and
continue the treatment as an outpatient accordingly.
It is recommended that patients who are referred to SC due to failure to respond to treatment be tested
for HIV and TB which are common underlying causes of acute malnutrition.
Investigate the cause of failure

The health worker/HEW should investigate the cause of treatment failure in OTP so that to identify the
cause early and take remedial action timely. This will help to improve the quality and performance of
OTP care.

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Common causes of treatment failure in OTP:
Problems with the treatment facility Problems of individual children
• Inappropriate selection of patients to go directly to OTP; • Sharing within the family;

• Poorly conducted Appetite test; • All eating from the same plate
• Inadequate instructions given to caretakers; (the malnourished child should
• Wrong amounts of RUTF dispensed to children; always have his / her own
• Excessive time between OTP attendancer oedema still present portion of food);
or no weight gain on day 21 [third visit] • Unwilling caretaker;
• Secondary failure: failed appetite test or 5 per cent weight loss • Caretaker overwhelmed with
or no weight gain for two consecutive visits or failure to gain other work
2.5g/kg/day on day 21 for edematous child or on day 15 for a • and responsibilities.
non-edematous child in OTP care • Illness
• Causes of failure to respond
• The HW should investigate the cause of treatment failure in
OTP to identify the cause early and take action on time. This will
help to improve the quality and performance of the OTP care.
Usual causes of treatment failure in OTP include problems with
the treatment facility or the HW or the individual child.
• Some of the actions required when failure to respond is
commonly seen in a program are:
• Follow-up through home visits by HEWs/HDAs/outreach
workers to check whether a child should be referred back to the
clinic between visits
• Discuss with caregivers on aspects of the home environment
that may be affecting the child’s progress in the program
A follow-up home visit is essential when:
• Caregiver refused admission to in-patient care despite advice
• Failure to attend appointments at the out-patient program
• At the health facility carry out medical check and appetite test;
• Re-calibration of scales and length-boards
• Review of the supervision of staff with refresher training to
improve their skills
Action required when failure to respond is commonly seen in a program:

• Follow-up through home visits by HEWs / HDAs / outreach workers to check whether a child
should be referred to the clinic between visits.
• Discuss with care taker on aspects of the home environment that may be affecting the child’s
progress in the program.
• At health facility carry out medical check and Appetite test;
• Re-calibration of scales.
• Provide refresher or on jobs training for the health care providers as needed.

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Tracing of absentees and defaulters

If children default and do not complete the treatment, they are still at risk of death. It is necessary to
understand why people are defaulting, as may be something can easily be changed e.g. changing day
of follow-up. In addition, efforts can be made to encourage the mothers / care takers to bring their
children back to the health facility.
Each week a list of absentees / defaulters can be compiled. In order to be able to trace absentees /
defaulters, it is very important that the address section of the OTP card is correctly filled out with ; • the
child’s name, • the father’s name, • grandfather’s name, • kebele and gott. The Health extension worker
can liaise with the HDA to follow up absentees and defaulters.
If defaulters are traced and come back to the health facility, they are admitted and continue the
treatment as return after defaulting. This can happen only if they do not fulfil the discharge criteria
(recovered).
8.6 OTP Discharge criteria and procedure

Discharge Criteria for Children 6-59 Months
*Note: The same anthropometric indicator that is used to identify and confirm SAM on admission should be
used to determine recovery and discharge from treatment
Table 16: Criteria for discharge from outpatient care (children aged 6–59 months)
Criteria for discharge Notes
Weight-for-height/length Z-score is ≥ –2 SD, and child has had
no oedema for at least 2 weeks;
OR
MUAC is ≥ 125 mm and child has had no oedema for at least 2
Cured weeks
(use the same indicator as for admission)
No oedema for 2 consecutive weeks
Clinically well and alert
Defaulted Absent for two consecutive visits
Died Died during treatment in outpatient care
Non-responder Did not meet the discharge criteria after 4 months in
treatment
Note that a non-responder is a person whose condition is not responding to treatment, is referred for further
investigation and additional treatment for infections or underlying pathologies or is referred to inpatient care for closer
monitoring.

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Movements between services include children leaving a specific health facility or level of treatment, but
not the treatment. These children are not counted as discharged as they are continuing their treatment
for severe acute malnutrition. They should be recorded as follows.
The child fulfils criteria for referral to inpatient care

Transfer to inpatient
according to admission criteria or action protocol
Transfer to another Child with severe acute malnutrition in treatment in
outpatient service one site moves to another outpatient site to continue
treatment
Discharge Procedures for Children 6-59 Months

• Give feedback to the caregiver on the final treatment outcome.
• Ensure that the caregiver understands how to use continuing medications.
• Give the final on week supply of RUTF ration.
• Give Vitamin A supplementation on discharge based on age and inform the mother /
caregiver that the child should not to administer until 6 months in cases of campaign /routine
micronutrient supplementation programs.
• Record the exit category on the Registration Book for SAM and the OTP Treatment and Follow-up
Card.
• Counsel on WASH, good nutrition, and IYCF practices.
• Advise the mother/caregiver to immediately come back the health facility/HP if child experience
any signs of deterioration.
• Refer the caregiver to PSNP and other complementary health and nutrition services.

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EXERCISE B
In this exercise, you will review information of cases to determine if they are making progress or if they
are failing to respond.
Case 1: Bekele
Bekele was admitted to outpatient care with a MUAC of 11.9 cm and a weight of 11.5 kg. He has had ++
bilateral pitting edema at admission. By the third week, he weighs 11 kg and edema reduced to +1.
a. Is Bekele’s progress satisfactory? Why? Or why not?
b. What action do you take now for Bekele?
Case 2: Taye
Taye is 7 months old boy and he was admitted with a weight of 4 kg and MUAC of 11 cm, no edema. In
the 3rd visit, he still weighs 4.0 kg. His medical assessment does not show any signs of illness or medical
complications and has good appetite.
a. Is Taye’s progress satisfactory? WHY?
b. What problem have you identified?
c. What action do you take?
Case 3. Molla
Molla was admitted to OTP 2 months ago. His filled OTP card is provided on the next page. Study the
information about Molla and answer the questions below.
a. What is the admission history of Molla?
b. Is Molla making progress? If so describe the progress?
c. What action do you take? Why? Write the decision into the action taken section.

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Case 4: Debalke
Debalke was admitted to OTP three weeks ago. He has received Plumpy’nut and routine medicines.
The Follow up part of his OTP card is provided below Page X. Study the information about Debalke and
answer the questions below.
a. Is the OTP card filled out properly at each visit?
b. Is Debalke making progress? If so, describe his progress.
c. What relevant information was missed at each visit?
d. If you are the one who is responsible to provide the service, what action do you take during the
second Visit and the third visits?
When you have completed this exercise, please discuss your answers with a facilitator

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ADMISSION DETAILS: OTP Treatment Card

Full Name Molla Registration N
o
001/OTP
Age (months) Sex M F Date of admission 12/06/2010
Mother’s Name
o
Reg. N
Region Woreda Bati Kebele Horo

OTP Site Bati Health Post Distance to the house (hours)
Community Volunteer
Referred by Other (neighbours etc.) Self-referred
Name:
Admission (circle) New Case Relapse Returned Defaulter From Routine or Community Health Days From Stabilisation Centre Stabilisation Centre Refusal
Re-Admission (relapse) No Yes Additional information
Admission Anthropometry
Bilateral pitting oedema + ++ +++
MUAC (cm) 10.4cm Weight (kg) 6.4kg Height/length (cm) 74cm Weight for height/length (WFH)
Bilateral
Admission criteria pitting MUAC Weight for height Other:
oedema
History
Diarrhoea yes no # Stools/day 1-3 4-5 >5
Vomiting yes no Passing urine yes no
Cough yes no If bilateral pitting oedema, how long swollen?
Appetite good poor none Breastfeeding status (children 6 to 23 months) yes no
Additional information
Physical Examination
Respir. rate (# min) <30 30 – 39 40 - 49 50+ Chest Indrawing yes no
0
Temperature C Conjunctiva normal pale
Eyes normal sunken discharge Dehydration None moderate severe
Ears normal discharge Mouth Normal sores candida
Enlarged lymph nodes none neck axilla groin Hands & feet normal cold
Skin changes none scabies peeling ulcers / abscesses Disability yes no
Additional information
Routine Medications
ADMISSION: Drug date Dosage Drug Date Dosage
Amoxicillin 12/06/2010
Measles Immunisation No Yes date:
Malaria treatment yes no date Fully immunised No Yes
2nd VISIT: drug date Dosage

Mebendazole/Albendazol
e
Other Medication
Drug Date Dosage Drug Date Dosage
Transfer-in and Transfer-out during treatment for SAM
Transfer In Transfer Out
Location Date Reg No of other Facility Reason Location Date Reg No.
Home Visit
Date Reason for Home Visit Date of Home Visit Findings

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FOLLOW UP: OTP

NAME Registration No / 001/OTP
ADM
Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
( =0 )
Date 0 6 /12 /2 0 10 0 7 /12 /2 0 10 0 8 /12 /2 0 10 0 9 /12 /2 0 10 10 /12 /2 0 10 11/12 /2 0 10
Anthropometry
Bilateral Pitting
Oedema 0 0 0 0 0 0
(+ ++ +++)
MUAC (cm) 1 0 .4 1 0 .4 1 0 .5 1 0 .9 1 1 .1 1 1 .2
Weight (kg) 6 .4 6 .4 6 .9 7 .1 7 .9 8 .2
Weight loss *
(Y/N)
Height/length
(cm)
Weight for
Height/length
* If below admission weight on week 3 refer for home visit; If no weight gain by week 5 refer to SC
History
Diarrhoea (#
days)
Vomiting (# days)
Fever (# days)
Cough (# days)
0
Temperature ( C) 3 6 .9 3 7 .2 3 6 .8 3 7 .1 37
Respiratory rate 32 36 28 30 38
(# /min)
Dehydrated
(Y/N)
Anaemia /
palmar pallor
Skin infection
(Y/N)
Appetite test / feeding
RUTF test P P P P P
(Passed/Failed)
RUTF (# units 18 18 18 21 21
given)
Breastf
eeding
(Y/N)
Action / follow up
ACTION NEEDED
(OT P/S C/Home OT P OT P OT P OT P OT P
follow up)
Other medication
(see front of card)
Name of HF HF HF HF HF
examiner
OUTCOME OK OK OK OK OK
OK=Continue A=Absent DF= Defaulter (Absent for 2 consecutive visits and confirmed by a home visit) T=Transfer RR=Refused referral C=Cured NR=Non-responder HV= Home visit
D=Died
Action taken during follow-up (include date)
Name of outreach worker:

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Name: Debalk
FOLLOW UP: OTP

NAME Registration No / /
ADM
Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
( =0 )
Date
Anthropometry
Bilateral
Pitting
(+ ++ +++)
MUAC (cm) 1 1 .2 1 1 .1 1 1 .1
Weight (kg) 8 .4 8 .6 8 .7
Weight loss *
(Y/N)
Height/length
(cm)
Weight for
Height/length
* If below admission weight on week 3 refer for home visit; If no weight gain by week 5 refer to SC
History
Diarrhoea (# N N N
days)
Vomiting (#
days)
Fever (# days)
Cough (# days)
Temperature 3 6 .9 37
(0C)
Respiratory 32
rate (# /min)
Dehydrated
(Y/N)
Anaemia /
palmar pallor
Skin infection
(Y/N)
Appetite test / feeding
RUTF test
(Passed/Failed)
RUTF (# units 21 25 25
given)
Breast
feedin
Action / follow up
ACTION
NEEDED OT P
(OTP/SC/Home
follow up)
Other
amoxacillin
medication 2 50 mg B ID
(see front of
Name of
examiner
OUTCOME
OK=Continue A=Absent DF= Defaulter (Absent for 2 consecutive visits and confirmed by a home visit) T=Transfer RR=Refused referral C=Cured NR=Non-
responder HV= Home visit D=Died
Action taken during follow-up (include date)
Name of health extension worker:

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Answers to short answer questions

Case 1. Chaltu
a) Yes,she has SAM – Her MUAC is < 11.5cm.
b) She needs to be admitted at SC because she has failed appetite test.
c) Referral: Fill out a referral slip and tell her mother about the importance of SC admition or
inpatient care for her child.
Case 2. Abera
a) Yes, because his MUAC is < 11.5 cm
b) Admit to SC, since he is Marasmic kwash child, despite the good appetite and the absence of
medical complication.
Case 3. Guluma
a) Yes, because he has oedema.
b) OTP, because he has SAM without medical complication and with good appetite.
c) Admit at OTP and provide all needed services based on the action protocol.
Case 4. Alemitu
a) Yes, she has oedema +
b) SC, because she is < 6 months old.
c) Refer her for SC and counsel the mother to continue breast feeding.
Case 5. Mulu
a) Yes, she has MAM.
b) TSFP
c) She is moderately malnourished.
Case 6. Abdulaziz
a) Yes, because his MUAC is less than 12.5cm. (MAM)
b) Admit to TSFP and counsel the mother to continue breast feeding and complementary feeding.

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MANAGEMENT OF MODERATE ACUTE MALNUTRITION
(MAM)
S-9 SFP
Introduction
Moderate Acute Malnutrition, or moderate wasting, is defined by a MUAC ≥ 11.5 cm and < 12.5 cm or a
WFH ≥ -3 z-score and < -2 z-score (WHO standards) in children 6-59 months old. And, PLW with MUAC <
23cm.
This session describes two types of Supplementary Feeding Programmes (SFPs) used to manage MAM.
The session highlights on the principles, criteria, and process of implementation. It is recommended that
MAM interventions are linked with SAM treatment, IYCF, and social behavior change communication
(SBCC), WASH and other health and nutrition interventions.
Learning Objectives
By the end of the session participants will be able to:
• Describe the Principles of Supplementary Feeding Program (SFPs)
• Identify the types of the Supplementary Feeding Program(SFPs)
• Describe the admission to, entry and discharge criteria
• Know the admission procedure to SFPs and steps to follow.
• Discuss Medical Treatment and Nutrition Rehabilitation for the Management of MAM
• Know the Organization of SFP services

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9.1 Principles of Supplementary Feeding Program (SFPs)

• SFPs aim to prevent and rehabilitate acute malnutrition.
• A take-home specialised nutritious food is provided to the patient, with follow-up visits
conducted at a nearby health facility every two weeks.
• For SFPs to achieve the intended outcomes, it is critical that effective and appropriate linkages
are made with food security interventions to avoid the risk of sharing the specialised nutritious
food with other members of the household.
Types of Supplementary Feeding Programme

9.2 Blanket Supplementary Feeding Programme (BSFP)
A supplementary ration is provided to everyone in an identified vulnerable group for a defined period.
BSFP is implemented when the Global Acute Malnutrition (GAM) levels are high and food insecurity is
severe. It can be implemented as part of an emergency response or as a response to seasonal shocks to
prevent spikes in acute malnutrition. BSPF aims to prevent acute malnutrition or further deterioration of
nutritional status among identified vulnerable groups.
Admission and discharge criteria

• The admission and discharge criteria for BSFP does not rely on anthropometric indicators.
• Define the targeted groups, for example, all children aged 6-23 months or 6-59 months, or all
pregnant and lactating women (PLW).
• BSFP normally operates for a period of about 3-6 months, after the situation has stabilized, it is
closed and those registered are discharged
Treatment and follow up procedure in BSFP

• Register all individuals within the defined target group for the BSFP.
• Screen the individuals by measuring MUAC and assessing for bilateral pitting oedema. The
screening is conducted to identify cases who may require referral for SAM management. It is not
used for admission to the BSFP.
• Provide a two-week supply of specialised nutritious foods to all those registered for BSFP.
• Monitor individual nutritional status by measuring MUAC and assessing for bilateral pitting
oedema during each bi-weekly follow-up visit.
• Ensure provision of other health services such as: vitamin A supplementation, deworming,
insecticide treated nets, water purification tablets, and health and nutrition education.

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When BSFP should be closed

BSFP should be closed when GAM is below 10% with no aggravating factors and the following met:
• The general food distribution is reliable and adequate, or food security is acceptable.

• Effective public health and disease control measures are in place.
• No seasonal deterioration of nutritional status is expected.
• The population size is stable, with no new displacement expected.
• There is availability and access to WASH facilities.
• Nutrition sensitive interventions are in place.
9.3 Targeted Supplementary Feeding program (TSFP)

Targeted Supplementary feeding is the provision of nutritious rations to vulnerable children (usually
classified at 6-59 months) or those with special dietary needs (e.g. pregnant and lactating women.
SFPs provide a ration that is additional (supplemental) to the food available at household level, or that
provided from a General Food Distribution (GFD). In other words, SFP rations should be in addition to,
and not a substitute for, the normal diet. Targeted SFPs are generally used for treatment of MAM within
individuals based on anthropometric admission criteria.
TSFP should be integrated with routine health services and OTP services.
Aims of TSFP:
• Treat patients with MAM;
• Prevent deterioration from MAM to SAM;
• Prevent mortality associated with MAM; and
• Prevent deterioration in maternal nutritional status and subsequently prevent poor birth
outcomes.
TSFP admission criteria and procedure

TSFP Admission Criteria
A. Children 6-59 months
MUAC >11.5 to <12.5 cm

OR
WFH >-3 to <-2 Z scores
AND
No bilateral pitting oedema
Clinically well and alert
B. PLW (up to 6 months post-partum)

MUAC < 23.0 cm

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Note:
 If moderately malnourished child has medical complication admit in TSFP and
treat the complication based on ICCM/IMNCI or refer for treatment as needed.
 If MUAC of PLM is < 18.5 cm admit in TSFP and refer to HC for farther
investigation.
TSFP admission procedure
Step 1: Take Anthropometric Measurements and Confirm Nutritional Status

• Determine the age of the patient based on the health card or caregiver’s recall.
• Check for bilateral pitting oedema and record the findings.
• Measure MUAC of the patient and record the measurement.
• Measure and record weight of the patient.
• Measure and record Height of the patient (done at health centre level)
• Classify nutritional status.
Step 2: Admit to the TSFP

• Explain the TSFP treatment procedures and care that will be provided.
• Decide which TSFP admission entry category to assign to the patient.
• Assign a registration number if the patient is a new admission.
• Give routine medicines in TSFP.
• If scheduled immunisations have not been given, administer them.
• Give the specialised nutritious food.
• Complete the TSFP Treatment and Follow-up Card.
• Register the patient in the registration book for MAM treatment. Be sure to use the appropriate
registration book for children or PLW.
• Provide nutrition counselling and education, including IYCF and maternal nutrition.
• Issue the patient with the TSFP Identification Card.
• Advise the caregiver or patient when to return for the next visit.
• Refer to other health and nutrition services such as antenatal care, post-natal care, and PSNP.
Table 17: TSFP Entry Categories

Category Definition
New admission New case who meet admission criteria for TSFP.
Readmission Re-admitted for treatment in TSFP due to relapse or a returned defaulter
who meets the admission criteria.
Relapse: Cured within the past 3 months and now meets the admission
criteria for TSFP.
Returned defaulter: Defaulted within the past 3 months and has
returned to continue treatment in TSFP. A returned defaulter should be
re-admitted if they meet the admission criteria.
Transfer-in Has moved in from another facility where s/he was receiving TSFP.

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TSFP medical treatment and care

Check and provide routine medications such as vitamin A, deworming, and routine immunizations
Table 18: Routine Medication and Treatment for Children in TSFP

Name of When Age Dose Prescription
Medicine
Albendazole On ≥ 24 months 400 mg Single dose on
admission admission
Or
Mebendazole On ≥ 24 months 500 mg Single dose on
admission admission
Measles On 9-59 months Refer to the national Refer to the national
vaccination admission if EPI guidelines, ICCM/ EPI guidelines, ICCM/
the child has IMNCI IMNCI
not received
the measles
vaccine
before.
Table 19: Routine Medication and Treatment for PLW in TSFP
Name of When Physiological Dose Prescription

Medicine Status
Albendazole Second Pregnant or 400 mg Single dose on admission,
or Third lactating if not already received in
Or trimester antenatal or postnatal care.
Mebendazole Second Pregnant or 500 mg Single dose on admission,
or Third lactating if not already received in
trimester antenatal or postnatal care.

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SHORT ANSWER EXERCISE

Use the information provided in the case scenario to identify whether the child should be admitted or
not.
Case 1: Fatima
Fatima, 18 months old girl with a mid-upper arm circumference (MUAC) of 12.7cm, weight of 13.4 kg
and no oedema and no medical complications.
a) What is Fatima `s nutritional status?
b) What action is needed?
Case Two: Emebet

Beza brought her 12 months old daughter, Emebet to the health post for monthly growth monitoring.
Her Weight was 7.7 kg and her MUAC is 11cm and the HEW also checked for bilateral pitting edema,
Emebet had +edema.
a) What is Emebet `s nutritional status?
Case Three: Bekele

Bekele is 36 months old referred to the HP by the HDA. His is MUAC 11.8cm, weight 12kg and no
oedema ,no medical complications.
a) What is Bekele `s nutritional status?
Case Four: Shambel

Mulu brought her child Shambel to the health post for immunization. Her MUAC was 11.6 cm, no edema
and child was clinically well.
a) What is the nutritional status of Shambel?

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Case Five: Hilina

Hilina is a 27-year-old pregnant woman. She came for her antenatal service to the health post and the
HEW measure her weight and MUAC. Her Weight is 52 kg and her MUAC is 21cm.
a) What is Hilina`s nutritional status?
Case Six: Marta

Marta has a 3 months old baby and came to the health post for family planning service. Her baby is
breastfeeding well. Nutrition assessment of Marta showed that her MUAC was 22 cm.
a) What is the nutritional status of Marta?
b) What action is needed to be taken?
Case Seven: Demberu

Demberu is 25 months old boy referred to the Health post by the Health Development Amy (HAD). His
MUAC is 11.1cm, weight 12 .3 kg and no oedema, no medical complications, and passed appetite test.
a) What is the nutritional status of Demberu?
3. Use the information from the above cases and complete the appropriate treatment cards and
registration books and issue identification card to clients.
When you have completed this exercise, please tell the facilitator to discuss and check the answer at
the back of the manual.

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9.4 Nutrition Rehabilitation at SFPs

• There are a range of specialised nutritious foods used for nutrition rehabilitation of patients with
MAM.
• Fortified blended food (FBF) e.g., Super Cereal Plus, and ready-to-use supplementary food (RUSF)
are the two types of specialised nutritious foods used for management of MAM in Ethiopia.
• Ideally RUSF is used for nutrition rehabilitation of children with MAM, if not available, FBF should
be used.
Nutrition Rehabilitation with FBF
Table 20: FBF Ration Size per Patient
Target Group Daily Quantity Ration for Two Weeks Ration for One Month
Children 6-59 months 200 g 3.0 kg 6.0 kg
PLW 250 g 3.75 kg 7.5 kg
STEP 1: Health, nutrition, and hygiene education

Explain the following key messages on FBF to the caregiver or patient:
• The ration is for the patient with MAM. Do not share with the rest of the family.
• Do not give FBF to infants 0-6 months. They should be exclusively breastfed.
• If the child is 6-23 months, continue to breastfeed on demand. Mother’s milk is best for infants
and young children.
• FBF should be consumed in addition to, and not as a substitute for, the household diet and
breastfeeding.
• Ensure that the FBF porridge is consumed within 30 minutes of cooking, this will avoid
contamination.
• Once the FBF has been prepared, the remainder should be store in a closed bag in a cool, dry
and hygienic place, away from insects or rodents.

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STEP 2: Demonstrate how to prepare the FBF porridge

• Demonstrate to the caregivers or patient how to prepare FBF at home.
• Wash hands thoroughly using water and soap.
Figure 18: Preparation of FBF porridge

• Also wash the utensils with soap and water
• If the water to be used for preparation is not clean safe drinking water, it should be boiled for 15-
20 minutes before adding the FBF
• Open the FBF bag carefully
• Mix 1 part (e.g., cup) of the FBF with 4
parts (e.g., cups) of water.
• Prepare to a thick porridge (not too thick
or too thin).
• Cook mixture over low heat for 5-10
minutes stirring constantly
• Serve warm and consume within 30 minutes.
• Tightly close the bag of remaining FBF.
Good Poor thickness

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STEP 3: Distribute the FBF.

• Distribute the ration of FBF to the care giver or patient
Ready –to-Use Supplementary Food (RUSF)

• RUSF is a ready-to-use food that does not require be preparing, cooking, or mixing with water
prior to consumption.
Table 21: RUSF Ration Size per Patient

Food Item Daily Quantity For Two Weeks For One Month
RUSF 1 Sachet 15 Sachets 30 Sachets
Explain the following to the caregiver or patient:
• Gently mix by pressing the sachet for 30 seconds.
• Make a small opening in the corner of the sachet. The patient can eat directly from the sachet.
• Drink clean safe drinking water while eating the RUSF to keep hydrated.
• If the child is breastfeeding, continue to offer breast milk on demand.
• RUSF is complementary to the normal meals not a replacement, therefore should be consumed
between normal meals, continue consuming other nutritious foods during the treatment.
• RUSF is ready to be used, therefore should not be mixed with other foods.
• If the patient has diarrhoea, do not stop feeding. Continue to breastfeed and give extra food
and clean water.
• Once opened, store the RUSF sachet in a clean, cool and dry place.
9.5 Monitoring During TSFP Follow-Up Visits

Monitor the following parameters and record information on the TSFP Treatment and Follow-up Card at
each follow-up visits.
• MUAC
• Weight
• Presence of bilateral pitting oedema
• Weight gain (patients who lose weight, do not gain weight, or have weight fluctuations
should receive special attention during home visits)
• Inform the caregiver or patient on the progress of treatment.
• Conduct individual and/or group counselling on health, WASH, and IYCF.
• Indicate any necessary follow-up actions on the TSFP Treatment and Follow-up Card, such as:
• Home visits for patients requiring special attention
• Transfer to OTP for patient whose nutritional status deteriorates to SAM
• Prioritize patients for a home visit if the patient:
• Is losing or not gaining weight
• Is absent or defaulted treatment (defaulters are patients absent for 2 consecutive visits).
Failure to Respond to Treatment

HIV/AIDS or TB may be the underlying cause of acute malnutrition; it is recommended that patients who
are failing to respond to MAM treatment are offered HIV counselling and testing, and TB testing. Other
reasons for failure to respond to treatment may include:
• Problems with the application of the protocol
• Home and social circumstances of the individual
• Excessive sharing of the TSFP ration
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Steps to take if a patient with MAM is failing to respond to treatment
1. Review the patient’s TSFP Treatment and Follow-up Card to confirm that the TSFP protocols are
adhered to correctly. Ensure that the details on the card are correct.
2. Conduct a full medical examination and nutrition assessment. If the MAM patient presents with any
signs of medical complications or nutrition deficiencies, conduct investigate /provide treatment if
necessary refer for further investigation.
3. Conduct a home visit to assess the patient’s home and social situation. Assess if the patient is taking
the treatment correctly, if the treatment is acceptable and tolerated, or if it is being shared with
other members of the household for home visit checklist.

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S-9 SFP
9.6 Discharge Criteria and Exit Categories

Note: The same anthropometric indicator that is used to identify and confirm AM on admission should be
used to determine recovery and discharge from treatment
Table 22: TSFP Discharge Criteria
Children 6–59 Months Old Pregnant Women and Lactating Women (up
to 6 Months Postpartum)
If admitted based on MUAC, discharge MUAC ≥ 23.0 cm for two consecutive visits
cured when: MUAC ≥ 12.5 cm for two
consecutive visits AND Clinically well and
alert. OR
If admitted based on WFH/WFL discharge

cured when: WFH/WFL ≥ -2 z-score for two
consecutive visits AND Clinically well and Lactating mother whose infants reaches 6
alert. months of age.
Table 23. TSFP Exit Categories

Category Definition
Cured Has reached the discharge criteria for MAM treatment.
Died Dies while receiving treatment in TSFP.
Defaulted Absent for two consecutive visits. Default should be confirmed.
Does not reach the MAM discharge criteria after 16 weeks (4 months) in
Non-responder
treatment.
Condition has deteriorated to SAM and referred for OTP or moved out to
Transferred-out
receive TSFP in another facility.
Pregnant woman who has delivered or a lactating woman whose infant is 6
Other
months and above.
TSFP discharge procedure

• Give feedback to the caregiver or patient on the final treatment outcome.
• Give the final 2-week supply of the specialised nutritious food (FBF or RUSF).
• Record the exit category
• Counsel on WASH, good nutrition, and IYCF practices.
• Advise the caregiver or patient to immediately go to the nearest health facility if they experience
any signs of deterioration.
• Refer the caregiver to PSNP and other complementary health and nutrition services.

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S-9 SFP
EXERCISE A
Case management and/or referral decision exercise
• Q1. Fatima is 18 months old girl, was admitted to an SFP with a mid-upper arm circumference
(MUAC) of 11.7cm, weight of 10 kg and no medical complications. At the third visit/weighing,
she developed bilateral pitting oedema on the feet (bilateral oedema +). What action is needed?
• Q2. Biniyam is 36 months old, he has fever and has lost appetite. He has come to the Health
post to get treatment. The HEW measured his MUAC and it is 11cm. His temperature is 390c.
What action is needed?
• Q3. Shemsu is 8 months old, was admitted to the TSFP with a MUAC of 11.6 cm. After four
weeks, the child has lost weight and MUAC is now 11.4 cm. What action is needed?
• Q4. Samuel is 7 months old came to the Health post for Vitamin.A supplementation and he is
breast feeding and has started complementary feeding at 6 months. He looks well and weighs
6.5 kg and his MUAC is 12.7cm with no oedema. What is the nutritional status of Samuel and
what action is needed?
• Q5. Getu was admitted to OTP 2 months ago with oedema ++ and MUAC of 12.0 cm. Starting
from his 3rd visit, he has lost the oedema. Now, his MUAC is measured 12.4 cm. What action is
needed now?
When you have completed this exercise, please tell to the facilitator for group discussion.

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S-9 SFP
9.7 Organization of OTP and TSFP services

Setting up OTP& TSFP
OTP and TSFP care facilities can be set up at health facilities part of the routine health services.
Each health facility may have different options for when to see new admissions and when to appoint
follow up cases. Some may offer the service every day and others may need to fix certain days a week as
an OTP day (e.g. Wednesday & Friday) and every two weeks for MAM. This is up to the health facilities
to manage as they wish and may depend on the number of admissions, but it is advisable to accept
admissions on any day as part of under-five child services; the cares should be asked to come back for
follow-up on the ‘fixed’ OTP- or TSFP day.
Resources
Human resource
A trained health worker or HEW can manage the OTP & TSFP program. They need to be able to identify
danger signs and decide when and whether referral for inpatient care is necessary. They should be
able to identify loss of appetite and assess progress of children (weight gain, oedema and MUAC), fill in
registration books and patient’s cards and manage stores and supplies of food and drugs.
Equipment and supplies

MUAC tape (both child and adult), weighing scales, length/height board (if applicable only) medicines
(as per protocols), ready-to-use therapeutic food (RUTF), RUSF/FBF, OTP & TSFP treatment cards, quick
reference tally sheets, reporting sheets, soap; stationery, thermometer, and Job Aids are needed, in
addition to the normal requirements.
Supplies must be ordered through the health facility before they run out. Forward planning is vital;
especially pre planning in rainy season is advisable.
It is necessary to follow-up on the order. The supply chain is long, and the order may get stuck
somewhere. Document how much RUTF/FBF /RUSF and how many drugs are being used. Stocks should
be carefully managed to ensure fast turn over and avoid prolonged storage.

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S-9 SFP
Answers to short answer

Case 1.Fatma
• Normal
• Congratulate the mother and counsel her to continue feeding
Case 2.Emebet
• SAM (both wasting and oedema)
• Refer to SC
Case 3. Bekele
• MAM
• Admit him to TSFP and provide him with the needed service based on the protocol
Case 4. Shambel
• MAM
• Admit him to TSFP
Case 5. Helina (Pregnant mother)
• MAM (MUAC <23cm)
• Admit her to TSFP
Case 6.Marta (Postpartum mother)
• MAM (Her MUAC is <23cm)
• Admit her to TSFP
Case 7. Demberu
• SAM
• Admit him to OTP

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S-10 Supply
Chain
Management
SUPPLY CHAIN MANAGEMENT FOR AM TREATMENT

S-10 Supply Chain Management
Introduction
Provision of quality services in the management of acute malnutrition needs to establish a good supply
chain management system.
This session describes the essential supplies for acute malnutrition and their management. It also
highlights on the processes and procedures that need to be undertaken to ensure consistent availability
of SAM and MAM supplies at the facility level. Successful treatment of acute malnutrition requires an
uninterrupted supply of nutrition commodities; such as RUTF, FBF and RUSF and routine medicines,
anthropometry equipment, and print materials including protocols, quick references, patient follow
up cards, registration books and monthly reporting forms. Through good supply planning and timely
forecasting, we can avoid malnourished children missing treatment because of stock outs; and avoid
excess stocks to manage space.
Learning objectives:
By the end of the session participants will be able;
• Identify the essential supplies needed for AM management

• To estimate the needed commodity for AM treatment service
• Know proper handling and storing methods of AM treatment commodities and supplies

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10.1 Essential Supplies for Acute Malnutrition

Supply
An efficient and uninterrupted supply management should always be maintained. You can see lists the
essential supplies needed for the management of SAM and MAM annexed at the back of the manual.
Procurement
Procurement of the essential SAM and MAM supplies should follow national and international standards
and regulations.
Requesting Supplies
The quantity of supplies needed depend on the SAM or MAM caseload, the amount normally used in
each period (e.g., each quarter), frequency of requests, and the existing storage capacity.
10.2 Quantifying the Need

The first step in requesting supplies is to quantify the need. When quantifying needs at the health
facility, woreda, zonal or regional level, the service provider should do the following:
1) Identify the item or product needed.
2) Determine the number of SAM or MAM cases receiving treatment in the area. To do this, use the
routine programme data, or in the absence of routine programme data, use the most recent
prevalence of SAM or MAM in the area
3) Determine the average consumption of the item or product.
4) Decide the period for which supplies are needed (i.e, one month, three months, or one year).
This will be based on the storage space available, the distance and roads availability from the
collection point, and product expiry date.
5) Calculate the need using the caseload, average consumption, and period for which supplies are
needed. Add a 10% buffer stock to the need. Consider recent events such as influx of internally
displaced people that will increase the need and modify the buffer accordingly.
6) Finally, check the current stock levels for the balance. Subtract the stock balance from the esti-
mated need.

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How to Quantify Supplies Need

Estimating F-75 and F-100 therapeutic milk (Tins)
• All orders for therapeutic milk should be requested in tins.
• There are 24 tin in one carton. Each tin contains 400g of F-75 and F-100 therapeutic milk powder.
Example: Chiro Hospital has 10 children 6-59 months in SC at the end of Ginbot 30 /2010. The health
facility will estimate the amount of F-75 needed for the next three months as follows:
• F-75 required for 1 child with SAM per cure = 3.075 (No of tin)
• F-75 required for 10 children = 30.75 (No of tin)
• Add 10% buffer stock = 33.825 (30.75+3.075)
Convert to cartons = 1.4 carton (33.825/24)
Item Packages Weight(gm) No of Total Ration per If Total # of For total
Description Tin per Weight beneficiary beneficiary beneficiary
beneficiary per per cure in Cartons
per cure cure Cartons
F-100 Tin 400 3.42 1368 0.14 10 1.425
F-75 Tin 400 3.075 1230 0.13 10 1.281
Estimating RUTF Needs

• Estimate on average children 6-59 months will consume about 2 ½ sachets of RUTF a day. Each
carton of RUTF contains 150 sachets of RUTF.
Example: Facility X has 20 children 6-59 months in OTP at the end of Miazia 30 /2011. The health facility
will estimate the amount of RUTF needed for the next three months as follows:
• RUTF required for 1 child with SAM for 1 months = 75 sachets (2.5 *30 days)
• RUTF required for 20 children for 3 months = 4500 sachets (75*20 children*3)
• Add 10% buffer stock = 4,950 (4500+450)
• Convert to cartons = 33 cartons (4,950/150)
Total amount to order for 3 months = 33 cartons of RUTF. Note: Always request full cartons of RUTF.

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Estimating RUSF Needs

• Children 6-59 months will consume 1 sachet of RUSF each day
• Each carton of RUSF contains 150 sachets of RUSF.
Example: Facility X had 100 beneficiaries receiving TSFP services at the end of Miazia 30/2011. The
health facility will estimate the amount of RUSF needed for the next three months as follows:
• RUSF required for 1 child with MAM for 1 month = 30 sachets
• RUSF required for 100 children for three months = 9,000 sachets (30*100 children*3)
• Add 10% buffer stock = 9,900 sachets (9000+900)
• Convert to cartons = 66 cartons (9,900/150)
Total amount to order for 3 months = 66 cartons of RUSF.
*Note: Always request full cartons of RUSF.
Estimating FBF Needs
Children 6-59 months will consume 6 kg of FBF each month.

Example: Facility X had 100 children receiving TSFP services at the end of Miazia 2011. The health
facility will estimate the amount of FBF needed for the next three months as follows:
• FBF required for 1 child with MAM for 1 month = 6 kg
• FBF required for 100 children for three months = 1,800 kg (6*100 beneficiaries*3)
• Add 10% buffer stock = 1,980 kg (1800+180)
• Convert kg into metric tonnes = 1.98 MT (1980/1000)
Total amount to order for 3 months = 1.98 MT of FBF
Pregnant or lactating women will consume 7.5 kg of FBF each month
Example: Facility X had 60 PLW receiving TSFP services at the end of Miazia 30/2011. The health facility
will estimate the amount of FBF needed for the next three months as follows:
• FBF required for 1 pregnant or lactating woman in 1 month = 7.5 kg
• FBF required for 60 PLW for three months = 1,350 kg (7.5*60beneficiaries*3)
• Add 10% buffer stock = 1,485 kg (1350+135)
• Convert kg into metric tonnes = 1.485 MT (1485/1000)

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Total amount to order for 3 months = 1.485 MT of FBF
*NOTE: in addition to specialized nutritious foods equipment and materials such as treatment cards, Multi-
charts, and registration books should always be quantified and included in the request for supplies.
Place a Request
Supplies should be requested at the end of the month, in emergency situations, a request may be
placed before the end of the month. To place a request for supplies, complete the “request for supplies”
columns in the Monthly Supplies Report for SAM and MAM. Annex…. Be sure to take note of the following:
1. Each item should be requested on its own row with a clear description of quantity needed, unit, and
period of request in months.
2. Request for complete packs or cartons. For example, if you need 1000 sachets of RUTF, 1 carton
contains 150 sachets, 1000/150 = 6.67 cartons, therefore, request 7 cartons.
Receiving Supplies
At least two people should receive and check the new deliveries before they are put in the storage
facility. The following should be checked:
• Delivery note, packing list, and contents against a copy of the requested items or products.
• Contents and quantity against the product list. Physically count to confirm.
• Outer and inner packaging for any signs of damage.
• Labels are legible and include complete information including the expiry date.
• Check the shelf life and expiry date. Do not accept products if the expiry date has passed.
• For equipment, check that all spare parts, accessories, instruction manuals, and warranty
documents are included.
• Note any inconsistencies and report immediately to the next level.
• If the correct amount and condition of supplies matches the delivery note, receive and sign.
Ensure that someone else verifies and signs a copy for record.
• File delivery documents together with the request documents.
• Store items and products immediately. Be sure to update the Bin Card and Stock Record Card with
the quantities received. Annex 17 and 18 respectively.

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10.3 Stock Management

Organising the Store
SAM and MAM supplies should be stored in a clean, dry and well-ventilated room to protect from
pests, rodents and spoilage. Ensure that therapeutic and supplementary food products are not stored
together with harmful chemicals.
The storage facility should meet the following conditions:
• The structure including the roof, ceiling, walls, and floor should be well maintained and lit.
• Secure and always locked
• Dry and at room temperature of 25-30°C
• Well ventilated with adequate space for storage
• Has shelves or wooden pallets at least 10 cm from the wall
• Not exposed to direct sunlight
• Items and products should be arranged by expiry date to make it easy to follow the “First-Expiry,
First-Out” (FEFO) principle.
• Expired, damaged, or items no longer in use should be separated while awaiting disposal and
must be immediately reported to the responsible person.
Monitoring Stock
The Bin Card and Stock Record Card should always be up-to-date with items or products received or
issued. The HEW or store keeper should do a physical stock count of all items and products at the end of
every month, before writing the monthly report.
Be alert of stock outs, as soon noted, a request should be placed immediately.
In case of excess stock, check the expiry date and report if the items or products need to be re-
distributed to another location.
Carry out an inventory of stock at least once a year.
Issuing Supplies
• Always record products or items issued from the store in the Bin Card and Stock Record Card.
• Record therapeutic or supplementary food commodities issued to beneficiaries in the treatment
card and ration card.

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Reporting Supplies
Report the essential SAM and MAM supplies at the end of every month using the Monthly Supplies
Report for SAM and MAM. To prepare the report:
• Confirm that each item or product is sorted by expiry date.
• Carryout a physical stock count.
• Verify the following data from the Bin Card and Stock Record Card; received, issued, and losses or
adjustments.
*Note: The stock balance at the end of the previous month should always equal the stock balance at the beginning of
the current month.
The reason for losses or adjustment should always be noted in the remark’s column of the Monthly Supplies
Report for SAM and MAM.

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Exercise A
RUTF/FBF/RUSF quantification exercises. For the following caseloads calculate the supply needed.
1) At the end of Ginbot 2011..Achura HP has 28 OTP beneficiaries (6-59 months). Estimate the
amount of RUTF needed for the next 03 months.(Given: On Average one child need 2 and ½
sachets per day, one cartoon of RUTF contains 150 sachets)
2) Bulbul HP has MAM service and at the end of Ginbot 2011 there are 20 children 6-59monts and
20 PLW. Estimate for FBF (CSB ++) amount needed for the next 03 months. (Given: -one child
need 6 kg of FBF per month and one PLW need 7.5kg of FBF, One bag of FBF (CSB++) = 1.5kg)
3) At the end of Sene 2011Guto HP has 40 MAM beneficiaries (6-59months old children) in the.
Estimate the amount of RUSF (plumpy-sup) needed for the next 03 months. (Given: One child
need on sachet of RUSF, and one cartoon contains 150 sachets).
4) At the end of Hamle 2011Arba Minch General hospital has 30 SAM children (6-59 months old).
Estimate the amount of F-100 therapeutic milk needed (Given: one cartoon contains 24 tins)?
Tell a facilitator when you have finished the exercise and check the answer at the back your
participant manual.

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ANSWERS TO SHORT ANSWER EXERCISE

Supply Chain Management system
1. 28x2.5x30x3=6,300 sachets = 6930 (6300+630)/150 = 46.2 cartoons of RUTF

2. 20x6x3=360kg= 396 kg (360+36) = 0.396 MT (for children)
20x7.5x3 =450kg = 495 (450+45) = 0.495 (for PLW)
3. 40x1x30x3=3,600 Sachets = 3,960 (3600+360)/150 = 26.4 cartons.
4. F-100 required for 1 child with SAM per cure = 3.42 (No of tin)
F-100 required for 30 children = 102.6 (No of tin)
Add 10% buffer stock = 112.86 (102.6+10.26)
Convert to cartons = 4.7 carton (112.86/24)

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SESSION 11
MONITORING AND REPORTING IN TFP AND TSFP
S-11 Monitoring and reporting TFP and SFP
Introduction
This session introduces participants to monitoring the performance of TFP and SFP. It also includes
discussions on recording and reporting systems of TFP and SFP services as an integral part of the service
delivery. Monitoring and reporting is an essential component of TFP without which the health facilities
cannot provide quality health services. Monitoring and reporting of TFP service allows for:
1) Monitoring the individual child progress and take immediate correction of the treatment, if
necessary and appropriate;
2) Properly track individual child when they are referred from in-patient to out-patient and vice versa;
3) monitoring the performance of the TFP and take the necessary action to maintain a high-quality
service;
4) Supervising and supporting the health care providers to maintain their skills and ensure quality TFP
service.
You have practiced recording of the child progress on the Multi Chart, OTP card and SFP card in the
previous sessions. This session introduces the participants to the TFP and SFP recording and reporting
systems including registration of children in the TFP and SFP registration book; preparation of the TFP
and SFP monthly statistic reports; and calculating and interpreting TFP and SFP performance indicators.
Learning Objectives
This session will describe Monitoring and reporting, highlighting owing knowledge and skills:
• Describe the Principles of a Monitoring System for TFP and SFP
• Describe individual client monitoring
• Complete TFP and SFP Tally Sheets and facility Report; Interpret the Findings
• Calculate and Discuss Program Performance
• Prepare a monthly TFP and SFP statistics Report

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11.1 MONITORING
Routine monitoring can be done through the reporting of key indicators monthly to identify factors that
can be improved.
Standardized key indicators (quantitative data) collected through monthly statistical reporting,
triangulated with qualitative information collected in consultation with the community and
stakeholders and through supervisory visits, will identify strengths and weaknesses, and provide a basis
for informed decision-making for timely quality improvement. The key indicators should be plotted
against time (months) to provide a picture of how the performance of the services and the situation
have evolved.
Periodicity of monitoring of the activities
Routine monitoring of a programme is usually done monthly through data on admissions and weekly
follow-up on the progress of the children. However, during emergencies and when resources allow,
weekly monitoring of community-based management of acute malnutrition activities may be carried
out.
Reporting is based on calendar months. Therefore, 1 month will usually cover 4 weeks. This must be
taken into consideration when interpreting changes in trends (follow epidemiological weeks as per
national standards).
Monitoring and Recording in the individual follow-up cards
Inpatient multi-chart
You need to fill all the information for the individual child on the In-patient therapeutic treatment multi-
chart if a child is admitted for in-patient care. You have learned how to fill the Multi-chart in session 2
and as you progress through the previous in-patient sessions.
OTP card
The OTP card should be filled for each patient. It is the primary tool for monitoring individual child
progress and management in the OTP. You have learned how to fill the OTP card in session 8 and as you
progress through the previous sessions
TSFP card
The TSFP card is the primary tool for monitoring individual child progress and management in the TSFP
program.

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11.2 Recording in TFP and TSFP Registration book

All the information regarding the children under the program needs to be compiled in the TFP and TSFP
registration books (see next page for a sample of the TFP and TSFP Registration books). This will help
you to prepare the monthly TFP and TSFP statistics report in section xx below.
The information needed includes:
• Identification information, e.g. names, address
• Anthropometric information, e.g. MUAC, height, weight
• All admissions by category (new admission, readmission)
• Outcome or exits (discharge) by category (cured, died, defaulted, and non-responder), transfer
out and transfer in to/from OTP or Inpatient and medical transfer, are registered daily on the TFP
and TSFP registration book.
11.3 Prepare Monthly OTP and TSFP Statistic Reports
The admissions and discharge/exit outcomes from the registration book are summarized monthly using
the monthly TFP and TSFP reporting format. This will help to calculate performance indicators for TFP
and TSFP services.
It should be disaggregated by gender. Review of the monthly report is recommended to assess and
improve the performance of your facility. After utilizing the data, report to the next level (catchment
health center, district, Zone or Regional Health bureau).
The facilitator will demonstrate how to fill the TFP and TSFP registration books and monthly reporting
format

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Description of the Admission and Discharge boxes of in the Monthly Statistics Report
IN-PATEINT/SC ADMISSIONS
New admission: New case who meets the admission criteria for SC
• MUAC or W/H or W/L- (B)
• Bilateral Pitting Oedema- (C)
Readmission: Re-admitted for treatment in SC due to relapse or a returned defaulter who meets the
admission criteria.
• Relapse (D): Cured within the past 3 months and now meets the admission criteria for SC
• Returned defaulters (E): Defaulted within the past 3 weeks and has returned to continue
treatment in SC. A returned defaulter should be re-admitted if they meet the admission criteria
Total Admissions (F) = B+C+D+E
Transfers-in from OTP, SC or another facility (G): Referred to the SC because condition deteriorated
in OTP or has moved in from another facility where s/he was receiving care in SC
Entry (H)= F +G
SC DISCHARGES
Cured (I): Has reached the discharge criteria for SAM treatment, i.e., the special cases that were not
referred to OTP
Died (J): Dies while receiving treatment in the SC
Defaulted (K): Absent for two consecutive days. Default should be confirmed.
Non-responder (L): Patient who remained in treatment in the SC does not reach the SAM discharge
criteria after 16 weeks (4 months) in treatment.
Stabilized (M): Condition has stabilized and referred to continue treatment in OTP.
Total discharged (N)= I +J +K+L
Transferred-out (O): Moved to another facility for further medical care or moved out to receive care in
another SC
Total exits (P) = N +O+M

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OTP ADMISSIONS
New admissions: Patients that are directly admitted to OTP to start the nutritional treatment are new
admissions. They are recorded into 2 different columns:
• MUAC or W/H or W/L- (B)
• Bilateral Pitting Oedema- (C)
Re-admission: Re-admitted for treatment in OTP due to relapse or a returned defaulter who meets the
admission criteria.
• Relapses(D) – Cured within the past 3 months and now meets the admission criteria for OTP.
Relapse cases require special attention therefore conduct home visit.
•
• Returned Defaulters(E)–Defaulted within the past 3 months and has returned to continue
treatment in OTP. A returned defaulter should be re-admitted if they meet the admission criteria.
Total Admissions(F)=B+C+D+E
Transfer In (G) - Continuing treatment in OTP after stabilisation in SC or has moved in from another
facility where s/he was receiving OTP.
Total Entry(H)=Total Admissions (F)+Transfer In (G)
OTP DISCHARGE
Cured (I) - Has reached the discharge criteria for SAM treatment.
Died (J)- Dies while receiving treatment in the OTP.
Defaulter (K)- Absent for two consecutive visits. Default should be confirmed (I).
Non-responder (L)-Does not reach the SAM discharge criteria after 16 weeks (4 months) in treatment.
Transfer Out (O) - Condition has deteriorated or not responding to treatment according to action
protocol and referred for treatment in the SC or moved out to receive OTP in another facility.
Total Discharge (N) =Cured (I) +Died (J) + Defaulter (K) + Non-Responder (L).
7
Total Exit (P) =Total Discharge (N)+Transfer out (O). *
TOTAL END OF THE MONTH (Q) = Total beginning of the month (A) + Total admissions (F) + Transfer In
(G) - Total discharges (N) + Transfer Out (O) OR
TOTAL END OF THE MONTH (Q) = Total beginning of the month (A) + Total Entry (H) -Total Exit (P).
7 Column M (Stabilized to OTP): used only during Inpatient (SC) report.

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Description of Admission and Discharge boxes in the monthly statistics Report

TSFP ADMISSIONS
New Admission - New case who meets the admission criteria for TSFP (B) i.e. MUAC or W/H or W/L (B)
Readmission- Re-admitted for treatment in TSFP due to relapse or a returned defaulter who meets the
admission criteria. Relapses and Retuned defaulter cases are considered as readmissions.
• Relapses (D) – Cured within the past 3 months and now meets the admission criteria for TSFP.
• Returned Defaulters (E) – Defaulted within the past 3 months and has returned to continue
treatment in TSFP. A returned defaulter should be re-admitted if they meet the admission
criteria.
Total admissions: B + D + E
Transfer In (G): - Has moved in from another facility where s/he was receiving TSFP.
Entry (H) = F + G
TSFP DISCHARGE
1. Cured (H) - Has reached the discharge criteria for MAM treatment.
2. Died (I) - Dies while receiving treatment in the TSFP.
3. Defaulter (J) - Absent for two consecutive visits. Default should be confirmed.
4. Non-responder (K) - Does not reach the MAM discharge criteria after 16 weeks (4 months) in
treatment.
5.Others, pregnant and delivered or lactating with infants >6months (L).
Transfer Out (N)- Condition has deteriorated to SAM and referred for OTP or moved out to receive TSFP
in another facility.
Total Discharged (M) = Cured (H) +Died (I) + Defaulter (J) + Non-Responder (K) + Others (L).
Total Exit (O) = Total Discharge (M) +Transfer Out (N)
TOTAL END OF THE MONTH (P): = Total beginning of the month (A) + Total admissions (E) +TI(F) -
Total discharges (M) + Transfer Out (N)
OROTAL END OF THE MONTH (P) = Total beginning of the month (A) + Total Entry (G) -Total Exit (O)

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Table 24: Summary of Entry and Exit Categories
SC for the Management of SAM OTP for the Management TSFP for the Management of
with Medical Complications of SAM without Medical MAM
Complications
ENTRY CATEGORIES
New admission: New case who New admission: New case New admission: New case
meets the admission criteria for SC who meets the admission who meets the admission
criteria for OTP criteria for TSFP.
Readmission: Re-admitted for Readmission: Re-admitted Readmission: Re-admitted

treatment in SC due to relapse or a for treatment in OTP due to for treatment in TSFP due to
returned defaulter who meets the relapse or a returned defaulter relapse or a returned defaulter
admission criteria who meets the admission who meets the admission
criteria. criteria.
Relapse: Cured within the past Relapse: Cured within the Relapse: Cured within the
3 months and now meets the past 3 months and now meets past 3 months and now meets
admission criteria for SC the admission criteria for OTP. the admission criteria for TSFP
Relapse cases require special
attention.
Returned defaulter: Defaulted Returned defaulter: Returned defaulter:

within the past 3 weeks and has Defaulted within the past 3 Defaulted within the past 3
returned to continue treatment months and has returned to months and has returned to
in SC. A returned defaulter should continue treatment in OTP. A continue treatment in TSFP. A
be re-admitted if they meet the returned defaulter should be returned defaulter should be
admission criteria. re-admitted if they meet the re-admitted if they meet the
admission criteria admission criteria.
Transfers in: Referred to the SC Transfers in: Continuing Transfers in: Has moved in
because condition deteriorated in treatment in OTP after from another facility where s/
OTP or has moved in from another stabilisation in SC or has he was receiving TSFP.
facility where s/he was receiving moved in from another facility
care in SC where s/he was receiving OTP

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11.4 Monitor Performance of Therapeutic Feeding Program (TFP)

Quantitative data are collected on the outcome of all activities of TFP including in-patient care, and
standard indicators mentioned below are calculated. This enables the quality and effectiveness of TFP in
this case in-patient care to be monitored. They should be calculated for infants less than 6 months, and
children 6 months to 5 years of age separately.
Calculate Performance Indicators

Each TFP should calculate the following performance indicators separately for in-patient and out
patient. Refer the monthly statistics report chart. If a health center has both in-patient treatment
(Stabilization Center) and out-patient treatment (OTP), the monthly performance of each should
be calculated separately, and sent to the next level separately. This is because the interpretation of
some of the performance indicators significantly differs for OTP and in-patient. For example, deaths
in OTP are much less acceptable even if very few as the outpatient team should pick up deterioration
through weekly follow up and home visit and admit any severely malnourished child who presents with
complications or develops complications while on OTP follow up. In addition, while OTP is under the
out-patient department, Stabilization Center is in the in-patient department in many health facilities.
The performance of these two teams should be assessed separately to allow appropriate feedback for
continuously increasing performance.
The performance indicators include: Cured, defaulter, died and non-response

Cured: Proportion who are discharged from SAM or MAM treatment having reached the cure discharge
criteria.
Cured = Total cured (I) X 100
Totals discharged (Cured + Died + defaulters + None-responders) (N)
Died: proportion that have died while in the programme (TFP or TSFP) among those discharged. This is
calculated monthly. This will allow improvements to be seen rapidly.
To calculate:
• Determine the number of those children who died in the past month (J).
• Determine the total number of children discharged from the program in the past month (N)
• Divide the number of deaths by the number of children who were discharged from the
programme (TFP or TSFP) and express the result as a percentage. ((J/N) *100)
Died = Total died (J) X 100

Totals discharged (Cured + Died + defaulters + None-responders) (N)
*Note: Any death in OTP is alarming and should be thoroughly audited
For in-patient treatment, a death rate of:

>15% is Alarming
10-15 % is poor
<10% is acceptable

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Defaulted: Proportion discharged having defaulted

Defaulted = Total defaulters X 100
Totals discharged (Cured + Died + defaulters + None-responders)
Non-responder rate: Proportion discharged having not achieved the cure discharge criteria.
Non- response = Total non-response X 100
Total discharged (cured+ died+ defaulters+ non-response)
Other Service Indicators
Average length of stay (LOS): The number of days that a patient spends in treatment from admission
to discharge. LOS is only calculated for patients cured.
Average Weight Gain (AWG): The rate of weight gain per kilogram of body weight per day. AWG is
only calculated for patients discharged cured.
*Note: When calculating the LOS and weight gain, separate the OTP cards in two group: those who had bilateral pitting
oedema, and those with wasting (MUAC + WFH).

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11.5 SHPERE standards Outcome Indicators

The table below provides the international reference standards for MAM and SAM outcome indicators.
Table 25: Sphere standards indicators

Indicator TFP SFP
Acceptable Acceptable
Cured > 75% > 75%
Died < 10% < 3%
Defaulted < 15% Not stated
Mean Weight gain >= 5 g/kg/day
*
Not applicable
Mean Length of stay Approximately 60 days Approximately 90 days
* A weight gain of 5g/kg/day is a suggested guideline (WHO 2005) for community-based programmes. Weight
gains may vary for patients with wasting and bilateral pitting

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2019
Instructions on How to Complete the Registration Book for SAM.

The registration book for SAM is used in SC and OTP. The data is aggregated at the end of each
month and used to prepare the Monthly Statistics Report for SAM and MAM.
Information on the Front Cover of the Registration Book

Region: Write the Region name of where the health facility is
located.
Zone: Write the Zone name of where the health facility is
located.
Woreda: Write the Woreda name of where the health facility is
located.
Kebele: Write the Kebele name of where the health facility is
located.
Health Facility: Write the name of the health facility where the service is
provided.
Register Start Date: Write the date of the first entry in the register, written as
(EC) Day/Month/Year (DD/MM/YY).
Register End Date: Write the date of the last entry in the register, written as
(EC) Day/Month/Year (DD/MM/YY).
Background Information
1. Registration Number Write sequential registration numbers. The registration
number is issued when the patient is admitted, it includes
a service code indicating where treatment was initiated
(SC or OTP). For Example: 001/OTP for the first patient
admitted in OTP, or, 003/SC for the third patient admitted
in SC.
2. MRN Write the patient’s Medical Record Number (MRN).
3. Full Name Write the full name of the patient.

4. Address Write the Gott or Village where the patient resides.
5. Sex Write F for female or M for male.
6. Age Write the age of the child in months.
7. New Admission Write Y if a new admission and N if not. [A new admission
is a new case who meets the admission criteria for OTP or SC].
8. Relapse Write Y if a relapse and N if not. [Relapse is a patient
who cured within the past 3 months and now meets the
admission criteria for OTP or SC].
9. Retured Defaulter Write Y if a returned defaulter and N if not. [In OTP, patient
who defulted within the past 3 months and has returned
to continue treatment in OTP. In SC, patient who defaulted
within the past 3 weeks and has returned to continue
treatment in SC].
10. Transfer-in Write Y if transfer-in and N if not. [In OTP, a transfer in is a
patient continuing treatment in OTP after stabilisation in
SC, or, has moved in from another facility where they were
receiving OTP. In SC, is a patient referred to the SC because
condition deteriorated in OTP or, has moved in from another
facility where they were receiving SC].
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2019
Admission/Entry Information
11. Admission Date Write the date of admission to service, written as (EC) Day/
Month/Year (DD/MM/YY).
12. Bilateral Pitting Odema Write the grade of bilateral pitting oedema as follows:
0 = No bilateral pitting oedema
+ = Mild: Both feet/ankles
++ = Moderate: Both feet,

plus lower legs, hands and lower arms
+++ =
Severe: Generalized bilateral pitting oedema, including
both feet, legs, arms, and face
13. MUAC Write the MUAC measurement value in cm.
14. Weight Write the weight measurement value in kg.
15. Height Write the height measurement value in cm.
16. WFH/ WFL Write the WFH/WFL value in z-score.
17. Recent weight loss or failure to gain weight Write Y if the infant 0-6 months had recent weight loss or
(Infants 0-6 months). failure to gain weight on admission and N if not.
18. Severe Wasting with Bilateral Pitting Oedema Write Y if the patient has severe wasting with any grade of
bilateral pitting oedema and N if not.
Discharge/Exit Information
19. Discharge Date Write the date of discharge from service, written as (EC)
Day/Month/Year (DD/MM/YY).
20. Bilateral Pitting Odema Write the grade of bilateral pitting oedmea as follows:
0 = No bilateral pitting oedema
+ = Mild: Both feet/ankles
++ = Moderate: Both feet,

plus lower legs, hands and lower arms
+++ =
Severe: Generalised bilateral pitting oedema, including
both feet, legs, arms, and face
21. MUAC Write the MUAC measurement value in cm.
22. Weight Write the weight measurement value in kg.
23. Height Write the height measurement value in cm.
24. WFH/ WFL Write the WFH/WFL value in z-score.
25. Adequate weight gain (Infants 0-6 months). Write Y if the infant 0-6 months had adequate weight gain
on discharge and N if not.

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26. Outcome Write the code for the treatment outcome:
C = Cured: Has reached the discharge criteria for SAM

treatment.
D = Died: Dies while receiving treatment in the OTP or SC.
DF = Defaulted: Absent for two consecutive visits in
OTP and two consecutive days in SC. Default should be
confirmed.
NR = Non-responder: Does not reach the SAM discharge
criteria after 16 weeks (4 months) in treatment - OTP or SC.
S = Stabilised: Condition has stabilised and referred to
continue treatment in OTP.
T = Transfer out: Condition has deteriorated or not
responding to treatment and referred for treatment in the
SC, or, moved out to receive treatment in another OTP or
SC.
27. Remark Write any notes the service provider wants to
document.

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Registration Book for the Management of SAM - SC and OTP
Admission/Entry Information Discharge/Exit Inormation
10. Transfer- 17. Recent 25.
2. Medical 9. 18. Severe 20. 26. Outcome
1. 7. New in from weight loss Adequate
Record 5. Sex 6. Age 8. Relapse Returned 11. 12. Bilateral wasting with 19. Bilateral
Registration 3. Full Name 4. Address (Village/Gott) Admission other faility, or failure to weight (Cured, Died, 27. Remarks
Number (F/M) (months) (Y/N) Defaulter Admission Pitting 13. MUAC 14. Weight 15. Height 16. bilateral Discharge Pitting 21. MUAC 22. Weight 23. Height 24.
Number. (Y/N) SC or OTP gain weight gain. Defaulted, Non-
(MRN) (Y/N) Date Odema (N, (cm) (kg) (cm) WFH/WFL pitting Date Odema (cm) (kg) (cm) WFH/WFL
(Y/N) (Infants 0-6 (Infants 0-6 responder, Stabilised,
(DD/MM/YY) +, ++, +++) oedema (DD/MM/YY) (N, +, ++,
months). months) Transfer-out)
(Y/N) +++)
(Y/N) (Y/N)
PARTICIPANT MODULE
Count of Number of Children. Count of Admissions by Criteria. Count of Discharge Outcomes.
Bilateral pitting Odema MUAC or WFH/WFL Cured
Died
Defaulted
Non-responder
Stabilised
Transfer-out
333
2019
Exercise A
Calculate the performance indicators for the In-patient care or OTP. State whether the rate is
unacceptable, poor, or acceptable.
1. The TFU at Hawasa Hospital is small. Over the past 1 month, there have been 30 admissions and 20
exits. Five of these children died. What is the died?
2. Look at the Hamle TFP monthly report of Jimma Hospital that was extracted from the TFP registra-
tion book on the next page. Calculate the performance indicators. What do you think the perfor-
mance of Jimma Hospital inpatient care?
3. Review the Debarek Health Center OTP Monthly Reporting format on page 338. Calculate the Death,
cure, and defaulter rates for Debarek HC. What problem did you identify? What are the possible
causes and solutions?
4. Look at the Nehassie OTP monthly report of Addis Ketema Health center on page 340 that was
extracted from the TFP registration book. Calculate the performance indicators: Death, cure, and
defaulter rates. What do you think the performance of Addis Ketema HC OTP care? What are the
possible causes and solutions?
When you have finished this exercise, please discuss your answers with a facilitator

PARTICIPANT MODULE
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2019
EXERCISE B
Calculate the performance indicators for the OTP care described below. State whether the rate is
unacceptable, poor, or acceptable.
1. At the end of the month Bulbul HP had 12 OTP beneficiaries. Review the information provided in the
TFP registration book provided on the next page
a) Prepare the monthly OTP report.
b) What do you think is the performance of the OTP?
c) Calculate the Death, cure, and defaulter rates for Bulbul HP
d) What problem did you identify? What are the possible causes and solutions?
2. At the end of the month Achura HP had 41 beneficiaries (6 PLW & and 35 children under five). Review
the TSFP registration book and use the information to answer questions 2
a) Prepare the monthly TSFP report.
b) b. Calculate the cure, defaulter rate and death rate for Achura HP.
When you have finished this exercise, please discuss your answers with a facitator

PARTICIPANT MODULE
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2019
338
2019
Monthly
Monthly statistics
statistics report
report for
for SAM
SAM
Region: Amhara
Zone: South Gonder Debark HC
Name of Facility:_______________________________
Woreda: Debark : Sr. Hiwot
Report Prepard by:______________________________
Type of facility: Health center Month/Year
Month/Yearof Reporting:
ofReporting: Hamle 2010
SEVERE ACUTE MALNUTRITION (SAM) Opening Date: 07/05/98
New Admissions Re-admissions Discharged

Discharged
Total at the Bilateral Total Transfer-in Total at the
beginning MUAC or pitting Returned admissions from OTP, SC or Total Transfer-out to end of the
of the WFH/WFL Oedema Relapse defaulters [(F)= other facilty Entry [(H)= Stabilized to discharged to SC or other Exit month
Service Age month (A) (B) (C) (D) (E) B+C+D+E)] (G) F+G)] Cured (I) Died (J) Defaulter (K) Non-responder (L) OTP (M) [(N)=I+J+K+L] facility (O) [(P)= N+O+M)] [(Q)=A+H-P)]
6-59 months
Outpatient theraputic
program (OTP)
Total
< 6 months
6-59 months 35 30 4 0 1 35 4 39 30 3 6 9 0 48 0 48
Stabilization center (SC)
Total
% % % %
Target (Sphere standards) >75% <10% <15%
PARTICIPANT MODULE
Monthly
Monthly statistics
statistics report
report for
for SAM
SAM
Region: Oromia
Zone: Jimma JU hospital
Name of Facility:_______________________________
PARTICIPANT MODULE
Woreda: Jimma City Administration : Sr. Blen
Type of facility: Referral hospital Month/Year
Month/Yearof Reporting:
ofReporting: Hamle 2010
Opening Date: 07/05/96
SEVERE ACUTE MALNUTRITION (SAM)
Discharged
Service Age month (A) (B) (C) (D) (E) B+C+D+E)] (G) F+G)] Cured (I) Died (J) Defaulter (K) Non-responder (L) OTP (M) [(N)=I+J+K+L] facility (O) [(P)= N+O+M] [(Q)=A+H-P)]
6-59 months

program (OTP) Total
< 6 months
6-59 months 18 15 4 1 0 10 5 2 2 1 5 0
Total
% % % %
339
2019
340
2019
Monthly statistics report for SAM
Region: Addis Ababa
Zone: Addis Ketma HC
Name of Facility:_______________________________
Woreda: Kolfe Kifle Ketma : Sr. Halima
Type of facility: Health center Month/Year of Reporting: Nehase 2011
Opening Date: 07/05/01
Service Age month (A) (B) (C) (D) (E) B+C+D+E)] (G) F+G)] Cured (I) Died (J) Defaulter (K) Non-responder (L) OTP (M) [(N)=I+J+K+L] facility (O) [(P)= N+O+M] [(Q)=A+H-P)]
6-59 months 140 110 10 0 7 127 7 134 60 15 18 4 97 5 102

program (OTP) Total
< 6 months
6-59 months
Total
% % % %
PARTICIPANT MODULE
Monthly
Monthlystatistics
statisticsreport
reportfor
forSAM
SAM
Region:
Zone:
Name of Facility:_______________________________
PARTICIPANT MODULE
Woreda: Report Prepard by:______________________________
Type of facility: Month/Year of Reporting:

Discharged
beginning MUAC or pitting Returned admissions from OTP, SC Total Transfer-out to end of the
of the WFH/WFL Oedema Relapse defaulters [(F)= or other facilty Entry Stabilized discharged to SC or other Exit month
Service Age month (A) (B) (C) (D) (E) B+C+D+E)] (G) [(H)= F+G)] Cured (I) Died (J) Defaulter (K) Non-responder (L) to OTP (M) [(N)=I+J+K+L] facility (O) [(P)= N+O+M)][(Q)=A+H-P)]
6-59 months 5

program (OTP) Total
< 6 months
6-59 months
Total
% % % %
341
2019
342
2019
10.Registration Book for the Management of SAM - SC and OTP 24.
2. Trans Admission/Entry Information Discharge/Exit Inormation Outco
9. 17.
Medic fer-in
10. me
24.
1. 4. 7. Retu 12. Severe 19.
al
2. 8. from
Trans WFA 18. WFA Cured,
(Outco
Regist Addres 6. Age New rned
9. 11. Bilatera 15. 16. wasting
17. Bilatera 22. 25.
Recor
Medic 3. Full 5. Sex Relap other
fer-in 13. 14. (Infan Discharge 20. 21. 23. (Infan Died,
me
ration
1. s
4. (month Admis
7. Defa
Retu Pitting
Admission l12. Heig WFH with
Severe Pitting
l19. Heig R emar
d
al Name (F/M) se
8. failit
from MUAC Weight ts
WFA0-6 Date
18. MUAC Weight WFH/ ts
WFA0-6 Default
(Cured,
Numb
Regist (Village
Addres 6. s)
Age sion
New ulter
rned Date
11. Odema
Bilatera ht
15. /WF
16. bilatera
wasting Odema
Bilatera ht
22. ks
25.
Numb
Recor 3. Full 5. Sex (Y/N)
Relap y, SC
other (cm)
13. (kg)
14. mont
(Infan (DD/MM/Y
Discharge (cm)
20. (kg)
21. WFL
23. mont
(Infan ed,
Died,
er.
ration /Gott)
s (month (Y/N)
Admis (Y/N
Defa (DD/MM/YY) (N, +,
l Pitting (cm)
Heig LWFH l pitting
with (N, +,
l Pitting (cm)
Heig R emar
er
d Name (F/M) se or Admission
failit MUAC Weight hs)
ts 0-6 Y) MUAC Weight WFH/ hs)
ts 0-6 Non-
Default
Numb (Village s) sion )
ulter Date ++, +++)
Odema ht /WF oedem Date
bilatera ++, +++)
Odema ht ks
(MRN)
Numb (Y/N) OTP
y, SC (cm) (kg) mont (DD/MM/Y (cm) (kg) WFL mont respon
ed,
er. /Gott) (Y/N) (Y/N (DD/MM/YY) (N, +, (cm) L (Y/N)
lapitting (N, +, (cm)
er or
(Y/N) hs) Y) hs) der,
Non-
) ++, +++) oedem ++, +++)
(MRN) OTP Stabilis
respon
1 1114 Abebe Wonsho M 9 Y 11 4.5 Na (Y/N) 19/02/2010 N 12.6 6.8 Cured
(Y/N) 01/10/2010 N der,
Stabilis
21 1118
1114 Abera
Abebe Wonsho M 9 Y 19/01/2010
01/10/2010 1N 11 11.8 4.5 5.5 N 19/02/2010
19/02/2010 N 12.6
12.7 6.8
7.5 Cured
Cured
32 1118
1119 Teshome
Abera Wonsho M 9
15 Y 19/01/2010 1 11.8 5.5
6.5 N 22/02/2010
19/02/2010 N 12.7
12.6 7.5
10 Cured
43 1121
1119 Frew
TeshomeWonsho M 815 Y 20/01/2010
19/01/2010 N
1 11
11.8 4.5
6.5 N 02/11/2010
22/02/2010 N 12.6 6.2
10 Cured
54 1121
1122 Wonsho
Demelash
Frew W onsho M 8
18 Y 20/01/2010
21/01/2010 2N 11
11.6 4.5
10 N 20/02/2010
02/11/2010 N 12.6
12.7 6.2
14 Cured
65 1123
1122 Chaltu Wonsho
Demelash
Wonsho FM 10
18 Y 23/01/2010
21/01/2010 12 11.7
11.6 6.4
10 N 25/02/2010
20/02/2010 N 12.8
12.7 8
14 Cured
76 1123
1124 Chaltu Wonsho F
Saron 10
18 Y
N 23/01/2010 1 11.7
11.9 6.4
10 N 24/02/2010
25/02/2010 N 12.8
12.6 8
13 Cured
87 1125
1124 Beletu
Saron Wonsho F 10
18 YN 24/01/2010
23/01/2010 1 11.6
11.9 6
10 N 24/02/2010 N 12.7
12.6 8.2
13 Cured
98 1125
1126 Beletu Wonsho F
Diribe 910 Y 24/01/2010
25/01/2010 1
N 11.6
10.9 4.76 N 02/12/2010 N
24/02/2010 1 12.7
10.3 8.2
4.9 Cured
TO
9
10 1126
1128 Diribe Wonsho F
Halima 9
18 Y 25/01/2010 1N 10.9
11.9 4.7
10.5 N 02/07/2010 1
02/12/2010 2 10.3
11.9 4.9
10.6 TO
10 1128 Halima Wonsho F 18 Y 25/01/2010 1 11.9 10.5 N 02/07/2010 2 11.9 10.6 TO

Bilateral pitting Odema
MUAC or WFH/WFL Cured
Count of Number of Children. Count of Admissions by Criteria. Died
Count of Discharge Outcomes.
PARTICIPANT MODULE
Bilateral pitting Odema
MUAC or WFH/WFL Cured
Defaulted
Died
Non-responder
Stabilised
Defaulted
Transfer-out
Non-responder
Stabilised
Transfer-out

2. 4. 9. 10.
1. Medic Ad 7. Ret Transf 17. 19.
8. 16 24. Outcome
Regi al 3. dr 6. New urn er-in 12. WFA Severe Bilater
PARTICIPANT MODULE
5. Rel 11. . 18. 23. WFA (Cured, Died,
stra Recor Ful ess Age Adm ed from Bilateral 13. 14. 15. (Infa wasting al 20. 21. 22. 25.
Sex aps Admissio W Discharg WF (Infant Defaulted,
tion d l (Vil (mo issio Def other Pitting MU Weig Heig nts 0- with Pitting MU Wei Heig R emar
(F/M e n Date FH e Date H/ s 0-6 Non-
Nu Numb Na lag nths n ault faility, Odema AC ht ht 6 bilateral Odema AC ght ht ks
) (Y/ (DD/MM / (DD/MM WF month responder,
mbe er me e/ ) (Y/N er SC or (N, +, (cm) (kg) (cm) mon pitting (N, +, (cm) (kg) (cm)
N) /YY) W /Y Y ) L s) Stabilised,
r. (MRN Go ) (Y/ OTP ++, +++) ths) oedema ++,
FL Transfer-out)
) tt) N) (Y/N) (Y/N) +++)
11 1129 Mehret
Wonsho
F 9 Y 25/01/2010 2 12 6.1 N 29/02/2010
N 13 7.5 Cured

12 1130 AbduWonsho
M 21 Y 25/01/2010 1 12 9.5 N
13 1131 JemalWonsho
M 18 Y 25/01/2010 N 11 9.9 N 30/01/2010 Defaulted
14 1132 KedirWonsho
M 11 Y 25/01/2010 N 11 6.1 N
15 1133 Kedija
Wonsho
F 15 Y 26/01/2010 N 11 7 N
16 1134 Tayitu
Wonsho
F 31 Y 02/01/2010 1 12 12 N
17 1135 RahelWonsho
F 13 Y 02/01/2010 N 11 7 N
18 1136 Rebeca
Wonsho
F 8 Y 2 12 6.2 N
05/02/2010
19 1137 Fatima
Wonsho
F 8 Y N 10/02/2020 12 4 N 12/02/2020 Died
20 1138 Keneni
Wonsho
F 30 Y 15/02/2010 N 11 11 N TO

Bilateral pittingMUAC
Odemaor WFH/WFL Cured
Died
Defaulted
Non-responder
Stabilised
343
2019
Transfer-out
344
2019
Registration Book for MAM Treatment - Children 6-59 months
10. Admission/Entry Information
Medication Administered Discharge/Exit Inormation
2. 4. 9. Transfer-
1. 14. 15. 17.Outcome
Medical 7. New 8. 11.
Registrat 3. Full Address 5. Sex 6. Age Returned in from 12. Mebendaz Discharge (Cured,Died,De 18.
Record Admission Relapse Admission 13. 16.MUAC
ion Name (Village/G (F/M) (months) Defaulter other MUAC ole/Albend Date faulted,Non- R emarks
Number (Y/N) (Y/N) Date Vit.A (cm)
Number. ott) (Y/N) TSFP (cm) azole (DD/MM/Y Y responder,Tran
(MRN) (DD/MM/YY)
(Y/N) (Yes/No) ) sfer out)
1 1129 Meselu Achura F 9 Y 25/01/2011 11.7 25/03/2011 12.7 cured
2 1130 Abdu Achura M 21 Y 25/01/2011 11.6 25/03/2011 12.7 cured
3 1131 Jemal Achura M 18 Y 25/01/2011 11.8 30/01/2010 Deid
4 1132 Mamush Achura M 11 Y 25/01/2011 11.9 25/03/2011 12.6 cured
5 1133 Kedija Achura F 15 Y 26/01/2011 11.6
6 1134 Tayitu Achura F 31 Y 02/01/2011 11.7
7 1135 Rahel Achura F 13 Y 02/01/2011 11.9
8 1136 Sadiya Achura F 8 Y 02/05/2011 11.7
9 1137 Hana Achura F 8 Y 02/10/2011 11.7
10 1138 Burtukan Achura F 30 Y 15/02/2011 11.6

Count of Number of Children. Count of Discharge Outcomes.
PARTICIPANT MODULE
Cured
Died
Defaulted
Non-responder
Transfer-out

Registration Book for MAM treatment -PLW
Admission/Entry Information Discharge/Exit Categories
10.
1. 2. Medical 8. Transfer- 16. Outcome
13.Mebend
7. New 9. Returned
PARTICIPANT MODULE
4. Address 5. Expected (Cured, Died,
Registrati Record 3. Full Relaps in from 11. Admission azole/Albe 14.Discharge
(Village/Go Delivery Date 6. Age Admission Defaulter 15.MUAC Defaulted, Non- 17. R emarks
on Number Name e other Date 12.MUAC(cm) ndazole Date
tt) (DD/MM/YY) (Y/N) (Y/N) responder,
Number. (MRN) (Y/N) TSFP (DD/MM/YY) (Yes /No) (DD/MM/YY) (cm)
Transfer-
(Y/N)
out,Other)
1 1114 Beletech Achura 20/05/2011 28 Y 25/01/2011 23 25/03/2011 24 cured
2 1118 Aberash Achura 31 Y 19/01/2011 22 25/03/2011 24 cured
3 1119 Halima Achura 30/06/2011 23 Y 19/01/2011 23 25/03/2011 24 cured
4 1121 Fetenech Achura 25 Y 20/01/2011 23

defaulted
5 1122 Bogalech Achura 32 Y 21/01/2011 23 25/03/2011 24 cured
6 1123 Chaltu Achura 29 Y 10/02/2011 23
7 1124 Demekech Achura 27 Y 12/02/2011 22
8 1125 Beletu Achura 33 Y 20/02/2011 23
9 1126 Diribe Achura 26 Y 01/03/2011 23

10 1128 Fanaye Achura 34 Y 05/03/2011 23
Count of Discharge Outcomes.

Cured
Died
Defaulted
Non-responder
Transfer-out
Other
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ANNEXS
ANNEX 1: Explanation of Z-scores (SD-scores)
What does a Z-score tell us?
The reference lines on the growth charts – the so-called Z-score lines – are based on Z-scores, also
known as standard deviation (SD) scores. Z-scores are used to describe how far a measurement is from
the median (or average). A weight-for-height Z-score of –2.33, for example, means that the child’s
weight is 2.33 SDs below the expected median weight of children of the same height. The child has a
lower weight for his or her height compared to the standard and is classified as “wasted”. A positive
Z-score indicates that the child’s weight is to the right of the median – that is, the child is heavier
compared to the standard.
Z-scores are calculated differently for measurements that are distributed normally or non‑normally in
the reference population.
Normally distributed measurements

The concept of a normal distribution is helpful for understanding what a Z-score is. In a normal
distribution, most values are grouped around the middle, as shown below.
Normal bell-shaped curve cut into Z-score
The distribution of heights of all boys (or all girls) of a given age forms a bell-shaped curve, or a normal
(or almost normal) distribution. Each segment on the horizontal axis represents one standard deviation
or Z-score, and the Z-scores −1 and 1 are at equal distances in opposite directions from the median. The
distance from the median to 1 is half of the distance to 2.
The Z-score of an observed point in this distribution is calculated as follows:
Z-score = (observed value) − (median reference value)
Z-score of the reference population
Non-normally distributed measurements

Unlike the distribution of height, the distribution of weight has a shape when graphed that looks like a
“deformed” bell, the right side of which is longer than the left (right skewed):

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It is more difficult to calculate Z-scores for weight-based indicators. Unlike in a normal distribution,
distances between adjacent Z-scores are not constant.
To calculate the Z-score of an observed point involves a series of mathematical calculations that take
into account the non-normal distribution of measurements in the reference population. The following
formula is used:
Z-score = (observed value ÷ M) L − 1
L×S
In this formula, M, L and S are values for the reference population. M is the reference median value,
which estimates the population mean; L is the power needed to transform the data in order to remove
skewness (i.e. to normalize the data); and S is the coefficient of variation (or equivalent).
This formula (sometimes called the LMS formula) is used to calculate Z-scores for weight-for-age,
weight-for-length/height, and body mass index (BMI)-for-age.
To select children for interventions if they are below specified weight-for-height cut-offs based on the
WHO standards, simplified field tables should be used.

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ANNEX 2A: Weight -for-Length Reference cards
Boys’ weight (kg) Lengtha Girls’ weight (kg)
–3 SD –2 SD –1 SD Median (cm) Median –1 SD –2 SD –3 SD
1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9
2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0
2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2
2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3
2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4
2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6
2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8
2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9
3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1
3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3
3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5
3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7
4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9
4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1
4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3
4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5
4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7
5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9
5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1
5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3
5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5
5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6
6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8
6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0
6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1
6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3
6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5
7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6
7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8
7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9
7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1
7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2
7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4
7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5
8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7
8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8
8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0
8.5 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1
8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3
8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5
9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7
9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9
9.5 10.2 11.1 12.0 87 11.7 10.7 9.9 9.1
9.7 10.5 11.3 12.2 88 12.0 11.0 10.1 9.3
9.9 10.7 11.5 12.5 89 12.2 11.2 10.3 9.5
10.1 10.9 11.8 12.7 90 12.5 11.4 10.5 9.7
10.3 11.1 12.0 13.0 91 12.7 11.7 10.7 9.9
10.5 11.3 12.2 13.2 92 13.0 11.9 10.9 10.1
10.7 11.5 12.4 13.4 93 13.2 12.1 11.1 10.2
10.8 11.7 12.6 13.7 94 13.5 12.3 11.3 10.4
11.0 11.9 12.8 13.9 95 13.7 12.6 11.5 10.6
11.2 12.1 13.1 14.1 96 14.0 12.8 11.7 10.8
11.4 12.3 13.3 14.4 97 14.2 13.0 12.0 11.0
11.6 12.5 13.5 14.6 98 14.5 13.3 12.2 11.2
11.8 12.7 13.7 14.9 99 14.8 13.5 12.4 11.4
12.0 12.9 14.0 15.2 100 15.0 13.7 12.6 11.6
a
Length is measured for children aged under 2 years or, if age is not known, below 87 cm. These reference cards are based on
the WHO Child Growth Standards 2006.

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ANNEX 2B: Weight-for-height reference card
Boys’ weight (kg) Heighta Girls’ weight (kg)
–3 SD –2 SD –1 SD Median (cm) Median –1 SD –2 SD –3 SD
5.9 6.3 6.9 7.4 65 7.2 6.6 6.1 5.6
6.1 6.5 7.1 7.7 66 7.5 6.8 6.3 5.8
6.2 6.7 7.3 7.9 67 7.7 7.0 6.4 5.9
6.4 6.9 7.5 8.1 68 7.9 7.2 6.6 6.1
6.6 7.1 7.7 8.4 69 8.1 7.4 6.8 6.3
6.8 7.3 7.9 8.6 70 8.3 7.6 7.0 6.4
6.9 7.5 8.1 8.8 71 8.5 7.8 7.1 6.6
7.1 7.7 8.3 9.0 72 8.7 8.0 7.3 6.7
7.3 7.9 8.5 9.2 73 8.9 8.1 7.5 6.9
7.4 8.0 8.7 9.4 74 9.1 8.3 7.6 7.0
7.6 8.2 8.9 9.6 75 9.3 8.5 7.8 7.2
7.7 8.4 9.1 9.8 76 9.5 8.7 8.0 7.3
7.9 8.5 9.2 10.0 77 9.6 8.8 8.1 7.5
8.0 8.7 9.4 10.2 78 9.8 9.0 8.3 7.6
8.2 8.8 9.6 10.4 79 10.0 9.2 8.4 7.8
8.3 9.0 9.7 10.6 80 10.2 9.4 8.6 7.9
8.5 9.2 9.9 10.8 81 10.4 9.6 8.8 8.1
8.7 9.3 10.1 11.0 82 10.7 9.8 9.0 8.3
8.8 9.5 10.3 11.2 83 10.9 10.0 9.2 8.5
9.0 9.7 10.5 11.4 84 11.1 10.2 9.4 8.6
9.2 10.0 10.8 11.7 85 11.4 10.4 9.6 8.8
9.4 10.2 11.0 11.9 86 11.6 10.7 9.8 9.0
9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2
9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4
10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6
10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8
10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0
10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2
10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4
11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6
11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8
11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9
11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1
11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3
11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5
12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7
12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0
12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2
12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4
13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6
13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9
13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1
13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4
13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7
14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9
14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2
14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5
14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8
15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1
15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4
15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7
16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0
16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3
16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6
16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9
17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3
For children aged 2 years and above (or, if age not known, 87 cm or more), height is measured.
a.

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ANNEX 3: Composition of F-75, F-100 and RUTF diets
Constituent Amount per 100 ml Amount per 100 g
F-75 F-100 RUTF
75 kcal 100 kcal 520–550 kcal
Energy
(315 kJ) (420 kJ) (2176–2300 kJ)
Protein 0.9 g 2.9 g 11 g
Lactose 1.3 g 4.2 g –
Potassium 3.6 mmol 5.9 mmol 1.3 mg
Sodium 0.6 mmol 1.9 mmol 290 mg
Magnesium 0.43 mmol 0.73 mmol 110 mg
Zinc 2.0 mg 2.3 mg 12.5 mg
Copper 0.25 mg 0.25 mg 1.6 mg
Percentage of energy
from:
Protein 5% 12% 10–12%
Fat 32% 53% 45–60%
Osmolarity 333 mOsmol/L 419 mOsmol/L

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ANNEX 4: Recipes for F-75 and F-100 (only if commercially produced
products not available)
a. Where pre-prepared CMV is not available, a mineral mix should be used (20 ml for 1 litre of
preparation). Contents of the mineral mix are given in Annex 6.
b. Important note about adding water. Add just the amount of water needed to make 1000 ml of
formula. (This amount will vary from recipe to recipe, depending on the other ingredients.) Do not
simply add 1000 ml of water, as this will make the formula too dilute. A mark for 1000 ml should be
made on the mixing container for the formula, so that water canbe added to the other ingredients up to
this mark.

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Directions for making cooked F-75 with cereal flour
You will need a 1-litre electric blender or a hand whisk (rotary whisk or balloon whisk), a 1-litre
measuring jug, a cooking pot, and a stove or hot plate. Amounts of ingredients are listed on the
previous page. Cereal flour may be maize meal, rice flour, or whatever is the staple cereal in the area.
It is important to use cooled, boiled water even for recipes that involve cooking. The cooking is only
4 minutes of gentle boiling, and this may not be enough to kill all pathogens in the water. The water
should be cooled because adding boiling water to the powdered ingredients may create lumps.
If using an electric blender:
1. Put about 200 ml of the boiled, cooled water into the blender. (If you will use liquid milk instead
of milk powder, omit this step.)
2. Add the flour, milk or milk powder, sugar, oil and blend.
3. Add cooled, boiled water to the1000 ml mark and blend at high speed.
4. Transfer the mixture to a cooking pot and boil gently for 4 minutes, stirring continuously.
5. Some water will evaporate while cooking, so transfer the mixture back to the blender after
cooking and add enough boiled water to make 1000 ml. Add the Combined Mineral and Vitamin
Mix (CMV). Then blend again.
If using a hand whisk:
1. Mix the flour, milk or milk powder, sugar, oil in 1-litre measuring jug. (If using milk powder, this
will be a paste.)
2. Slowly add cooled, boiled water up to 1000 ml.
3. Transfer to cooking pot and whisk the mixture vigorously.
4. Boil gently for 4 minutes, stirring continuously.
Some water will evaporate while cooking, so transfer the mixture back to the measuring jug after
cooking and add enough boiled water to make 1000 ml. Add the Combined Mineral and Vitamin Mix
(CMV), then whisk again.
Directions for making non-cooked F-100 recipes

If using an electric blender:
1. Put about 200 ml of the boiled, cooled water into the blender. (If you will use liquid milk instead
of milk powder, omit this step.)
2. Add the required amounts of milk or milk powder, sugar, oil, and mineral mix.
3. Add boiled cooled water to the 1000 ml mark and then blend at high speed.*
If using a hand whisk:
1. Mix the required amounts of milk powder and sugar in a 1-litre measuring jug; then add the oil
and stir well to make a paste (If you use liquid milk, mix the sugar and oil, and then add the milk.)
2. Add mineral mix, and slowly add boiled, cooled water up to 1000 ml, stirring all the time.*
3. Whisk vigorously.
*Whether using a blender or a whisk, it is important to measure up to the 1000 ml mark before
blending/whisking. Otherwise, the mixture becomes too frothy to judge where the liquid lin
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ANNEX 5: Composition of mineral and vitamin mix solutions
Composition of mineral mix solution
Ingredients Quantity
Potassium chloride 89.5 g
Potassium citrate (tripotassium 32.4 g
citrate)
Magnesium chloride (MgCl2·6H2O) 30.5 g
Zinc acetate 3.3 g
Copper sulphate 0.56 g
Sodium selenatea 10 mg
Potassium iodidea 5 mg
Water 1000 ml
a. If it is not possible to weight exactly these very small quantities, this substance may be omitted.
Composition of vitamin complex

Vitamins Quantity per litre of liquid food
Hydrosoluble
Thiamine (vitamin B1) 0.7 mg
Riboflavin (vitamin B2) 2.0 mg
Niacin (vitamin B3) 10 mg
Pyridoxine (vitamin B6) 0.7 mg
Cyanocobalamin (vitamin B12) 1 mg
Folic acid 0.35 mg
Ascorbic acid (vitamin C) 100 mg
Pantothenic acid (vitamin B5) 3 mg
Biotin 0.1 mg
Liposoluble
Retinol (vitamin A) 1.5 mg
Calciferol (vitamin D) 30 mg
a-Tocopherol (vitamin E) 22 mg
Vitamin K 40 mg

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ANNEX 6: Physiological basis for treatment of severe acute
malnutrition
Affected
organ/ system Effects Treatment
Cardiovascular • Cardiac output and stroke vol- • If the child appears dehydrated,
system ume are reduce Infusion of saline give system ReSoMal or F-75 diet.
may cause an increase in venous Do not give fluids intravenously
pressure unless the child is in shock
• Any increase in blood volume can • Restrict blood transfusion to 10
easily produce acute heart failure; ml/kg and give a diuretic
any decrease will further compro-
mise tissue perfusion
• Blood pressure is low
• Renal perfusion and circulation
time are reduced
• Plasma volume is usually normal
and red cell volume is reduced
Liver • Synthesis of all proteins is reduced • Do not give the child large meals
• Abnormal metabolites of amino • Ensure that the amount of protein
acids are produced given does not exceed the met-
• Capacity of liver to take up, metab- abolic capacity of the liver, but is
olize and excrete toxins is severely sufficient to support synthesis of
reduced proteins (1–2 g/kg per day)
• Energy production from substrates • Reduce the dosage of drugs that
such as galactose and fructose is depend on hepatic disposal or
much slower than normal are hepatotoxic
• Gluconeogenesis is reduced, • Ensure that sufficient carbohy-
which increases the risk of hypo- drate is given to avoid the need
glycaemia during infection for gluconeogenesis
• Bile secretion is reduce • Do not give iron supplements,
which may be dangerous because
transferrin levels are reduced
Genitourinary • Glomerular filtration is reduced • Prevent further tissue break-
system • Capacity of kidney to excrete ex- down by treating any infections
cess acid or a water load is greatly and providing adequate energy
reduced (80–100 kcalth or 336–420 kJ/kg
per day)
• Urinary phosphate output is low
• Do not give the child more pro-
• Sodium excretion is reduced tein than is required to maintain
• Urinary tract infection is common tissues
• Ensure that high-quality proteins
are given, with balanced amino
acids
• Avoid nutrients that give an acid
load, such as magnesium chloride
• Restrict dietary sodium (see
section 5.2 above). Ensure that
water intake is sufficient but not
excessive

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Gastrointestinal • Production of gastric acid is re- • Give the child small, frequent
system duced feeds
• Intestinal motility is reduced • If absorption is poor, increase the
• Pancreas is atrophied and pro- frequency and reduce the size of
duction of digestive enzymes is each feed
reduced • If there is malabsorption of fat,
• Small intestinal mucosa is atro- treatment with pancreatic en-
phied; secretion of digestive zymes may be useful
enzymes is reduced
• Absorption of nutrients is reduced
when large amounts of food are
eaten
Immune system • All aspects of immunity are dimin- • Treat all children with
ished broad-spectrum antimicrobials
• Lymph glands, tonsils and the • Because of the risk of transmis-
thymus are atrophied sion of infection, ensure that
• Cell-mediated (T-cell) immunity is newly admitted children are
severely depressed kept apart from children who are
recovering from infection
• Immunoglobulin A levels in secre-
tions are reduced
• Complement components are low
• Phagocytes do not kill ingested
bacteria efficiently
• Tissue damage does not result
in inflammation or migration of
white cells to the affected area
• Acute phase immune response is
diminished
• Typical signs of infection, such as
an increased white cell count and
fever, are frequently absent
• Hypoglycaemia and hypothermia
are both signs of severe infection
and are usually associated with
septic shock
Endocrine • Insulin levels are reduced and the • Give the child small, frequent
system child has glucose intolerance feeds
• Insulin growth factor 1 (IGF-1) lev- Do not give steroids
els are reduced, although growth
hormone levels are increased
• Cortisol levels are usually in-
creased
Circulatory • Basic metabolic rate is reduced by • Keep the child warm to prevent
system about 30% hypothermia; dry the child quick-
• Energy expenditure due to activity ly and properly after washing and
is very low. Both heat generation cover with clothes and blankets,
and heat loss are impaired; the ensure that windows are kept
child becomes hypothermic in a closed at night and keep the
cold environment and hyperther- temperature of the living environ-
mic in a hot environment ment at 25–30°C
• If a child has fever, cool the child
by sponging with tepid (not cold)
water (never alcohol rubs)

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Cellular • Sodium pump activity is reduced • Give large doses of potassium
function and cell membranes are more and magnesium to all children
permeable than normal, which • Restrict sodium intake
leads to an increase in intracellular
sodium and a decrease in intracel-
lular potassium and magnesium
• Protein synthesis is reduced
Skin, muscles • The skin and subcutaneous fat are • Rehydrate the child with ReSoMal
and glands atrophied, which leads to loose or F-75 diet
folds of skin
• Many signs of dehydration are
unreliable; eyes may be sunken
because of loss of subcutaneous
fat in the orbit
• Many glands, including the sweat,
tear and salivary glands, are atro-
phied; the child has dryness of the
mouth and eyes and sweat pro-
duction is reduced
• Respiratory muscles are easily
fatigued; the child is lacking in
energy

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ANNEX 7: MULTICHART
Health facility MRN .................................................... Referred from:. Major Problems Date of admission(EC) (DD/MM/YY): Date of Discharge (DD/MM/YY):..............
Registration # ............................................................. Age (d/m/y specify):. Time: AM /PM Cured Causes
Sex:.. Re-admission (Y/N): Died
Full Name: (Relapse or Returned defaulter: circle type of

Breastfeeding (Y/N):.......................................................... Defaulted
readmission)
Complementary feeding (Y/N): From:.................................................................... Non-responder
Address (Kebele, Woreda, Region): Old registration #:................................................. Stablized To:.......................................... .........................................................
Transferred-out
Followed up by:.......................................................................................................................
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
Height/Length (cm)
Anthropometric
Weight (kg)
Chart
WFH/WFL z-score
MUAC (cm)
Bilateral pitting oedema (0, +, ++,
+++)
Wt gain (g/kg/day)
Lethargic Yes No
If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give IV DIARRHOEA Dry mouth/tongue Yes No
SHOCK glucose as described under Blood Glucose (left). Then give IV fluids:
Blood in stool? Yes No
Restless/Irritable Yes No Thirsty Yes No
Monitor every 10 minutes *2nd Monitor every 10 minutes Monitor every hour. Amount of ReSoMal to offer:*
Start:
hr
INITIAL MANAGEMENT

Pulse rate
Weight

MEASLES Yes No
If corneal clouding or ulceration, give vitamin A & atropine immediately. Record
EYE SIGNS None Left Right on Special Medicine section. Number vomits
EYE CARE

Bitots' spot
Amount taken (ml) F-75 F-75 F-75 F-75 F-75
6-11 months 100,000 IU
Pus/inflammation *Stop ReSomal if: Increase in pulse,& resp.rates, Jugular veins engorged, increasing oedema eg. Puffy eyes, weight gain exceeds th weight before diarrhoae or is above 5% of the weight before rehydration
BLOOD GLUCOSE (mg/dl): HAEMOGLOBIN (Hb) (g/dl): Blood type:

Corneal clouding
>12 months 200,000 IU If <54mg/dl and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG). If <54mg/dl and If Hb <4g/dl or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
WEIGHT CHART
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
Phase
Diet Name
ml/feed
#/feed/day

A= Absent
V= Vomit
R= Refuse
NG = NG
THERAPEUTIC DIET
Tube
IV = IV
Fluid
>80%
75%
X X
X
50%
X
X
25%
X
Porridge
Family Meal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Other Date
Diarrhoea (Tally)
Vomit (Tally)
SURVEILANCE CHART
Dehydration (Y/N)
Cough (Y/N)
Septic Shock (Y/N)
Respiratory Rate
Palmer pallor (Y/N)
Temp. AM Ax/Rect
Temp. PM Ax/Rect
Deramtosis( 0, +, ++, +++)
Liver Size (cm)

Failure to Respond
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
ROUTINE MEDICINE
Antibiotic 2: Time
Antibiotic 3: Time
ReSoMal (ml)
IV Fluids
SPECIAL MEDICINE
Blood
NG Tube
Give day 1, day 2 and 15 if child admitted with eye signs or recent measles
Vitamin A
Drugs for eye problems
Tetracycline 1 drop 4 X daily
Atropine 1 drop 3 X daily
Others
Enter name, dose and route of administration (oral- PO , intramascular-IM or intravenous-IV) for each drug. Enter "X"in the upper left corner if prescribed - the nurse signs the box when the drug is given.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
Hemoglobin (g/dl)
RESULTS
Glucose Test (mg/dl)

TEST
Malaria Test
TB Test
HIV Test
OBSERVATION: Card
Y
N Birth 1 2 3 4
BCG
Polio
Pentavalent
PCV
Rota
Measles
Discharge
Counselling and Education Given on: Date Sign

Cause of Malnutrition
Diarrhoea, RTI, Fever
Skin, eye and ear infection
Play and stimulation
Child nutrition
Child care
WASH
Sexually transmitted disease
Family Planning
Other, sepcify.................................
Immunisation up to date
Breastfeeding on discharge

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ANNEX 8: Danger signs related to pulse, respiration and temperature
Indicator Danger sign Suggests
Summary of danger signs related to pulse, respiration and temperature

Normal pulse rate in children
Age (years) Normal pulse rate (range)
0 to 1 100–160
1 to 3 90–150
3 to 6 80–140
Source: WHO Pocket book of hospital care for children, second edition, page 261 (see footnote 1).
Normal respiration rate in children

Age Normal respiration rate
< 2 months < 60 breaths/min
2 to 11 months < 50 breaths/min
1 to 5 years < 40 breaths/min
Source: WHO Pocket book of hospital care for children, second edition, page 76 (see footnote 1).

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ANNEX 9A: F-75 Reference Card
For children of different weights, NO oedema or with mild or moderate oedema (0 + ++).
Child Volume of F-75 per feed (ml)a
Daily total 80% of daily totala
weight minimum)
Every 2 Every 3 Every 4 hours (130 ml/kg)
(kg)
hoursb hoursc
(6 feeds)
(12 feeds) (8 feeds)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
4.8 55 80 105 624 500
5.0 55 80 110 650 520
5.2 55 85 115 676 540
5.4 60 90 120 702 560
5.6 60 90 125 728 580
5.8 65 95 130 754 605
6.0 65 100 130 780 625
6.2 70 100 135 806 645
6.4 70 105 140 832 665
6.6 75 110 145 858 685
6.8 75 110 150 884 705
7.0 75 115 155 910 730
7.2 80 120 160 936 750
7.4 80 120 160 962 770
7.6 85 125 165 988 790
7.8 85 130 170 1014 810
8.0 90 130 175 1040 830

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8.2 90 135 180 1066 855
8.4 90 140 185 1092 875
8.6 95 140 190 1118 895
8.8 95 145 195 1144 915
9.0 100 145 200 1170 935
9.2 100 150 200 1196 960
9.4 105 155 205 1222 980
9.6 105 155 210 1248 1000
9.8 110 160 215 1274 1020
10.0 110 160 220 1300 1040
10.2 110 165 220 1326 1060
10.4 115 170 225 1352 1080
10.6 115 175 230 1378 1100
10.8 115 175 235 1404 1125
11.0 120 180 240 1430 1145
11.2 120 180 245 1456 1165
11.4 125 185 245 1482 1185
11.6 125 190 250 1508 1205
11.8 130 190 255 1534 1225
12.0 130 195 260 1560 1250
12.2 130 200 265 1586 1270
12.4 135 200 270 1612 1290
12.6 135 205 275 1638 1310
12.8 140 210 275 1664 1330
13.0 140 210 280 1690 1350
13.2 145 215 285 1716 1375
13.4 145 220 290 1742 1395
13.6 145 220 295 1768 1415
13.8 150 225 300 1794 1435
14.0 150 230 305 1820 1455
14.2 155 230 310 1846 1475
14.4 155 235 310 1872 1500
14.6 160 235 315 1898 1520
14.8 160 240 320 1924 1540
15.0 165 245 325 1950 1560
a
Volumes in these columns are rounded to the nearest 5 ml.
b
Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhea (<5 watery stools per day), and
finishing most feeds, change to 3-hourly feeds.cAfter a day on 3-hourly feeds: If no vomiting, less diarrhea, and finishing most
feeds, change to 4-hourly feeds
**** For weight above 10.0 kgs use by adding the volume for two different weight that sums up to the desired weight (eg:-
11kg then the volume for 9 kg plus the volume for 2 kg.)
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ANNEX 9B: F-75 Reference chart
For children of different weights, generalized oedema (+++)
Volume of F-75 per feed (ml)a
Every 2 hoursb Every 3 hoursc Every 4 hours Daily total
Weight 80% of daily
of child (12 feeds) (8 feeds) (6 feeds) (130 ml/kg) totala minimum)
3.0 25 40 50 300 240
3.2 25 40 55 320 255
3.4 30 45 60 340 270
3.6 30 45 60 360 290
3.8 30 50 65 380 305
4.0 35 50 65 400 320
4.2 35 55 70 420 335
4.4 35 55 75 440 350
4.6 40 60 75 460 370
4.8 40 60 80 480 385
5.0 40 65 85 500 400
5.2 45 65 85 520 415
5.4 45 70 90 540 430
5.6 45 70 95 560 450
5.8 50 75 95 580 465
6.0 50 75 100 600 480
6.2 50 80 105 620 495
6.4 55 80 105 640 510
6.6 55 85 110 660 530
6.8 55 85 115 680 545
7.0 60 90 115 700 560
7.2 60 90 120 720 575
7.4 60 95 125 740 590
7.6 65 95 125 760 610
7.8 65 100 130 780 625
8.0 65 100 135 800 640
8.2 70 105 135 820 655
8.4 70 105 140 840 670
8.6 70 110 145 860 690
8.8 75 110 145 880 705
9.0 75 115 150 900 720
9.2 75 115 155 920 735
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Volume of F-75 per feed (ml)a
Every 2 hoursb Every 3 hoursc Every 4 hours Daily total
Weight 80% of daily
of child (12 feeds) (8 feeds) (6 feeds) (130 ml/kg) totala minimum)
9.6 80 120 160 960 770
9.8 80 125 165 980 785
10.0 85 125 165 1000 800
10.2 85 130 170 1020 815
10.4 85 130 175 1040 830
10.6 90 135 175 1060 850
10.8 90 135 180 1080 865
11.0 90 140 185 1100 880
11.2 95 140 185 1120 895
11.4 95 145 190 1140 910
11.6 95 145 195 1160 930
11.8 100 150 195 1180 945
12.0 100 150 200 1200 960
12.2 100 155 205 1220 975
12.4 105 155 205 1240 990
12.6 105 160 210 1260 1010
12.8 105 160 215 1280 1025
13.0 110 165 215 1300 1040
13.2 110 165 220 1320 1055
13.4 110 170 225 1340 1070
13.6 115 170 225 1360 1090
13.8 115 175 230 1380 1105
14.0 115 175 235 1400 1120
14.2 120 180 235 1420 1135
14.4 120 180 240 1440 1150
14.6 120 185 245 1460 1170
14.8 125 185 245 1480 1185
15.0 125 190 250 1500 1200
a
Volumes in these columns are rounded to the nearest 5 ml.
b
Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5
watery stools per day), and finishing most feeds, change to 3-hourly feeds.
c
After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and finishing most feeds, change to
4-hourly feeds.

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ANNEX 10: F-100 Reference Card
Child Range of volumes per 4-hourly feed Range of daily volumes of F-100
weight (kg) of F-100 (6 feeds daily)
Minimum (ml) Maximum (ml) ª Minimum Maximum
(150 ml/kg/day) (220 ml/kg/day)
2.0 50 75 300 440
2.2 55 80 330 484
2.4 60 90 360 528
2.6 65 95 390 572
2.8 70 105 420 616
3.0 75 110 450 660
3.2 80 115 480 704
3.4 85 125 510 748
3.6 90 130 540 792
3.8 95 140 570 836
4.0 100 145 600 880
4.2 105 155 630 924
4.4 110 160 660 968
4.6 115 170 690 1012
4.8 120 175 720 1056
5.0 125 185 750 1100
5.2 130 190 780 1144
5.4 135 200 810 1188
5.6 140 205 840 1232
5.8 145 215 870 1276
6.0 150 220 900 1320
6.2 155 230 930 1364
6.4 160 235 960 1408
6.6 165 240 990 1452
6.8 170 250 1020 1496
7.0 175 255 1050 1540
7.2 180 265 1080 1588
7.4 185 270 1110 1628
7.6 190 280 1140 1672
7.8 195 285 1170 1716
8.0 200 295 1200 1760
8.2 205 300 1230 1804
8.4 210 310 1260 1848
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Child Range of volumes per 4-hourly feed Range of daily volumes of F-100
weight (kg) of F-100 (6 feeds daily)
Minimum (ml) Maximum (ml) ª Minimum Maximum
(150 ml/kg/day) (220 ml/kg/day)
8.8 220 325 1320 1936
9.0 225 330 1350 1980
9.2 230 335 1380 2024
9.4 235 345 1410 2068
9.6 240 350 1440 2112
9.8 245 360 1470 2156
10.0 250 365 1500 2200
10.2 255 375 1530 2244
10.4 260 380 1560 2288
10.6 265 390 1590 2332
10.8 270 395 1620 2376
11.0 275 405 1650 2420
11.2 280 410 1680 2464
11.4 285 420 1710 2508
11.6 290 425 1740 2552
11.8 295 435 1770 2596
12.0 300 440 1800 2640
12.2 305 445 1830 2684
12.4 310 455 1860 2728
12.6 315 460 1890 2772
12.8 320 470 1920 2816
13.0 325 475 1950 2860
13.2 330 485 1980 2904
13.4 335 490 2010 2948
13.6 340 500 2040 2992
13.8 345 505 2070 3036
14.0 350 515 2100 3080
14.2 355 520 2130 3124
14.4 360 530 2160 3168
14.6 365 535 2190 3212
14.8 370 545 2220 3256
15.0 375 550 2250 3300
ª Volumes per feed are rounded to the nearest 5 ml.

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ANNEX 11: RUTF Reference card (example of suggested quantities)
Number of RUTF sachets per day
Child’s weight Daily weight of RUTF (g)
(if one sachet = 92g).
3 83 1
3.2 88 1
3.4 94 1
3.6 99 1.2
3.8 105 1.2
4.9 135 1.5
4.2 116 1.5
4.4 121 1.5
4.6 127 1.5
4.8 132 1.5
5 138 1.5
5.2 144 1.5
5.4 149 1.75
5.6 155 1.75
5.8 160 1.75
6 166 1.75
6.2 171 2
6.4 177 2
6.6 182 2
6.8 188 2
7 193 2.2
7.2 199 2.2
7.4 204 2.2
7.6 210 2.5
7.8 215 2.5
8 221 2.5
8.2 226 2.5
8.4 232 2.5
8.6 237 2.75
8.8 243 2.75
9 248 2.75
9.2 254 2.75
9.4 259 3
9.6 265 3
9.8 270 3
10 276 3

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ANNEX 12a: Therapeutic milk feeds in stabilization for infants less than
6 months with or without prospect to breastfed
Check the weight of the child and see the volume of milk needed for 24 hours and frequency of
meals expected.
Do not make adjustments for edema
Try at all costs to feed very small babies at least 8 times a day.
To give all the necessary volume in 24 hours, when the ideal frequency is impossible to follow, it is
better to reduce the number of meals without reducing the total daily amount than to skip meals.
Total feed Volume of feed according to feed frequency (per 24 hours)
Weight of Infant volume in
24h 12 feeds 10 feeds 8 feeds 7 feeds 6 feeds 5 feeds
(kg) (ml) (ml) (ml) (ml) (ml) (ml) (ml)
1.2 240 20 20 25 30 35 45
1.3 240 20 25 30 30 35 45
1.4 240 20 25 30 35 40 45
1.5 240 20 25 30 35 40 45
1.6 300 25 30 35 40 45 60
1.7 300 25 30 35 40 45 60
1.8 300 25 30 40 40 45 60
1.9 300 25 30 40 45 50 60
2.0 300 25 35 40 45 50 65
2.1 300 25 35 40 45 50 65
2.2 360 30 35 45 50 60 70
2.3 360 30 35 45 50 60 70
2.4 360 30 35 45 50 60 70
2.5 420 35 40 50 55 65 75
2.6 420 35 40 50 55 65 75
2.7 420 35 40 50 55 65 75
2.8 420 35 40 55 60 65 75
2.9 420 35 40 55 60 70 80
3.0 480 40 45 60 65 75 85
3.1 480 40 45 60 65 75 85
3.2 480 40 45 60 65 75 85
3.3 480 40 45 60 65 75 85
3.4 480 40 45 60 65 75 85
3.5 480 40 50 65 70 80 95
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ANNEX 12a: Therapeutic milk feeds in stabilization for infants less
than 6 months with or without prospect to breastfed
3.6 480 40 50 65 70 80 95
3.7 480 40 50 65 70 80 95
3.8 480 40 50 65 70 80 95
3.9 480 40 50 65 70 80 95
4.0 540 45 55 70 75 85 110
4.1 540 45 55 70 75 85 110
4.2 540 45 55 70 75 85 110
4.3 540 45 55 70 75 85 110
4.4 540 45 55 70 75 85 110
4.5 600 50 60 80 90 95 120
4.6 600 50 60 80 90 95 120
4.7 600 50 60 80 90 95 120
4.8 600 50 60 80 90 95 120
4.9 600 50 60 80 90 95 120
5.0 720 60 70 90 100 110 130
5.1 720 60 70 90 100 110 130
5.2 720 60 70 90 100 110 130
5.3 720 60 70 90 100 110 130
5.4 720 60 70 90 100 110 130
5.5 720 60 80 100 110 120 150
5.6 720 60 80 100 110 120 150
5.7 720 60 80 100 110 120 150
5.8 720 60 80 100 110 120 150
5.9 720 60 80 100 110 120 150
6.0 840 70 85 110 120 140 175
Note: when the weight is between the given weight on this table give the feed for the lowest weight
(eg: - 5.75 kg then give the feed volume for 5.7Kg)

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How total feed volumes are calculated for initial feeding
The lower the weight of the infant, the higher the volume of feed per kg required. As a guide, the
average volume of feed /kg, according to weight in the stabilization phase is:
Weight Feed ml/kg/24 hours*

1.2 – 1.5 kg 180 ml/kg
1.6 – 1.9 kg 170 ml/kg
2.0 – 3.0 kg 155 ml/kg
3.1 – 3.5 kg 145 ml/kg
3.6 – 6.0 kg 130 ml/kg
*average rounded to nearest 5ml, therefore absolute volumes per kg body weight may vary a little,
these are guidance volumes.

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ANNEX 12b: Therapeutic milk feeds in transition for infants less than 6
months with no prospect to breastfeed
Volume of feed according to feed frequency (per 24
Weight Total feed hours)
of volume in
Infant 24h 8 7 6 5
12 feeds 10 feeds
feeds feeds feeds feeds
1.2 300 25 25 35 40 45 60
1.3 300 25 30 40 40 45 60
1.4 300 25 30 40 45 50 60
1.5 300 25 30 40 45 50 60
1.6 360 30 40 45 50 60 70
1.7 360 30 40 45 50 60 70
1.8 360 30 40 50 50 60 80
1.9 360 30 40 50 60 65 80
2.0 360 30 45 50 60 65 85
2.1 360 30 45 50 60 65 85
2.2 480 40 45 60 65 80 90
2.3 480 40 45 60 65 80 90
2.4 480 40 45 60 65 80 90
2.5 540 45 50 65 70 85 100
2.6 540 45 50 65 70 85 100
2.7 540 45 50 65 70 85 100
2.8 540 45 50 70 80 90 105
2.9 540 45 50 70 80 90 105
3.0 600 50 60 80 85 100 110
3.1 600 50 60 80 85 100 110
3.2 600 50 60 80 85 100 110
3.3 600 50 60 80 85 100 110
3.4 600 50 60 80 85 100 110
3.5 600 50 65 85 90 105 125
3.6 600 50 65 85 90 105 125
3.7 600 50 65 85 90 105 125
3.8 600 50 65 85 90 105 125
3.9 600 50 65 85 90 105 125

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ANNEX 12b: Therapeutic milk feeds in transition for infants
less than 6 months with no prospect to breastfeed
4.0 720 60 70 90 100 110 145
4.1 720 60 70 90 100 110 145
4.2 720 60 70 90 100 110 145
4.3 720 60 70 90 100 110 145
4.4 720 60 70 90 100 110 145
4.5 780 65 80 105 125 125 155
4.6 780 65 80 105 125 125 155
4.7 780 65 80 105 125 125 155
4.8 780 65 80 105 125 125 155
4.9 780 65 80 105 125 125 155
5.0 960 80 90 115 130 145 170
5.1 960 80 90 115 130 145 170
5.2 960 80 90 115 130 145 170
5.3 960 80 90 115 130 145 170
5.4 960 80 90 115 130 145 170
5.5 960 80 105 130 145 155 195
5.6 960 80 105 130 145 155 195
5.7 960 80 105 130 145 155 195
5.8 960 80 105 130 145 155 195
5.9 960 80 105 130 145 155 195
6.0 1080 90 110 145 155 180 225
How total feed volumes are calculated for initial feeding

average volume of feed /kg, according to weight in the transition phase is:

1.2 – 1.5 kg 225 ml/kg
1.6 – 1.9 kg 205 ml/kg
2.0 – 3.0 kg 200 ml/kg
3.1 – 3.5 kg 180 ml/kg
3.6 – 6.0 kg 170 ml/kg
*average rounded to nearest 5ml. Refer to the large table to manage individual infants.

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ANNEX 12c: Therapeutic milk feeds in the recovery phase for infants
less than 6 months with no prospect to breastfeed.
Weight Total feed Volume of feed according to feed frequency (per 24 hours)
of volume in 5
Infant 24h 12 feeds 10 feeds 8 feeds 7 feeds 6 feeds
feeds
1.2 360 30 30 40 50 55 70
1.3 360 30 40 50 50 55 70
1.4 360 30 40 50 55 65 70
1.5 420 35 40 50 60 70 80
1.6 480 40 50 55 65 70 90
1.7 480 40 50 55 65 70 90
1.8 480 40 50 65 65 70 95
1.9 480 40 50 65 70 80 95
2.0 480 40 55 65 70 80 105
2.1 480 40 55 65 70 80 105
2.2 600 50 55 70 80 95 110
2.3 600 50 55 70 80 95 110
2.4 600 50 55 70 80 95 110
2.5 660 55 65 80 90 105 120
2.6 660 55 65 80 90 105 120
2.7 660 55 65 80 90 105 120
2.8 660 55 65 90 95 110 130
2.9 660 55 65 90 95 110 130
3.0 780 65 70 95 105 120 135
3.1 780 65 70 95 105 120 135
3.2 780 65 70 95 105 120 135
3.3 780 65 70 95 105 120 135
3.4 780 65 70 95 105 120 135
3.5 780 65 80 105 110 130 150
3.6 780 65 80 105 110 130 150
3.7 780 65 80 105 110 130 150
3.8 780 65 80 105 110 130 150
3.9 780 65 80 105 110 130 150
4.0 840 70 90 110 120 135 175
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ANNEX 12c: Therapeutic milk feeds in the recovery phase
for infants less than 6 months with no prospect to
breastfeed.
4.1 840 70 90 110 120 135 175
4.2 840 70 90 110 120 135 175
4.3 840 70 90 110 120 135 175
4.4 840 70 90 110 120 135 175
4.5 960 80 95 130 145 150 190
4.6 960 80 95 130 145 150 190
4.7 960 80 95 130 145 150 190
4.8 960 80 95 130 145 150 190
4.9 960 80 95 130 145 150 190
5.0 1140 95 110 145 160 175 210
5.1 1140 95 110 145 160 175 210
5.2 1140 95 110 145 160 175 210
5.3 1140 95 110 145 160 175 210
5.4 1140 95 110 145 160 175 210
5.5 1140 95 130 160 175 190 240
5.6 1140 95 130 160 175 190 240
5.7 1140 95 130 160 175 190 240
5.8 1140 95 130 160 175 190 240
5.9 1140 95 130 160 175 190 240
6.0 1320 110 135 175 190 225 280
How total feed volumes are calculated for catch-up/rehabilitation (non-breastfed infants)
average volume of feed /kg, according to weight in the catch-up phase is:

1.2 – 1.9 kg 270 ml/kg
2.0 – 3.0 kg 270 ml/kg
3.1 – 3.5 kg 240 ml/kg
3.6 – 6.0 kg 230 ml/kg
*average rounded to nearest 5ml. Refer to the large table to manage individual infants.

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ANNEX 13: DAILY WARD FEED CHART
DATE:________________________ WARD: _______________________
F-75 F-100
Name of Child Number Amount/ Total Number Amount/ Total
feeds feed (ml) (ml) feeds feed (ml) (ml)
F-100 (total ml) needed

F-75 (total ml) needed for 24 hours
for 24 hrs
Amount needed for __
Amount needed for __ hours*
hours*
Amount to prepare
Amount to prepare (round up to whole liter) (round up to whole
liter)
*Divide daily amount by the number of times food is prepared each day. For example, if feeds
are prepared every 12 hours, divide daily amount by 2.

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Annex 14: Key messages about the use of RUTF
Important notes to give to a mother before referral for rehabilitation through outpatient care:
1. RUTF is both a food and medicine for malnourished children only. It should not be shared.
2. Give small regular meals of RUTF and encourage the child to eat often (if possible eight meals a
day).
3. During the first week of treatment at home, give mainly RUTF to the child. Over the following
weeks, the child will need to receive, in alternate with RUTF, locally available foods, nutrient rich
and varied. The health center will instruct the mother how to feed the child with food available
locally.
4. For young children, continue to breastfeed regularly.
5. Always offer the child plenty of clean water to drink or breast milk when the child takes RUTF.
6. Wash the child’s hands and face with soap before eating, if possible.
7. Keep food clean and covered, including sachets of RUTF which should be kept closed and
covered.
8. Always keep the baby covered and warm.
9. When a child has diarrhea, continue to feed him. Offer frequent meals in small quantities if the
child’s appetite is reduced.

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Annex 15: Monitoring record Chart

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ANNEX 16: Monitoring checklists
1. Checklist for monitoring food preparation
No OBSERVE: YES NO COMMENTS
1 Are ingredients for the recipes available?
2 Is the correct recipe used for the ingredients
that are available?
3 Are ingredients stored appropriately and
discarded at appropriate times?
4 Are containers and utensils kept clean?
5 Do kitchen staff (or those preparing feeds)
wash hands with soap before preparing food?
6 Are the recipes for F-75 and F-100 followed
exactly? (If changes are made due to lack of
ingredients, are these changes appropriate?)
7 Are measurements made exactly with
proper measuring
utensils (e.g., correct scoops)?
8 Are ingredients thoroughly mixed (and
cooked, if necessary)?
9 Is the appropriate amount of oil mixed in (i.e.,
not left stuck in the measuring container)?
10 Is mineral mix added correctly?
11 Is correct amount of water added to make up
a liter of formula? (Staff should not add a liter
of water, but just enough to make a liter of
formula.)
12 Is food served at an appropriate temperature?
13 Is the food consistently mixed when served
(i.e., oil is mixed in, not separated)?
14 Are correct amounts put in the dish for each
child?
15 Is leftover prepared food discarded promptly?
16 Other:

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2. Checklist for monitoring ward procedures
Feeding
1 Are correct feeds served in correct amounts?
2 Are feeds given at the prescribed times, even on
nights and weekends?
3 Are children held and encouraged to eat (never left
alone to feed)?
4 Are children fed with a cup (never a bottle)?
5 Is food intake (and any vomiting/diarrhea) recorded
correctly after each feed?
6 Are leftovers recorded accurately?
7 Are amounts of F-75 kept the same throughout the
initial phase, even if weight is lost?
8 After transition, are amounts of F-100 given freely and
increased as the child gains weight?
Warming
9 Is the room kept between 250C to 300C (to the extent
possible)?
10 Are blankets provided and children kept covered at
night?
11 Are safe measures used for re-warming children?
12 Are temperatures taken and recorded correctly?
Weighing
13 Are scales functioning correctly?
14 Are scales standardized weekly?
15 Are children weighed at about the same time each
day?
16 Are they weighed about one hour before a feed (to the
extent possible)?
17 Do staff adjust the scale to zero before weighing?
18 Are children consistently weighed without clothes?
19 Do staff correctly read weight to the nearest division of
the scale?
20 Do staff immediately record weights on the child’s
MULTICHART?
21 Are weights correctly plotted on the Weight Chart?
Giving antibiotics, medications, supplements

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22 Are antibiotics given as prescribed (correct dose at
correct time)?
23 When antibiotics are given, do staff immediately make
a notation on the MULTICHART?
24 Is folic acid given daily and recorded on the
MULTICHART?
25 Is vitamin A given according to schedule?
26 Is a multivitamin given daily and recorded on the
MULTICHART?
27 After children are on F-100 for 2 days, is the correct
dose of iron given twice daily and recorded on the
MULTICHART?
Ward environment
28 Are surroundings welcoming and cheerful?
29 Are mothers offered a place to sit and sleep?
30 Are mothers taught/ encouraged to be involved in
care?
31 Are staff consistently courteous?
32 As children recover, are they stimulated and
encouraged to move and play?

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3. Check List for Monitoring Hygiene
Hand washing
1 Are there working hand-washing facilities in the ward?
2 Do staff consistently wash hands thoroughly with
soap?
3 Are their nails clean?
4 Do they wash hands before handling food?
5 Do they wash hands between each patient?
Mothers’ cleanliness
6 Do mothers have a place to bathe, and do they use it?
7 Do mothers wash hands with soap after using the
toilet or changing diapers?
8 Do mothers wash hands before feeding children?
Bedding and laundry
9 Is bedding changed every day or when soiled/wet?
10 Are diapers, soiled towels and rags, etc. stored in
bag, then washed or disposed of properly?
11 Is there a place for mothers to do laundry?
12 Is laundry done in hot water?
General maintenance
13 Are floors swept?
14 Is trash disposed of properly?
15 Is the ward kept as free as possible of insects and
rodents?
Food storage
16 Are ingredients and food kept covered and stored at
the proper temperature?
17 Are leftovers discarded?
Dishwashing
18 Are dishes washed after each meal?
19 Are they washed in hot water with soap?
Toys
20 Are toys washable?
21 Are toys washed regularly, and after each child uses
them?
PARTICIPANT MODULE
382
2019
ANNEX 17: BIN CARD

PARTICIPANT MODULE
383
2019
ANNEX 18: STOCK CARD

PARTICIPANT MODULE
384
2019

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TRAINING COURSE ON THE

Training course on the management of acute malnutrition

Government of Ethiopia, Federal Ministry of Health,

Training course on the management of acute malnutrition

Training course on the management of acute malnutrition

• FMOH; Kidist woldesenbet, Frezer Abebe, Hiwot Darsene

• ENCU; Cecile Basquin, Bekele Negussie

• Concern World Wide: Abdi Yusuf, Annie Zhou

• Goal Ethiopia: Hilina Tufa

• USAID Tranform- PHCU; Dr. Yared Abebe

• USAID: Melanie Thurber

Federal Ministry of Health

Training course on the management of acute malnutrition

Training course on the management of acute malnutrition

Training course on the management of acute malnutrition

1.1 Importance of severe malnutrition as a health problem

1. Community outreach/mobilization: Health Extension workers conduct community

Figure 1: Components of community management of acute malnutrition

1.3 Purpose of this training course

Training course on the management of acute malnutrition

Optional reference materials:

Training course on the management of acute malnutrition

1.5 Learning objectives of the module

Session 2: Principles of care

Session 3: Initial management

Session 5: Daily care

Training course on the management of acute malnutrition

Session 6: Monitoring and problem solving

Session 7: Involving mothers in care

Session 8: Out-patient therapeutic program

Session 9: Supplementary feeding program

Session 10: Supply Chain management in acute malnutrition treatment

Training course on the management of acute malnutrition

1.6 Objectives for clinical practice sessions

Day 2: Tour of ward(s) and Clinical Signs

Day 3: Initial management

Day 4: Feeding and Daily Care

Additional Objectives for In-Patient Clinical Practice

Training course on the management of acute malnutrition

Training course on the management of acute malnutrition

SESSION 2: PRINCIPLES OF CARE

Training course on the management of acute malnutrition

In addition, the session will describe:

Training course on the management of acute malnutrition

2.1 Recognize signs of acute malnutrition

Visible severe wasting

• Is the outline of the child’s ribs easily seen?

Look at the back view of the child:

Figure 2: Child with visible severe wasting

Training course on the management of acute malnutrition

This child has +++ bilateral pitting oedema (severe). It

Figure 3: Grading of edema in severe acute malnutrition

• + (mild): discoloration or a few rough patches of skin

• Pus and inflammation (redness) are signs of eye infection.

Figure 4: Picture of an eye

Training course on the management of acute malnutrition

Medical Complications associated with severe acute malnutrition

Training course on the management of acute malnutrition

Photos 3 and 4 (front and back view of same child):

Training course on the management of acute malnutrition

Training course on the management of acute malnutrition

2.2 Weigh and measure length/height of the child

Work with a partner, One person should

Training course on the management of acute malnutrition