CBNP-Standard Operation Procedures

Islamic Republic of Afghanistan
Ministry of Public Health

General Directorate of Disease Control and Prevention
Public Nutrition Directorate
Standard operation procedures for nutrition activities

(MIYCN, IMAM, Micronutrient and CBNP)
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Contents
Section 1 ........................................................................................................................................................................................................................ 9
Maternal, Infant and Young Child Nutrition “MIYCN” SoPs ........................................................................................................................................ 9
1.1. Supporting nutrition of pregnant women ............................................................................................................................................................. 9
1.2. Supporting nutrition of Lactating women ........................................................................................................................................................... 14
2. Nutrition support of children 0-24 Months ............................................................................................................................................................ 17
2.1- Growth Monitoring/ screening of 0-24 Months children ............................................................................................................................... 17
2.2. Screening of 24-59 months old children.......................................................................................................................................................... 23
3.Assessing breastfeed, breastfeeding observation and history taking ................................................................................................................... 26
4. Breast condition and Management ........................................................................................................................................................................ 27
5. Refusal to breastfed and crying .............................................................................................................................................................................. 29
6. Expressing breastmilk ............................................................................................................................................................................................. 31
7. Not enough Milk ...................................................................................................................................................................................................... 34
8. Breastfeeding low birth weight and sick children .................................................................................................................................................. 35
9. Increasing breastmilk and re-lactation ................................................................................................................................................................... 36
10. Facility Based Food Demonstration ...................................................................................................................................................................... 38
Section 2 ...................................................................................................................................................................................................................... 40
Integrated Management of Acute Malnutrition (IMAM SoPs).................................................................................................................................. 40
1. Community Outreach for the Integrated Management of Acute Malnutrition ................................................................................................... 40
1.1. Principle of community outreach .................................................................................................................................................................... 40
2
2. Management of Moderate Acute Malnutrition and Uncomplicated Severe Acute Malnutrition in Children 6–59 Months of Age. ................. 44
2.1- Screening .......................................................................................................................................................................................................... 45
2.2 Making decision about nutrition status and referral of malnourished cases to relevant services ................................................................ 46
Location of action: Nutrition Counselor Room ....................................................................................................................................................... 46
Responsible staff: Nutrition Counselor and Nutrition Nurse ................................................................................................................................. 46
Whenever you competed Screening and determined nutritional status of the child, then make decision according to below malnutrition
classification and commands. .................................................................................................................................................................................. 46
2.3.Emergency assessment and treatment: ........................................................................................................................................................... 47
Location of action: OPD-SAM section .................................................................................................................................................................... 47
Responsible staff: Doctor/Nurse .......................................................................................................................................................................... 47
Children who are detected as MAM or SAM in screening area and referred to medical doctor of HFs to proceed with further treatment may
have some life-threatening health problems which need emergency response and caring. To know the health status, the medical doctor or
assigned nurse should check the general IMNCI danger sings and other sings that indicate presence of medical complications with child.
Children with danger sing of life-threatening condition will receive emergency care and are stabilized before referral to hospital or IPD-SAM. If
there is not any dander sing and child has MAM or SAM that can be treated in OPD-MAM or OPD-SAM by giving supplementary and
therapeutic food. Below are the standard procedures that can help the service provider to make decision for proper treatment service. ....... 47
3. Management of Moderate Acute Malnutrition for Children 6-59 Months in OPD - MAM: ................................................................................ 50
4. General case management of uncomplicated severe acute malnutrition in OPD-SAM for children aged 6-59 months .................................... 52
5. Management of Complicated Severe Malnutrition in Children 6-59 Months of Age ........................................................................................... 56
5.1- initial management: ......................................................................................................................................................................................... 56
5.2- Feeding: ............................................................................................................................................................................................................ 62
After covering and response to live threatening complications, its required to start feeding for admitted child. As nearly all children with SAM
have poor appetite when they admit to hospital. Hence, patience and coaxing is needed to encourage the children to complete their each
feed. Therefore, its required to start feeding gradually for children with complicated SAM. ................................................................................ 62
For children with, no appetite, shock status, mouth ulcers, unconscious state or if child is very weak, apply NG-tube and feed them through
tube until getting better and improvement of appetites. ....................................................................................................................................... 62
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6.Management of uncomplicated and complicated sever acute malnutrition in infants under 6 months of age .............................................. 66
Location of action: OPD-SAM & IPD-SAM ............................................................................................................................................................... 66
Responsible staff: Pediatric specialist, pediatrician, and nutrition nurse .............................................................................................................. 66
Severe acute malnutrition is less common in infants < 6 months than in older children. An organic cause for the malnutrition or failure to
thrive should be considered, and, when appropriate, treated. Infants less than 6 months of age with severe acute malnutrition with any of the
following complicating factors should be admitted for inpatient care: .................................................................................................................. 66
This chapter provides guidance on management of uncomplicated and complicated severe acute malnutrition (SAM) in infants under 6
months of age in Outpatient Department-SAM (OPD-SAM) and Inpatient Department-SAM (IPD-SAM) as part of the Integrated Management
of Acute Malnutrition (IMAM) approach. ................................................................................................................................................................ 66
The development of SAM in infants under 6 months commonly reflects suboptimal breastfeeding practices. Hence, re-establishing satisfactory
breastfeeding is at the core of treatment. .............................................................................................................................................................. 66
6.1- screening .......................................................................................................................................................................................................... 66
Be careful that screening children in this category (<6months) is different with screening of children above 6-59 months ................................ 66
Intervention ............................................................................................................................................................................................................. 67
No............................................................................................................................................................................................................................. 67
Activity Objective: ................................................................................................................................................................................................... 67
intervention status .................................................................................................................................................................................................. 67
Remarks ................................................................................................................................................................................................................... 67
6.2- Classification of Malnutrition and Making Decision ....................................................................................................................................... 68
Location of action: Nutrition Counselor Room ....................................................................................................................................................... 68
Responsible staff: Nutrition Counselor and Nutrition Nurse ................................................................................................................................. 68
Whenever screening competed and nutritional status of the child diagnosed, then make decision according to admit the patient in OPD-SAM
or refer to IPD-SAM. Use below table for decision making. .................................................................................................................................... 68
6.3--Management of uncomplicated infants less than 6 months of age in OPD-SAM ......................................................................................... 69
Location of action: Nutrition counselor’s room ...................................................................................................................................................... 69
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Responsible staff: Pediatrician and Nutrition nurse ............................................................................................................................................... 69
Previous recommendations advised inpatient management for all infants under 6 months of age with SAM. New recommendations propose
outpatient management of uncomplicated SAM in infants under 6 months of age............................................................................................... 69
6.4 Management of complicated children <6 months of age in IPD-SAM ............................................................................................................ 71
Infants with SAM with the prospect of breastfeeding should receive all support needed for the mother or carer to re-establish breastfeeding
and are given a supplement through supplementary suckling until full recovery. ................................................................................................. 71
Management of complicated SAM in infants under 6 months of age in IPDSAM is complementary to the care in IPD-SAM for children 6–59
month of age discussed in Chapter 5. ..................................................................................................................................................................... 71
6.5- Special support for low birth weight infants .................................................................................................................................................. 74
Location of action: IPD-SAM section ....................................................................................................................................................................... 74
Responsible staff: Pediatric specialist, pediatrician and nutrition nurse ............................................................................................................... 74
Low birth weight (<2.5kg) infants, especially those born earlier than term or small for their gestational age, need additional care to survive and
stay healthy. ............................................................................................................................................................................................................. 74
7. Involving Mothers in Care of malnourished children ............................................................................................................................................ 76
Location of action: IPD-SAM section ........................................................................................................................................................................... 76
Responsible staff: Nutrition nurse and nutrition counselor...................................................................................................................................... 76
Mothers and carers are the most useful resources in caring and taking part in management of malnourished children. Technical staff can
encourage and involve them in feeding practice, sensory stimulations and physical and emotional supports during treatment and recovery
period of acute malnutrition and this an opportunity to their own health and wellbeing as well during their children’s admission in program. ... 76
Hence, its important to involve them in management of their children from admission time till recover. ............................................................... 76
8: management of Acute Malnutrition in Pregnant and Lactating Women (PLW) in OPD-MAM ............................................................................ 77
8.1- Classification of Malnutrition and Making Decision ....................................................................................................................................... 79
Location of action: MCH & Nutrition Counselor Room ........................................................................................................................................... 79
Responsible staff: Midwives, Nutrition Counselor and Nutrition Nurse ................................................................................................................ 79
Whenever screening competed and nutritional status of the mother diagnosed, then make decision according to below recommendations: . 79
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9.Treatment of Associated Medical Conditions in Children with Acute Malnutrition ............................................................................................. 81
10. Specialized Foods and Products for the Management of Acute Malnutrition.................................................................................................... 92
11.Management of Severe Acute Malnutrition in other Age Groups ....................................................................................................................... 94
Section 3 ...................................................................................................................................................................................................................... 97
Micronutrient supplementation and treatment SoPs ............................................................................................................................................... 97
1.Iron folic acid deficiency and anemia ...................................................................................................................................................................... 97
2. Vit-A ......................................................................................................................................................................................................................... 99
Zinc:............................................................................................................................................................................................................................ 101
4.Vitamin C ................................................................................................................................................................................................................ 102
5. Vitamin D ............................................................................................................................................................................................................... 103
6. Calcium: ................................................................................................................................................................................................................. 105
7. Multiple Micronutrient Powders (MNP) for children .......................................................................................................................................... 106
8. Standard Operational Procedures ( SOP ) to Supporting Deworming ................................................................................................................ 108
8.1 Supporting Deworming during pregnancy in Health Facility: ........................................................................................................................ 109
8.2 Supporting Deworming in Children under five at HFs: .................................................................................................................................. 110
Section 4 .................................................................................................................................................................................................................. 112
Community Based Nutrition Program ............................................................................................................................................................. 112
4.1 Growth monitoring and promotion (GMP) Sof under 2 year children (measuring weight for age) ...................................... 112
4.2 Screening of children under 5 years of age (using MUAC and checking of edema)................................................................ 115
4.3 Food demonstration session .................................................................................................................................................................. 117
Annexes ..................................................................................................................................................................................................................... 119
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7
Foreword
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Acknowledgement
Section 1
Maternal, Infant and Young Child Nutrition “MIYCN” SoPs
Sub-optimal maternal nutrition and infant and young child feeding practices are responsible for spectrum of malnutrition and other
morbidities in children and women and for unacceptable early child death.
The first 1000 days of life, from conception until a child is aged two years, provides a “critical window of opportunity” for providing
the optimum foundation for each child’s nutrition, growth and survival, with benefits to last the child’s entire life. Deficits acquired by
this age are difficult to reverse later. This window is the same period when recommended maternal nutrition and infant and young
child feeding practices are applied. Hence, its required to provide nutrition support and services through both maternal health section
(MCH section) and childhood health section (0 to 24 months GMP and nutrition counselling).
1.1. Supporting nutrition of pregnant women

Malnutrition in pregnant and lactating women can lead to irreversible, lifelong consequences for their infants. For children who
survive, nutrition deficiencies during the first 1000 days (270 days during antenatal period) of life can impair physical and intellectual
performance, reproductive outcomes, overall health status throughout their lives, and economic productivity during adolescence and
adulthood. For this purpose, maternal nutrition and particularly nutrition services during pregnancy is most important for children
growth.
Location: MCH section
Responsible staff: Midwife
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As first step for providing nutrition services for pregnant women is to assess their nutrition status, find the current status, her problems
and causes. Then, based on the result you can offer the solutions and proper services, which this assessment can be done as below:
Intervention No Activity Objective: intervention Remarks

status
Yes No
1: Greetings and 1 Welcome the client
welcoming 2 Introduce yourself
3 Show the client to have a set
4 Ask for the MCH Handbook
5 Complete the registration
6 Explain the processes
1 Use a beam type or SECA Uni scale for weighing the pregnant women
2: Assess weight 2 Record the weight figure in register and MCH Handbook with considering of 0.1 cm
3 Compare the weight with recommended weight gain table
4 Guide the client on the next steps (measuring the MUAC)
3: Assess MUAC. 1 Select the left arm
Ask the mother to remove the cloths of left arm
2 Ensure the per is not wearing clothing on their left arm
3 Use Adult type of MUAC
4 Bend the persons left arm across the chest at a 90-degree angle to the body
5 Find the bone that forms the tip of the shoulder (acromion process) and place the 0 cm of the
MUAC measure there (middle of window).
6 Extend the MUAC tape down to the tip of the elbow (olecranon process)
7 Measure the length of the upper arm; between the bone at the top of the shoulder and the tip
of the elbow (the woman’s arm should be bent).
8 Read the length in mm of the distance between shoulder and elbow; then divide this number
in half to find the mid-point.
9 Mark the mid-point with a pen, on the person’s arm, using your free hand.
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10 Ask the woman to then relax the arm so it is hangs straight alongside the body
11 Wrap the MUAC tape around the left arm with the window (0 cm) on the mid-point
12 Pull the tape until it fits securely around the arm while keeping the right hand planted
13 Read and record the measurement in the middle window of the MUAC tape where the arrows
point inward
14 Record the number to the nearest millimetre
15 If the MUAC is ≥ 230 mm, mother is well-nourished encourage to continue her current
nutrition practices.
16 If MUAC is < 230 mm provide mother counselling and refer her to OPD-MAM services
4: Assess dietary 1 Ask/Collect the information on the Food intake frequency for 24 hours
intake 2 Ask/Collect the information on the Food intake quantity in each meal
3 Ask/Collect the information on the Food items variety taken in last 7 days
4 Ask/Collect the information if Taken any nutritional supplements in last 24 hours
5: Provide 1 Provide counseling on Importance of adequate quantity of food intake during pregnancy.
individualized
2 Provide counseling on importance of frequent intake of food during pregnancy (at least 4
counselling during
times in day)
pregnancy
3 Provide counseling on importance of considering variety/diversity in food intake including
additional vegetable and fruits during pregnancy.
4 Specify and name locally available foods which are rich of nutrients and mother must take
Considering the
during pregnancy to have diversity in her nutrition. As below;
weight, MUAC and
5 Recommend eating extra meat, eggs or fish, and dairy products such as yogurt, every day.)
dietary intake
6 Recommend eating Organ meats, such as kidney, heart and spleen are particularly rich in iron.
status, provide the
liver is not recommended for pregnant women because of its very high content of vitamin A
counselling to
and the potential risk for toxicity.
woman using the
below messages 7 Advise to use iodized salt, infant’s brain and body to grow healthily and the mother to prevent
goiter.
8 Advise to drink plenty (2-3 liters) of clean water every day, between meals
9 Advise to eat small portions of food, if you feel nauseous, vomit, have heartburn or no
appetite.
11
10 Advise on maintaining Vitamin D levels through diet and through 15-30 minutes of sun
exposure
11 Give education on appropriate food preparation methods.
12 Give education on Food safety, Practice good personal and environmental hygiene
13 Advice to have physical activity like walking and get fresh air.
14 Advice to rest at least 1 hour each day.
15 Avoid sugary foods and sweet carbonated drinks, salty foods, and highly processed foods
16 Avoid drinking tea or coffee at mealtime, or within two hours of mealtimes.
17 Give education on avoidance of substance abuse (e.g. alcohol, drugs, smoking).
18 Give education on Nutrition precautions in special circumstances such as chronic diseases,
medications etc.
19 Get feedback from the pregnant women on what you advised and if she missed some of the
points then tell her repeatedly.
20 Advise eat at least 4 times each day; (3 meals + 1 small meal
21 Advise eat extra vegetables and fruits daily;
22 Advise eat extra meat, eggs or fish, and dairy products such as yogurt, every day.
23 Advise to take micronutrient supplements
24 Give education on appropriate weight gain during pregnancy.
25 Give education and counseling nutrient requirements.
26 Give education and counseling on Nutrient rich dietary sources.
27 Give education on Variety and Frequency of foods, minerals and vitamin rich foods such as
fruits and vegetables
29 Give education on locally available foods
30 Give education on Prevention of anemia.
6: Supplementary 1 Ask the pregnant women weather she already takes the supplement or not.
recommendation 2 Ask the mother what supplements she had taken if she remember the name of supplement or
has the blisters with her in current visit.
3 Ask the mother about side effects or reactions of micronutrients if she he experience of them.
4 Give education and counseling on Importance of micronutrient supplementation during
pregnancy.
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5 Provide and give below micronutrients supplements to mother
6 Iron supplementation: 60mg iron+400 mcg folic acid as soon as possible after gestation starts.
Continuing for the rest of pregnancy
7 Folic Acid supplementation: As above
8 Calcium Supplementation: 1.5 g–2.0 gr oral elemental calcium daily in 3 divided doses
preferably at mealtime, starting at 21st week of pregnancy until delivery.
7: Preparation for 1 Provide counseling on advantages and importance of early initiation of breastfeeding
delivery 2 Provide counseling on getting nutritious foods those improve production of breastmilk.
3 Inform mother for importance and advantages of breastfeeding and its continuation.
These practices 4 Tell mother that in first few days the milk is dense with reddish color which is called
are mostly colostrum. This is a physiologic change having enough energy and immune factors.
applicable for the 5 Practically support mother through demonstration of proper positioning and attachment
pregnant women during bread feeding to her child.
who are at the 3rd 6 Give information to mother on the advantage of space between pregnancies
trimester and 7 Advise to consider a 3-year interval between pregnancies
attend the HFs for
getting health 8 Advise the conditions for the exclusive breastfeeding Lactational Amenorrhea Method (LAM)
services. Or, the 9 Explain the mother different family planning methods.
old cases who
reach to this stage
8. Immediate Immediately after delivery clean the child and do suction the mucosa from his/her mouth and
support after 1 nose to make the baby ready for breastfeeding.
delivery 2 Clean the breast and particularly nipple and Arriola with a piece of sterile gauze pad.
3 Pot the baby on breast of mother with skin to skin contact and advise the mother to hold her
child and let to suck.
These are the
recommended 4 The skin to skin contact should be kept continued at least for one hour
supports to be 5 If mother is not conscious following on general anaesthesia and caesarean, encourage the
provided for caregiver to support the child and hold on breast of mother and let him/her to suck.
mother and child 6 If the local anaesthesia is applied, support the mother to secure initial breastfeeding within
after delivery one hour of birth.
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7 In case of preterm delivery or sick baby, help the mother to express her milk and give to baby
within 1 or 2 hours after birth
8 Practically support mother through demonstration of proper positioning and attachment at
discharge time.
9 If the mother is conscious encourage her to start breastfeeding to baby as soon as possible
after birth. No late than one hour after birth.
10 Check the cord, when pulsing reduces to minimum clamp it (Delayed cord clamping)
11 Immediately after birth secure skin to skin contact through putting the baby on
abdomen/chest of mother in prone position, no clothing should separate them from each
other
1.2. Supporting nutrition of Lactating women

Location: Midwifery section
Responsible staff: Midwife
Below are the standard activities to be performed to support nutrition of lactating women during visiting HFs for PNC services.
Interventions 1 Objective of activities Intervent

ion
status
Yes No
1. Greetings and 1 Welcome the client
3 Show the client to have a seat
4 Ask for the MCH Handbook
2: Assess weight 1 Measure the weight of mother by using an accurate adult scale.
14
2 Record the weight figure in register and PNC card For procedure
3 Compare the weight with normal cut-off see screening
3: Assess MUAC 1 Measure MUAC of the mother as explained in pregnant women section section in part-1
above.
2 ▪ If MUACH is ≥230mm encourage the mother to continue her current feeding
practices,
▪ if MUAC is <230mm provide counseling and refer her to OPD-MAM.
4: Assess dietary 1 Ask/Collect the information on the Food intake frequency for 24 hours.
intake of lactating 2 Ask/Collect the information on the Food intake quantity in each meal.
woman 3 Ask/Collect the information on the Food items variety taken in last 7 days.
4 Ask/Collect the information if Taken any nutritional supplements in last 24 hours.
5: Assess mental 1 If mother has depressed mood
health status of 2 If mother has Excessive crying or mother feels to cry
the lactating 3 If mother has Difficulty in bonding with baby
woman 4 If mother complain from Loss of appetite
5 If mother complain from Inability in sleeping or has of sleep disorder
6 If mother complain from Reduced interest and pleasure in activities you used to enjoy
7 If mother fears that she is not a good mother for her children and or fears that she is
not a good wife for his spouse.
8 In case of finding one of these signs/symptoms, provide counseling and make the
mother relax. Then, refer the mother to mental health counselor or medical doctor of
the HFs
6: Assess position 1 Offer a seat for mother to sit down and relax
and attachment of 2 Ask the mother to give her breast to her child and start to breast feed.
mother with baby 3 Observe the emotional contact of the mother during breastfeeding
during breast 4 Observe the physical contact/attachment of mother and child
feeding 5 Observe position of mother and child during breastfeeding
6 If there is problem in sucking, do physical exam of the breast and nipple, and
7 Check the plate and nose of the child for any malformation and block.
8 Ask the mother what she give to her child in addition to breastmilk (formula, water,
solid food, liquids …. etc.)?
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7: Provide 1 Advice to Continue to eat three main meals and two healthy snacks per day to ensure
individualized enough nutrients to enrich breast milk.
counselling during 2 Advise to eat a variety of foods from the 7 foods groups, according to the Food-Based
lactation Dietary Guidelines.
3 Advise to eat animal source foods (such as red meat and eggs), dark green and orange-
Considering the red vegetables and fruit, and fortified foods as often as possible.
weight, MUAC and 4 Advise to use iodized salt in kitchen, but in moderation
dietary intake 5 advise to drink plenty (2-3 liters) of clean water every day, between meals, to keep
status, provide hydrated.
counseling to 6 Advise to avoid sugary foods and sweet drinks, salty foods, and highly processed foods.
mother on these 7 Advise to avoid drinking tea and coffee within 1-hour after each meal.
topics and for 8 Provide counseling on considering hygiene in preparation, cooking food and at
detailed counseling consuming time.
and GMP of her 9 Advise to expose their skin to direct sunshine for about 30 minutes in the morning or
child refer the before evening when sunshine is not too much hot and burning.
mother to Nutrition 10 Advise to avoid strong spicy foods, as the baby tastes these in the breastmilk and may
counselor section. reject breastfeeding
11 Advise to avoid smoking tobacco or using opioids and alcohol.
6: Micronutrient 1 Provide Iron Folic acid supplements (60mg iron+400 mcg folic acid)
supplementation Iron & Folic Acid for lactating mother according to RMNCH policy and educate her
for lactating (IFA) how to use:
woman supplementation Advise the mother to use IFA with meals, Not in empty stomach.
Advise the mother to eat IFA with clean water
Advise the mother to don’t drink dark tea as it prohibits
absorption of Iron
Advise the mother to don’t use Anti Acid tablets or syrups when
she is using IFA
2 Iodine supplementation: advise the mother to use Iodized salt at home.
3 Vit D: Supplementation: advise the mother to expose her skin to direct sunshine for 30
minutes in the morning or before evening when sunshine is not burning.
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7: Family planning 1 Give information to mother on the advantage of birth spacing between pregnancies,
counselling for (advantages including benefits for mother, child, family and society)
lactating woman 2 Advise to consider a 3-year interval between pregnancies
3 Advise the conditions for the exclusive breastfeeding Lactational Amenorrhea Method
(LAM)
4 Explain the mother different family planning methods (based on RMNCH policy)
2. Nutrition support of children 0-24 Months

Nutrition deficiencies during the first 2 years of life (1000 days) are associated with significant morbidity and mortality and delayed
mental and motor development. These deficiencies can impair intellectual performance, reproductive outcomes, overall health status,
and economic productivity during adolescence and adulthood. 9 months (about 270 days) of children’s intrauterine growth cover
through ANC services and counseling. Hence, the remnant period 0-24 months need to be followed and supported by nutrition section
which responsibilities go to nutrition counselor and nutrition nurse through below interventions.
2.1- Growth Monitoring/ screening of 0-24 Months children

Location: Nutrition Counselor section
Responsible staff: nutrition counselor (in absence of counselor, then nutrition nurse)
Growth monitoring is the regular measurement of a child’s size in order to document growth. The child’s size measurements must then be
plotted on a growth chart. To perform proper growth monitoring program in a HF its required to consider the patient flow as all under
24 months children even if child has not any health problem and mother has brought with herself, have to visit GMP section and
complete GMP procedure before visiting other sections. GMP/Screening of under 24 months children needs below steps:
Interventions Objective of activities Intervention

status
Yes No
1: Greetings and 1 Welcome the client and thank her for coming to HFs
17
5 Ask for MCH Handbook (*if it’s a new case and her mother also doesn’t have, fill and new
card)
6 Complete the general information part of registration
7 *in clod season, ensure the temperature of screening room is between 27-30oC
2. Complete the 1 Ask name of the child
child personal 2 Aske the mother for age of the child by months, if mother doesn’t know the exact age of
details her child then use local calendar to determine age of the child.
3 Ask about breastfeeding history
4 Update the persona details in Growth cards of MCH Handbook and register
5 If this is first visit of the child, fill a new card, ask the mother her MCH handbook and fill
growth cards as the blue card for boys and red cards for girls
6 If mother the first visit of the child and her mother also doesn’t have MCH Handbook, fill
and new handbook.
7 If this is a revisit, fill the GMP cards follow the last visit of the child.
3: check for 1 Remove footwear from child, if wearing (shows and socks)
petting Edema 2 The child will be sit on the chair or on the mother arm and the legs will be stretched
3 Clam both feet by your hands at the same time as your all four finders locate at sole of
each foot.
4 Press by medium pressure on each foot at the middle part of metatarsus by your thumbs
for the three second
5 Take off your thumbs immediately
6 Look on both feet and see the sing of your thumbs on skin of each foot
7 If sign of the thumbs (petting sign) don’t appear, child doesn’t have edema (No-Edema)
8 If petting sign appears only on one of the foots, it’s not nutritional problem refer the child
to pediatrician.
9 If petting sign of Edema detected on both feet and it takes more than 3 seconds to
disappear its nutritional Edema or positive bilateral petting signs.
10 If edema detected on feet, check it in lower legs as well. In case it is positive in legs
observe it on the hands and around the eyes’ orbits
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11 If petting sign/Edema detected only on feet, the severity/degree of Edema is +
12 If petting sign/Edema detected on feet, legs and on the hands and arms, the
severity/degree of Edema is ++
13 If petting sign/Edema detected on feet. Legs, hands and face around the eyes, the
severity/degree is +++
4: MUAC 1 Ask the mother to unclothe the left arm of child
measurement 2 Ask the mother to bent left arm of child across the chest at a 90-degree angle to the body
3 Measure the length of the child’s upper arm; between the bone at the top of the shoulder
and the tip of the elbow
4 Find the midpoint of the upper arm and mark it with a pen on shoulder of the child.
5 Release the child’s arm, falling alongside his/her body.
6 Wrap the MUAC tape around the child’s arm on marked point, such that all of tape should
be in contact with the arm’s skin.
7 Pass tip of the MUAC through small window/bore and read the number placed across the
arrows in larger window/bore.
8 Try to read the MUAC by one-millimeter(mm) precision.
9 Record the number in a in register and MCH handbook’s GMP part
5: Weight 1 Calibrate the scale at starting each working day with 3, 5 and 10 kg
Measurement Weighting by standard weights
2 Salter scale Ask the mother and help her to unclothe the child.
3 Put the child in trouser and hang him/her in the hook of scale
4 Try to keep the child quiet and relax at weighting time to get the
accurate figure.
5 Let the scale hand to stand steady on one weight figure
6 Stand in front of the scale at 90o angle with hand and read the
indicated weight
7 Release the trouser smoothly from hook and give the child to mother
to remove the trouser
8 Record the figure in register and GMP part of MCH handbook
1 Calibrate the scale on starting each working day with 3, 5 and 10 kg
standard weight
19
Weighting by Tell the process to the mother
2 digital scale Ask the mother to unclothe the child, until you make ready the scale
3 (Uniscale) Be sure that the scale is placed on a flat, hard, even surface
4 Turn on the scale and wait become ready and the 0.0 appears.
5 Ask the mother to remove her shoes and stand in the middle of scale
6 Let the scale to display a figure that indicate on mother weight
7 The mother still must stay on the scale and her weight displayed tare
the scale by passing your foot slowly across the solar panel/switch
window, covering it for a second. (if Uniscale is not solar scale, then
press the 2in1 button to hide the mother’s weight.
8 Wait for a while until you see the number 0.00 in panel
9 Gently hand the naked baby to the mother and ask her to remain still.
10 Weigh a child If child can stand itself and looks relax, then let the baby to stand alone on
alone the scale with weighting the mother
11 The figure which appears on the screen is the baby’s weight.
12 Record the figure in Kg into register and GMP part of MCH handbook
6: Length 1 Use the standard weight measuring board (120 cm)
measurement 2 Orient the mother on the process and her contribution to measurement (act as assistant)
3 Ask the mother to remove footwears (shoes, sandals & socks), hat and hair clips the child
4 Ask the mother to lay down her child in supine position with his head against the fixed
headboard, compressing the hair and her/his feet against movable part of the board.
5 Ask the mother to move behind the headboard and grip the ears to hold the child’s head
so while the child is looking directly upwards and his eyes make 90 o angle with the board
6 Stand on the side of the length of board where you can see the measuring tape. Ensure
child lies straight along the board with no position change and Shoulders, occipital area of
the head, hip, back of the legs and heels touch the fixed part of the board.
7 Bring the child’s knees together with one hand, applying gentle. With the other hand bring
the moveable foot piece of the length board to rest against the child’s heels.
8 Read the measurement and record the child’s length in by Cm with one mm precision
9 Record the figure in register and growth cards according visit number.
20
7: Plotting the 1 Chose the correct type of card according to their colors and gender of screened child
GM card 2 *if this is the first attendance or a New Case, fill the personal information part according
register book
3 *if this is readmission, plot the figures in each chart as follow up.
Note: There are 1 Chart-1: Plot length or height on a vertical line (e.g. 75 cm, 78 cm). It will be round down
different kind of (Weight/Length) necessary to round the measurement to the nearest whole centimeter 0.1 to 0.4
growth cards to and round
analyses of the This chart reflects up 0.5 to 0.9
growth of 2 body weight Plot the weight as precisely as possible (100gr or 0.1kg) in horizontal
children and relative to the line that identified during weight measurement
follow up of its 3 child’s Length Continue the weight and length points/lines in horizontal and vertical
rend, which (wasting) axis and plot the crossing point
these cards 4 When points are plotted for two or more visits, connect adjacent
specified by points with a straight line to better observe the trend.
colors, as blue 1 Chart-2: Plot completed months on vertical line
cards express 2 (Weight/Age) Plot the weight as precisely as possible (100gr or 0.1kg) in horizontal
the growth line
status of boy 3 This chart reflects Continue the weight and length points/line in horizontal and vertical
babies and Red body weight axis and plot the crossing point
cards express 4 relative to the When points are plotted for two or more visits, connect adjacent
the growth child’s age points with a straight line to better observe the trend.
status of girl 1 Chart-3: Plot completed months of age on vertical line/axis (not between
babies (Length/Age) vertical lines).
2 Plot length on or between the horizontal lines as precisely as possible.
This chart reflects
3 Length relative to Continue the Length and Age points/line in horizontal and vertical axis
the child’s Age and plot the crossing point.
4 (Stunting) When points are plotted for two or more visits, connect adjacent
points with a straight line to better observe trends
21
8: Translate the 1 If the child’s weight/length, weight/age and length/age trend in continuous visits or plot
plots/trends to in first visit is between ≥-2 to ≤+2 Z score, child is well-nourished, appreciate the mother
decision and and encourage her to continue the same feeding practices in the future
action 2 Chart-1: If the child’s weight/length trend is ≥-2 to ≤+2 Z score in previous
visits and it is going toward <-2 or >+2 in recent visits or happening
Weight for Length any immediate drop in growth trend in this visit, inform the mother
for problems in feeding practices. And make a counseling session.
3 If the weight/length trend is <-2 to ≥-3 Z score, child is moderately
malnourished. Inform the mother for nutrition status of child, give her
counselling for improvement and refer the child to OPD-MAM services
if available and health facility’s doctor for further support
4 If the weight/length trend dropped <-3 Z score, inform the mother
that her child is severely malnourished, give her counselling and refer
her to OPD-SAM services
5 If the weight/length trend is between +2 & +3 Z Score, child is
overweight, inform the mother and Give counselling to her on proper
feeding practices and physical exercises.
6 If the weight/length trend goes beyond +3 Z, child is obese, inform the
mother and give her counselling on proper feeding practices and
physical exercises.
7 Chart-2: This chart indicates any changes in nutritional status of children
including Acute and Chronic malnutrition
Weight for Age
8 Chart-3: If the length/age trend is ≥-2 to ≤+2 Z score in previous visits and it is
going toward <-2 or >+2 in recent visits or happening any immediate
Length for Age drop in growth trend in this visit, inform the mother for problems in
feeding practices and provide her counselling for improvement.
9 If the length/age trend is <-2 to ≥-3 Z score child is moderately
stunted. Inform the mother for nutrition status of child, give her
counselling for improvement
22
10 If the length/age trend falls less than -3 Z score, child is severely
stunted, inform the mother give her counselling for improvement
11 Make appointment for next visit
12 Do not provide GM card to children who are identified MAM and SAM at first visit. They
will be enrolled in program after they become healthy and discharged from treatment
program, then are eligible to receive GMP card and follow their growth.
9: Translate 1 Normal No Petting Oedema
Edema, MUAC 2 nutrition MUAC is ≥125mm (≥12.5cm) (for children above six months)
and WHZ 3 Weight/Height is ≥ -2 Z-score
measurement to 4 Appreciate the mother and encourage to continue her current practice
decision/action 1 Moderate No Petting Oedema
2 Acute MUAC is <125mm to ≥115mm (<12.5cm to ≥11.5cm), (for children above 6
Malnutrition months)
(MAM)
3 Weight/Height is < -2 Z-score to ≥-3 Z-score
4 Provide counselling and refer to OPD-MAM
1 Severe No Petting Oedema (+, ++ or +++)
2 Acute MUAC is <115mm (<11.5cm), (for children above 6 months)
3 Malnutrition Weight/Height is <-3 Z-score
(SAM)
4 Provide counselling and refer to OPD-SAM
2.2. Screening of 24-59 months old children

The objective of screening is to find children with acute malnutrition at the health facility and community. This activity should be done
systematic for all children under five years old attending the health facilities.
Location: Screening room/nutrition counselor section

Responsible staff: nutrition nurse, Midwife or nutrition counselor
23
status
Yes No
1: Greetings and 1 Welcome the client and say thanks her for coming to HFs
4 Explain the processes and ask for her contribution during procedures
5 Complete the general information part of registration including name, age, sex and
address.
2: Checking 1 Remove footwear from child, if wearing
Edema 2 Grasp the foot so that it rests in your hand with your thumb on top of the foot
3 Use moderately firm thumb pressure over a bony area just above the ankle or the tops of both * For
feet for approximately three seconds. procedure
4 Release your thumb pressure see above
5 If an impression/indentation remains for at least a few seconds on both feet this is identified as GMP section
bilateral pitting edema and record it.
6 If edema detected in feet, check it in lower legs as well. In case it is positive in legs observe it
around the eyes’ orbits
3: MUAC 1 Ask the mother to unclothe the left arm of child
measurement 2 Ask the mother to bent left arm of child
3 Measure the length of the child’s upper arm; between the bone at the top of the shoulder and the
tip of the elbow
4 Find the midpoint of the upper arm and mark it with a pen.
5 The child’s arm should then be relaxed, falling alongside his/her body.
6 Wrap the MUAC tape around the child’s arm, such that all of it is in contact with the child’s skin. As per
7 feed the end of the tape down through the first opening and up through the third opening screening
protocols, for
8 Read the figure from the middle window where the arrows point inward. Record the number with
mm that meet sharply with arrows children less
Record the number in a slip than 24 months
9 Length
4: Weight 1 Use electronic scale. calibrate the scale on starting each working day with 3, 5 and 10 kg measurement
standard weight
measurement (laying
2 Place the electronic scale on a flat, hard surface.
position) and
3 Turn the scale on by waving your hand over the window. Make sure the scale is set to zero. for children
24
4 Ask the mother to remove shoes and any jacket, hat, scarf, head wrap, and other items of child so greater than 24
he or she is wearing minimal clothing. months up to
5 Ask the mother to stand the child on the middle of scale without touching anything and with his or 59 months
her weight equally distributed on both feet measurement
6 Read the weight in kg displayed in panel to the nearest 100 g (0.1 kg) and record it immediately of Height
on a piece of paper. (standing
5: Height 1 Use the standard weight measuring board (120 cm) position) is
measurement 2 Orient the mother on the process and her contribution to measurement (act as assistant) applicable
3 Ask her to lay the child on his back with his head against the fixed headboard, compressing the
hair.
4 Ask the mother to move behind the headboard and cup the ears to hold the child’s head so that
the child is looking directly upwards
5 Stand on the side of the length board where you can see the measuring tape. Ensure child lies
straight along the board with no position change and Shoulders touch the board
6 Bring the child’s knees together with one hand, applying gentle. With the other hand bring the
moveable foot piece of the length board to rest against the child’s heels
7 Read the measurement and record the child’s length in centimetres to the last completed 0.1 cm
6: Translate 1 Normal No Petting Oedema
Edema, MUAC 2 nutrition MUAC is ≥125mm (≥12.5cm) for over six months child
and WHZ 3 Weight/Height is ≥ -2 Z- score
measurement to 4 Appreciate the mother and encourage to continue her current practice
decision/action 1 Moderate No Petting Oedema
2 Acute MUAC is <125mm to ≥115mm (<12.5cm to ≥11.5cm) for over six months
Malnutrition child
(MAM)
3 Weight/Height is < -2 Z-score to ≥-3 Z-score
4 Provide counselling and refer to OPD-MAM
1 Severe No Petting Oedema (+, ++ or +++)
2 Acute MUAC is <115mm (<11.5cm) for over six months child
3 Malnutrition Weight/Height is <-3 Z- score
(SAM)
4 Provide counselling and refer to OPD-SAM
25
3.Assessing breastfeed, breastfeeding observation and history taking
Location: Midwifery section
Assessing a breastfeed helps you to decide if a mother needs help or not, and how to help her. You can learn a lot about how well or bad
breastfeeding is going by observing, before you ask questions. This is just as important part of clinical practice as other kinds of examination,
such as looking for signs of dehydration, or counting how fast a child is breathing. To know the root causes of problem with mother, we must
proceed with precise assessing breastfeeding and observation and then taking the history from mother for those issues which are not feasible to
be explored by observation. Following on the exercise we can identify the miss-practices with mother which need to be corrected through
proper counselling.
Interventions No Objective of activities Intervention Remarks
status
Yes No
1: Greetings 1 Welcome the client and thank her for coming to HFs
and 2 Show the client to have a set
welcoming/ 3 Introduce yourself and ask mother and child’s name
General 4 Ask her to tell you about her problems for which she attended HF
observation 5 Ask her for growth monitoring chart. If she has, quickly review it for child nutrition status
6 Ask her what have people told her about breastfeeding
7 Ask the mother whether she is carrying a feeding bottle in her bag
2: Assess 1 Assess mother’s mental status, refer to (2: Supporting nutrition of lactating women)
these signs 2 She holds her child securely and confidently, or nervously:
with mother 3 Look at his general health, nutrition, and alertness
and baby 4 Look for signs; blocked nose, difficult breathing, thrush, jaundice, dehydration, tongue tie, a cleft lip
or palate
3: Observe B- 1 Use the B-R-E-A-S-T observation form ➔ given in annex 1
R-E-A-S-T
4: History 2 Proceed with history taking filling ➔ given in annex 2
taking
26
4. Breast condition and Management
Location: Nutrition counselor section/Midwife
There are several common breast conditions which sometimes cause difficulties with breastfeeding:
− Flat or inverted nipples, and long or big nipples.

− Engorgement.
− Blocked duct and mastitis.
− Sore nipples and nipple fissure.
Diagnosis and management of these breast conditions are important both to relieve the mother, and to enable breastfeeding to continue. Below
is the standard operation procedure for treatment of such cases in HFs
Intervention No Objectives of activities Intervention Remarks

status
Yes No
1: Greetings and 1 Welcome the client and thank her for coming to HFs
welcoming 2 Show the client to have a set
3 Introduce yourself
4 Ask her to tell you about her problems for which she attended HF (flat and inverted nipple)
2: Management of 1 Build the mother’s confidence and ensure her that most nipples improve around the time of
flat or inverted delivery or during first two weeks without any treatment
nipples 2 Help her to make her nipple stand out more before a feed by stimulation
3 Help her to try different positions to hold her baby.
4 Practically help her on positioning and attachment
5 if the problem is remaining, apply the syringe method as below
6 Put the smooth end of the syringe over her nipple, as you demonstrated.
7 Gently pull the plunger to maintain steady but gentle pressure
8 Do this for 30 seconds to 1 minute, several times a day.
9 Push the plunger back to decrease the suction, if she feels pain.
10 Use the syringe to make her nipple stand out just before she puts her baby to the breast
1 Tell mother that effective treatment of this condition is removing of milk from breast, do not
advice the mother to rest her breast
27
3: Management of 2 Build the confidence of mother on ability of breastfeeding in this case
breast 3 If the baby can suckle, tell the mother to more frequently feed him/her
engorgement 4 If the baby is not able to suckle, help his/her mother to express her milk
5 Advise her to put a cold compress on her breasts after feeding the baby to reduce pain
4: Management of 1 Observe the breastfeeding practice of mother. Management
mastitis 2 Correct position and attachment by practical support. Advise mother to wear loose cloths of mastitis
3 Tell the mother to more frequently feed her baby should be
4 Advise her to gently massage the breast while her baby is suckling. treated by
5 Advise her to apply warm compresses to her breast between feeds. medical doc,
6 Tell mother to breastfeed the baby in different positions at different feeds. This helps to or Oby/gyn
remove milk from different parts of the breast more equally. specialist.
7 If the symptoms are severe, fissure is seen or no improvement after 24 hours with said Nutrition
measures. Add the below treatment as well Counselor
8 Advise antibiotic such as flucloxacillin 250 mg orally 6 hourly for 7-10 days or Erythromycin 250 don’t have the
mg orally 6 hourly for 7-10 days right of
medicine
prescription
9 Advise Analgesics to subside the pain. Paracetamol 500 mg 8 hourly
5: Management of 1 Observe the breast and nipple for severity of candidiasis (shiny red area of skin on the nipple and areola,
candida infection mother complaining burning or stinging after feeding and feeling as though needles are being driven into her breast)
2 Check the baby’s mouth for candidiasis. He may have white patches inside his cheeks or tongue
3 Advise local using of gentian violet 0.5% daily for 5 days to affected part of breast
4 Or, advise Nystatin cream 100000 IU/gr. Apply to nipples 4 times daily after breastfeeds.
5 Advise 0.25% gentian violet to baby’s mouth daily for 5 days
6 Or, apply Nystatin suspension 100,000 IU/ml 1 ml by dropper to child’s mouth 4 times daily
after breastfeeds for 7 days, or as long as mother is being treated.
6: Management of 1 Observe the baby breastfeeding, Examine the breasts, Look for signs of Candida infection with
nipple sore due to mother and baby
short frenulum If it is caused by short frenulum, advise the mother to get the child to take more of the breast
into his mouth
28
2 Build the mother’s confidence by explaining that the soreness is temporary
3 Help her to improve her baby’s attachment and tell her there is no need for rest of breast
4 If soreness is very severe, advise her to express milk and proceed feeding from another breast
5 Treat candidiasis if signs are existing
6 Advise her not to wash breasts more than once a day and not use medicated lotions/ ointments
5. Refusal to breastfed and crying
This session is about the problem of a baby refusing to breastfeed or being unwilling to suckle and cries a lot. In communities, refusal
is a common reason for starting artificial feeding which may lead to complete stopping of breastfeeding. Similarly, a mother may think
that she does not have enough breastmilk if her baby is “crying too much”. Many mothers start few feeds of animal milk or semi solid
foods if baby keeps on crying. An important way to help a breastfeeding mother is to counsel her about her baby’s crying and refusal
to feed. Below are the standard procedures that can help HFs staff to reach to this objective.
Location of action: Nutrition counselor section

Responsible staff: Nutrition counselor, Midwife or Nutrition Nurse
status
Yes No
4 Ask for MCH handbook
5 Kindly ask her to tell you about her problems for which she attended HF
2: Assess the 1 Check baby’s blocked nose, sore mouth, sedation, pain due to used instruments during
causes delivery and mother receiving some medication
2 Observe the breastfeeding techniques practically
29
3 Ask for changes if happened recently in surrounding environment (separation from
mother, mother illness, menstruation, pregnancy, change in mother smell, eating some
specific food)
4 Find weather it is real or apparent refusal (weight gain, normal urination, rooting for
breast)
5 Ask the bottle-feeding history
6 Find the result of excessive crying by searching signs of hungriness, high need babies or
colic
3: Provide 1 Build the confidence of mother and told her neither baby nor she is guilty
support 2 Correct the breastfeeding position and attachment if any mis-practice is recorded
3 If the refusal is not real, based on the GM card tell the mother that baby is growing well,
and she has enough milk to keep growth maintain.
4 If refusal is due to illness refer baby to OPD for further treatment.
5 If it is caused by environmental change, tell her to make the environment friendly and keep
child all the time with herself especially skit to skin contact is necessary.
6 If it is caused by bottle feeding, tell the mother to be patient for a while and continue
breastfeeding frequently, express milk into his mouth or feed baby by cup
4: General 1 Suggest that she lets him suckle from one breast only at each feed.
Counselling 2 Let him continue at the breast until he finishes by himself. Give the other breast at the
next feed
3 Advise her to takes less coffee and tea, and other drinks which contain caffeine
4 Explain that the best way to comfort a crying baby is to hold him close, with gentle
movement and gentle pressure on his abdomen.
5 Show her how to bring up her baby’s wind. She should hold him upright
6 Discuss the reason for the difficulty with the mother. When her baby is willing to breastfeed again,
you can help her more with her technique.
7 Explain her, If a baby is unable to suckle, he may need special care in hospital
30
6. Expressing breastmilk
Expressing breastmilk is necessary in some insentiences while baby is not able to suckle, or mother breast has any problem. Some
specific condition is refusal and crying, breast abnormalities, LBW babies, sick babies and working mothers. Expressing breastmilk help
both mother and baby to stay healthy in such cases. It maintains the growth of baby and stimulate the prolactin reflex continuously
to keep the breast functional to not stop milk production. Many mothers can express plenty of breastmilk using rather strange
techniques. If a mother’s technique works for her, let her continue to do it that way. But if a mother is having difficulty expressing
enough milk, teach her a more effective technique. Below are the specific steps for expressing the breastmilk that can be used by
frontline workers when they help a mother accordingly.
status
Yes No
1. Expressing 1 explain when it is useful for a mother to express breastmilk
breastmilk by 2 Help mother to stimulate prolactin and oxytocin reflexes
hand 3 teach a mother an effective technique for hand expression
4 Chose a cup, jag or jar with wide mouth.
5 Wash it with water and soap
6 Pour boiling water into the cup and leave it for a few minutes. Boiling water will kill most of the
germs
7 Tell mother to be ready for process.
8 Tell her to wash both hands with water and soap
9 Teach a mother to do this herself. Do not express her milk for her
10 Sit or stand comfortably, in a quiet place and hold the container near her breast
11 Put her thumb on her breast ABOVE the nipple and areola, and her first finger on the
breast BELOW the nipple and areola, opposite the thumb. She supports the breast with
her other fingers
31
12 Tell to gently press her thumb and first finger slightly inwards towards the chest wall.
She should avoid pressing too far or she may block the milk ducts.
13 Press her breast behind the nipple and areola between her finger and thumb. She must
press on the lactiferous sinuses beneath the areola
14 Press and release press and release. This should not hurt, if feeling any pain process is
wrong
15 Press the areola in the same way from the SIDES, to make sure that milk is expressed from
all segments of the breast.
16 Avoid rubbing or sliding her fingers along the skin. The movement of the fingers should be
more like rolling.
17 Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk. It
is the same as the baby sucking only the nipple
18 Express one breast for at least 3 - 5 minutes until the flow slows; then express the other
side; and then repeat both sides. She can use either hand for either breast or change when
they tired.
19 Explain that to express breastmilk adequately takes 20-30 minutes, especially in the first
few days when only a little milk may be produced. It is important not to try to express in
a shorter time.
2: Expressing 1 It is mostly recommended to engorged breasts with having pain. Tell the mother to wash
breastmilk by the pump with water and soap before use.
rubber bulb 2 Compress the rubber bulb to push out the air
breast pump
3 Place the wide end of the tube over the nipple. Make sure that the glass touches the skin
all around, to make an airtight seal.
4 Release the bulb. The nipple and areola are sucked into the glass
5 Compress and release the bulb again, several times
32
6 After compressing and releasing the bulb a few times, milk starts to flow. The milk
collects in the swelling on the side of the tube.
7 Break the seal to empty out the milk and start again.
3: Expressing 1 Make sure that syringe is not used before for injection of any drug and it is uncovered for
breastmilk by first time
syringe 2 Put the funnel-shaped wide end over the nipple
3 Make sure that it touches skin all round, to make an airtight seal.
4 Pull the outer cylinder down. The nipple is sucked into the funnel.
5 Release the outer cylinder, and then pull down again.
6 After a minute or two milk starts to flow and collects in the outer cylinder.
7 When milk stops flowing, break the seal, pour out the milk, and then repeat the
procedure.
8 A syringe pump is more efficient than a rubber bulb pump, and it is easier to clean and to
sterilize.
4: Expressing 1 This method is most useful to engorged breasts, tender breasts and tight nipples.
breastmilk using
2 Use a glass made bottle with 2 cm nick and at least 700 ml volume capacity
warm bottle
3 Full the bottle with hot water. Let the bottle stand for a few minutes to warm the glass
4 Cool the neck of the bottle with cold water, inside and outside.
5 Put the neck of the bottle over the nipple, touching the skin all round to make an airtight
seal.
6 Hold the bottle steady. After a few minutes the whole bottle cools, and makes gentle
suction, which pulls the nipple into the neck of the bottle
33
7 Keep the bottle there as long as the milk flows.
8 Pour out the breastmilk, and repeat if necessary, or do the same for the other breast.
7. Not enough Milk

One of the most common reasons that mothers give bottle feeds, or stop breastfeeding, is that they think that they “do not have
enough milk”. Usually, when a mother thinks that she does not have enough breastmilk, her baby is in fact getting all that he needs.
Almost all mothers can produce enough breastmilk for one or even two babies. They can almost all produce more than their baby
needs. Sometimes a baby does not get enough breastmilk. But it is usually because he is not suckling enough, or not suckling
effectively. It is rarely because his/her mother cannot produce enough milk. In such cases, mother need technical support from
frontline workers. Below is the recommended action to be taken while facing these cases in HFs

status
Yes No
1: Check and ask 1 If baby continuously loss weight beyond 10th day of birth, or → GM card can be used as
signs of not reference
getting proper 2 Birth weight not regained by 14th day, or → GM card can be used as reference
weight
3 Weight loss more than 10% of birth weight, or→ GM card can be used as reference
4 Baby gain less than 500 gr weight per month, or
5 Baby’s current weight less than birth weight after 2 weeks, or
6 Passing small amounts of concentrated urine or less than 6 times per day. Yellow and
strong smelling.
34
7 Existence of possible signs; baby cries often, not satisfied after breastfeeding, refusal and
no milk come out when mother expresses
2: Assess the 1 Breastfeeding factors; attachment, position, infrequent feeds, bottle, pacifier, no night
factors that may feeding
cause not 2 Mother’s physiological factors: lack of confidence, worry, stress, mental status
enough milk
3 Mother’s physical condition; taking contraceptive, diuretic, pregnancy, SAM,
4 Baby’s condition; LBW, nose block, illness and other abnormalities
3: Help the 1 Following on assessment, you identified the factor caused not enough milk. Use
mother whose counselling skills and provide her support for solution
baby does not 2 Build the confidence of mother
get enough
3 If mother or baby has any disease, refer them to doctor for further treatment
breastmilk
4 Tell mother to have weekly follow up visits until baby starts weight gain. Emphasize on
GM visits
4: Help the 1 Build the mother confidence
mother who 2 Explain her all signs in baby indicating on good weight gain (urination, 500 gr weight
think her baby gain/month)
does not get
3 Explain how breastfeeding work
enough
breastmilk
8. Breastfeeding low birth weight and sick children

Location: Health professional, Midwifery section and Nutrition counselor section
The term low birth weight (LBW) means a birth weight of a baby less than 2,500 grams. This includes babies who are born before term, and who
are premature, and babies who are full-term but small for gestational age. Babies may be small for both these reasons. Optimal breastfeeding
35
practices are extremely important for babies of low birth weight. Low birth weight babies are at particular risk of infection, and they need
breastmilk more than larger babies. Yet they are given artificial feeds and bottle feeds more often than larger babies.

status
Yes No
1: Babies who are less than 30-32 weeks gestational age→ Feed them by NG tube using
Breastfeeding expressed breastmilk
of LBW Babies between 32-34 weeks gestational age→ Give expressed breastmilk by cup or spoon
Babies from about 34-36 weeks gestational age or more→ Tell mother to feed them directly
from breast. Support them for proper positioning and attachment
Tell the mother that LBW children may take 4-5 sucks, and then pause for up to 4 or 5
minutes. It is important not to take him off the breast too quickly
Teach mother for best holding positions of LBW → underarm and across her body
Teach mother to wash her hands with water and soap whenever she touches or feed the
LBW baby- they are more prone to infection
Advice mother to keep baby warm and give breastmilk frequently
Jaundice can develop with LBW, tell mother to continue only breastfeeding more frequently
2: Advise mother to breastfeed the baby more frequently, even 12 feedings per day
Breastfeeding If baby does not suckle or refuse, teach her to express breastmilk and give it by cup or spoon
of sick If a baby is unable to take expressed milk from a cup; refer him to HFs to apply NG tube
children
9. Increasing breastmilk and re-lactation

If a mother’s breastmilk supply is reduced, she needs to increase it. This often happens when there is a difficulty in breastfeeding, or
the baby was sick and did not take breastfeeding for few days. If a mother has stopped breastfeeding, she may want to start again.
This is called re-lactation. The same principles and method apply for increasing a reduced supply, and for re-lactation, so we describe
36
them both together-lactation is more difficult and takes longer. The mother must be well motivated, and she needs a lot of support
to succeed. Sometimes it is also necessary to use the methods described in ‘Management of refusal to breastfeed.

status
Yes No
1: Help the 1 Take breastfeeding history and find the reason caused less milk production
mother to 2 Explain with the mother the reason for her poor milk supply
increase her milk 3 Explain what she needs to do to increase her supply. Explain that it takes patience and
perseverance (maybe restored in 1-2-week time)
4 Prior to giving the counselling, build mother’s confidence
5 Explain that she should keep her baby near her, give him plenty of skin-to-skin contact,
and do as much care as possible for him/her herself
6 Explain that the most important thing is to let her baby suckle more - at least 10 times in
24 hours, more if he is willing.
7 Observe the breastfeeding process, correct position and attachment if mother does not
know
8 Discuss how to give replacement feeds, while she waits for her breastmilk to come, and
how to reduce it as her milk increases (reducing 30-60 ml per day with little breastmilk
flow)
9 Explain that replacement feeding should be done by spoon or cup not by bottle of
pacifier
10 Advise her more eating, drinking, rest, and relax
11 Check the baby’s weight gain and urine output, to make sure that s/he is getting enough
milk
If s/he is not getting enough, do not reduce the artificial feed for a few days. Even
increase it
37
12 If her baby refuses to suckle on an ‘empty’ breast, help her to find a way to give the
baby animal milk while s/he is suckling. With a dropper or a breastfeeding supplementer
(need to admit the child in HFs during this period)
2: Help a mother 1 Ask the mother to hole the baby under her breast on proper position and attachment.
to use a 2 Wash properly you and mother hands for the use of breastfeeding supplementer (cup, tube
breastfeeding etc.).
supplementer Use a fine nasogastric tube and hold the cup full of milk.
3
4 Prepare a cup of milk (expressed breastmilk or artificial milk) containing the amount of milk that
her baby needs for one feed
5 Put one end of the tube along her nipple, so that her baby suckles the breast and the tube at the
same time. Tape the tube in place on her breast.
6 Put the other end of the tube into the cup of milk.
7 Tie a knot in the tube if it is of large size, or put a paperclip on it, or pinch it. This controls the
flow of milk, so that her baby does not finish the feed too fast
8 Control the flow of milk so that her baby suckles at the breast for about 30 minutes at each feed
if possible
9 Inform the mother, raising the cup makes the milk flow faster, lowering the cup makes the milk
flow more slowly.
10 Let her baby suckle at any time that he is willing - not just when she is using the supplementer
11 Clean and sterilise the tube of the supplementer and the cup each time she uses them.
12 Or help her to understand using syringe, dropper or dripping expressed milk in to child
mouth
10. Facility Based Food Demonstration

Facility based food demonstration is an activity to promote use of local available food in the communities for prevention and
treatment of malnutrition among children. If at the same facility and among families with almost similar accessibility to locally
available food items some children are well nourished and grow well, while the others are not growing well or suffer from
malnutrition. It suggests that families with malnourished children or those with failure in proper growth fail to use the available
food properly. Therefore, the facility-based food demonstration is helping them to use the available food properly, to feed their
children, to prevent and treat malnutrition.
38
Responsible staff: Nutrition counselor or Nutrition Nurse
status
Yes No
1: Greetings and 1 Welcome the clients
welcoming 2 Show the clients to have a set
4 Introduce the procedure and objective of your session
5 Ask them to pay attention carefully
2. FOOD 1 Wash hands and forearms with soap and water for 20 second before wearing gloves
DEMONSTRATION 2 Use local available foods
3 Organize your demonstration for less than two hours total
4 Consider a personal, environmental hygiene, sanitation and cleaning during food
demonstration and preparation
5 Try your best to encourage mothers to share their opinions and questions as well as
their participation
6 Try your best to have verbal and eye contact to all mothers to attract their attention.
7 Try to keep the balance of verbal and eye contact to all mothers the same.
8 Think about food ingredients for cooking balance diet for women and children
9 All the cooking materials and utensils including food items should be prepared on a
wide table to enable participants to watch them easily
10 consider the food balance including energy, protein, fat, and micronutrients,
especially Iron, vitamin A, and zinc.
11 Gives bellow message in each food demonstration session to the clients:
1) Eat fruits and vegetables, whole grains, and fat-free or low-fat milk products
every day.
2) Be physically active every day as part of a healthy lifestyle.
3) Balance caloric intake from food and beverages with calories expended.
39
12 Ask the mothers to share your questions if they have
13 Get feedback from mother to know how much they captured your messages
14 Retry to tell the points if mother couldn’t capture correctly.
Section 2
Integrated Management of Acute Malnutrition (IMAM SoPs)
1. Community Outreach for the Integrated Management of Acute Malnutrition
This chapter provides guidance on community outreach for acute malnutrition in children under 5 years of age and PLW as a core component of
the IMAM approach.
Location: Community
1.1. Principle of community outreach

Community outreach for IMAM is integral part of the CBNP. Below are the community outreach activities that includes:
1) community sensitization,
• nutrition counselling, health and nutrition education and food demonstrations
2) community screening
• growth monitoring and infant and young child feeding (IYCF) of children under 2 years of age,
• Screening for acute malnutrition of children under 5 years of age and PLW with an infant under 6 months of age
3) home visits for problem cases.
Intervention No Activity Objective: interventi Remarks

on status
40
Yes No
1: Community Sensitization to Increase Awareness and Involvement
1.1 Understanding the 1. CBNP monthly meeting (gathering) :

opportunities for 2. Community development committee (CDC)
community 3. Health post is also an opportunity for community sensitization awareness
sensitization 4. House to house case finding by doing screening of U5 children by CHWs in the HP
awareness: catchment area
5. Involving mothers or carers of children with acute malnutrition
6. Case finding through routine or special health outreach opportunities as mobile health
and nutrition teams (MHNTs) by measuring MUAC and checking for oedema of U5
children
7. Active adoptive case findings identify children with acute malnutrition, the case finders
then ask community members to refer them to children with similar signs, until no
more cases are found in the area.
8. Mass screening for acute malnutrition organized with the consent and cooperation of
village leaders can reach most children in a community with efficient screening.
9. Other community-based entry points for screening children for malnutrition include
carers seeking advice or care from private health practitioners, drug vendors, teachers
or mullahs when their children become sick. Sensitising and training opinion leaders on
how to measure MUAC and check for bilateral pitting oedema will be useful to not
delay treatment. Other community-based sensitization initiatives for promoting
healthy behaviors of WASH
10. Formal and informal community meeting and social gatherings e.g., meetings of FHA
groups and health shura, Friday prayer, weddings and funerals
11. The local radio and other public media may disseminate key messages via radio spots
or billboards, or community drama opportunities.
1.2 Select the specific 1. Give the sensitization messages on.

messages A. How malnutrition is caused?
B. Why it is serious?
C. How to prevent it?
D. How to identify malnutrition cases?
41
E. How to cure it and where to refer malnourished children and PLWs?
2. To achieve.
A. Improving the understanding of adequate nutrition and malnutrition and their effects
on the community.
B. Empowering communities by raising awareness that prevention is better than
treatment and that attending monthly growth monitoring, health and nutrition
education sessions and cooking demonstrations help prevention.
C. Encouraging the adoption of healthy behaviors and timely health seeking.
D. Encouraging to access treatment that it is freely available and retain in treatment until
full recovery.
2: Community Screening for Active Case Finding and Referral

2.1 Monthly growth 1. Tell the CHWs to do GM of all under two children using WAZ indicator on monthly base
monitoring 2. Then plot it in the GM chart
3. Identify their growth status and give relevant counselling to their care takers
4. Register all children in relevant formats
5. Refer the children to HFs who correspond the yellow or red growth line or have
breastfeeding difficulties
6. Counsel the mother based on the identified problems in the child nutrition status or
feeding practices (please refer to topic 2.5 for counselling messages)
2.2 Monthly screening CHW do the screening on monthly bases of all under children 5 years of age attending the
health post by:
1. measuring their mid-upper arm circumference (MUAC) of 6-59 months children, and
• If MUAC is greater than 125 mm tell mother to proceed with current nutrition
practices
• If MUAC is less than 125 mm refer the mother to take the children to nearest HFs for
further investigation
2. checking for bilateral pitting oedema of all U5 children
• Counsel the mother based on the identified problems in the child nutrition status or
feeding practices
42
2.3 Involving mothers • CHWs involve the mothers during screening and growth monitoring at the center of care
or carers of children and acknowledge their care role.
with acute • Tell the mother that they are in the best position to measure nutrition status of their
malnutrition: children by themselves
• CHWs can provide a MUAC tape and train mothers to measure MUAC correctly and check
for oedema in their own and other children in their close environment.
• CHWs train mothers on how to feed their children considering their age and when her
child need refer to the HF
Criteria for identifying and referring cases of acute malnutrition in the community
Infants under 6 months of Children 6–59 months Pregnant and
age of age lactating women
Bilateral pitting oedema Bilateral pitting oedema MUAC < 230
Visible wasting MUAC < 125 mm mm
Breastfeeding difficulties Loss of appetite
Loss of appetite
Failure to gain weight
2.4 Home Visits to During home visits, CHWs consider the below points to do:
Strengthen • Screening of 6-59 months children by MUAC measurement
Compliance with and • Checking the oedema of 0-59 months children
Retention in • Follow up of the referral cases
Treatment • Follow up of the current admitted SAM or MAM cases
• Tracking the defaulter cases and referring to the treatment
• Tracking the absent children during GMP session
• Counsel the mother based on the identified problems in the child nutrition status or
feeding practices
2.5 Counselling to the CHW will do counselling based on the below identified problems in the child nutrition status
mothers on the child and feeding practices:
nutrition status or 1. Counsel the mother on proper feeding to those children when identified problem in their
feeding practices nutrition status during GM and screening
2. In under 6 months children CHW investigate the exclusive BF, positioning and attachment,
if identified problem counsel the mother and solve the problem
43
3. In over 6 months children, ask about the proper feeding, if there was a problem, counsel
her considering FATVA regarding CF
a. Meals should be provided 2-3 times per day at 6-8 months of age
b. Meals should be provided 3-4 times per day at 9-11 months of age
c. Meals should be provided 3-4 times with additional nutritious snacks (such as piece of fruit
or bread or chapatti with nut paste) per day at 12-24 months. Offer 1-2 times per day as
desired.
4. Counsel the mother to continue here BF up to 2 years or beyond
5. Counsel the mother on how to feed sick child
6. Counsel the mother to wash hands with soap in critical times (i.e. after using the toilet,
before cooking and feeding of children)
7. Counsel the mother to use clean and safe water for hand washing, drinking and food
preparation
8. Reduce sugar intake and drink less gassy drinks
9. Use less salt, fats and processed foods
10. Pregnant and breastfeeding women should eat extra amounts of nutritious foods
11. Sleep under an insecticide-treated mosquito net to prevent malaria and seek prompt
treatment of malaria.
12. Counsel the lactating mother to continue to eat three main meals and two healthy snacks
per day to ensure enough nutrients to enrich breast milk.
13. Counsel the lactating mother to continue to eat foods from all the food groups,
especially fruits and vegetables and animal-source food, to ensure that your infant
gets enough vitamins and minerals for good physical and mental development.
Reporting CHW will prepare below reports and send to the CHS at the end of each month:
• Monthly activity report (MAR)
• Monthly CBNP report
2. Management of Moderate Acute Malnutrition and Uncomplicated Severe Acute Malnutrition in Children 6–
59 Months of Age.
44
Management of acute malnutrition performs in different level and approach according severity of weight loss and existence of complications.
Which, this part provides guidance on case management of moderate Acute Malnutrition (MAM) and uncomplicated SAM in children 6–59 months
of age in OPD-MAM and OPD-SAM respectively as part of the IMAM approach aligning with IMNCI. And for this purpose, you would need to follow
below instructions when work in nutrition section of a health facility to provide said services properly.
2.1- Screening
Location of action: Nutrition counselor’s room

Responsible staff: Nutrition counselor and nutrition nurse
By screening of children, you can assess the nutritional status of child, detect acute malnutrition, and classify types and severity of malnutrition.

on status
Ye No
s
1. Greetings and 1 Welcome the client

4 Ask for the MCH handbook for children below 24 months
2. Screening for Acute 1 Ask name, sex and age of the child *. For
Malnutrition, children 2 Consider a row in register book and record personal information of the child. details and
0-59 months 3 Ask the mother to remove the cloths, socks and shows of her child and tell her the procedure
reason and why you are asking it. of
4-a Check pitting sign for diagnosis of Edema on both feet. anthropom
4-b If you find Edema on feed. Then, assess for Edema on forelegs, arms and face of etric
the child to determine the severity of Edema. measurem
45
5 Measure the MUAC (Med Upper Arm Circumference) of the child if he/she is above ents please
6 months. * refer to
6 Measure the Weight of children by using UNISCALE or SECA Scale* GMP
section.
7 Measure Height of the children by using standard height board*
8 Use Moyo chart to determine Standard Deviation of Weight and Height (Z-Score)
9 Record all measures and information in register book
10 Tell mother about nutrition status of her child
2.2 Making decision about nutrition status and referral of malnourished cases to relevant services
Location of action: Nutrition Counselor Room

Responsible staff: Nutrition Counselor and Nutrition Nurse
Whenever you competed Screening and determined nutritional status of the child, then make decision according to
below malnutrition classification and commands.
1- Normal child 1 If nutritional edema is not present, and
2 if his/her MUAC is ≥125mm, and
3 Weight for Height (W/H) is ≥-2SD and
4 No visible wasting found
5 Appreciate and encourage the mother to continue her current feeding practice to
her child.
2-Child is Moderately 1 Nutritional Edema is not present, but
acute malnourished 2 Her/his MUAC is <125mm and ≥ 115mm, or
(MAM)
3 Weight for Height (W/H) is <-2SD and ≥-3SD
4 Then provide supplementary feeding counseling to mother and refer the child to
OPD-MAM section.
46
3-Child is Severely acute 1 If nutritional edema is present, or
Malnourished (SAM) 2 Her/his MUAC is <115mm, or
3 Weight for Height (W/H) is <-3SD
4 Then, provide child’s condition-based counseling and refer the child to OPD-SAM
section for treatment.
2.3.Emergency assessment and treatment:

Location of action: OPD-SAM section
Responsible staff: Doctor/Nurse
Children who are detected as MAM or SAM in screening area and referred to medical doctor of HFs to proceed with
further treatment may have some life-threatening health problems which need emergency response and caring. To know
the health status, the medical doctor or assigned nurse should check the general IMNCI danger sings and other sings that
indicate presence of medical complications with child. Children with danger sing of life-threatening condition will receive
emergency care and are stabilized before referral to hospital or IPD-SAM. If there is not any dander sing and child has
MAM or SAM that can be treated in OPD-MAM or OPD-SAM by giving supplementary and therapeutic food. Below are the
standard procedures that can help the service provider to make decision for proper treatment service.
1: Assis the general 1 Is the child able to drink or breastfeed?

dinger signs 2 Does the child vomit everything?
3 Has the child had convulsion?
4 Is the child lethargic or unconscious?
5 Is the child convulsing now?
2: Assess other signs 1 Children with +++ odema or miasmic kwashiorkor
that need urgent 2 Difficult/fast breathing, stridor, wheezing or chest indrawing
47
referral to inpatient 3 Age more than 6 months and weight less than 4 kg
services 4 Hypothermia
5 Severe anemia (laboratory test or palmar pallor)
6 Extensive skin lesions
7 Vit-A deficiency eye signs or active measles
Check for signs of dehydration associated with watery diarrhea
Perform appetite test (Give RUTF and wait for 30 min and compare with below
table)
Age / weight Good appetite Poor appetite

Less than 5 kg Eat at least ¼ packet Eat less than ¼
packet
More than 5 kg Eat at least 1/3 Eat less than 1/3
packet packet
Less than 6 months Don’t use RUTF/RUSF, refer them to IPD-
and less than 4 kg SAM
Make decision for Refer to Refer the child to IPD-SAM
proper treatment IPD-SAM
service 1. If child has even one of above medical complications
2. If child does not have appetites or has poor appetite
3. If child is Marasmic-kwashiorkor (existence of bilateral petting
Edema and MUAC <115mm or W/H<-3SD at same time)
4. Child has bilateral petting edema grade (+++)
5. Children above 6 months with less than 4kg body weight
Child has MAM criteria

Child does not have dinger sing
48
Treatment Child has appetite for RUSF
in OPD-
MAM
Treatment Child has criteria for SAM
in OPD-SAM If child is alert and does not have any complication as above
If child has good appetite, and
Child’s body weight is above 4kg
3: Referral 1 In case, any mentioned signs noticed in MAM or SAM child, urgently refer them to
inpatient services.
2 Provide the below emergency treatment prior to refer
1 Give 10% sugar water (10 gr or 2 heaped teaspoons in 10 ml water) to prevent
4: Emergency Hypoglycemia.
treatment prior to 2 Cover the child and keep him/her warm and away from draught.
referral 3 Give antibiotic, preferably Amoxicillin 40mg/kg two times per day or
Cotrimoxazole (trimethoprim 4 mg/kg + sulfamethoxazole 20 mg/kg) orally two
times per day.
4 If child has convulsion, give Diazepam 0.5mg/kg (or 0.1ml/kg from 10mg/2ml
Diazepam Injections), preferably give it rectal.
For giving the Diazepam rectally, use 1ml syringes, remove the needle then insert
it up to 4-5cm in rectum, inject the diazepam solution then hold the buttocks
together for few minutes.
5 If Corneal ulcer is present, give one dose of Vit-A according to child age (50000IU
for <6 months, 100000IU for 6-12 months and 200000IU for above 12 months).
Then,
Cover the affected eye with Saline Soaked pad and bandage the eye.
6 If child has high fever Don’t use PARACETAMOL because of the risk of Hepatic
damage.
7 Record anything you did for child in referral card and register book.
49
3. Management of Moderate Acute Malnutrition for Children 6-59 Months in OPD - MAM:
The child who were screened and detected as MAM by Nutrition counselor and clinically assessed by nurse or medical doctor and there is not any
medical complication can be treated in this program. The child will get MAM services as below.

on status
Yes No
4 Ask for the MCH handbook *
2: Treatment of child 6- 1 Ask name, age and sex of the child.
59 months in OPD- 2 Register the child and Fill a patient card with detailed address and health
MAM information
3 Treat for minor associated medical conditions according to IMNCI guide
4 Give single dose anti-helminthic on admission,
Mebendazole 250 mg for children 12-23 and 500 mg for children ≥ 2 years
Albendazole 200 mg for children 12-23 and 400 mg for children ≥ 2 years
5 Advice 14 sachets RUSF for two coming weeks (500 Kcal or one sachet of 92gr in
a day), (if RUSF distributes by food distributer, then ask the mother to recei RUSF
from distribution point)
6 Give the follow up card or mother card to caretaker and instruct her to get RUSF
from food distribution point in the HFs.
3: Counseling 1 Provide counselling on proper complementary feeding using home available food
2 Provide counseling on breastfeeding continuation until 2 years
Provide counselling on proper usage of RUSF and not sharing with others
3 Counsel the mother or carer on sensory stimulation and emotional support of the
child and convince them to play with child or let her/him to play with other
children.
4 Counsel the mother to come back if danger signs appear
5 Verify the immunization schedule and vaccinate the child if
50
needed.
6 Make an appointment for a follow-up visit biweekly and advice to have the follow
up card and empty sachets of RUSF with herself at each visit.
4: Follow up visit of 1 Check the patient card if two weeks has completed from her/his last visit, then
children 6-59 months follow as bellow.
with MAM 2 Check edema, measure weight, height, MUAC and determine Z-score
3 Check clinical signs of childhood diseases (Absence of health problem or medical
condition according to IMCNI)
4 Check treatment progress to determine whether the child gained weight or not
(weight change and MUAC improvement)
6 In case of failure to response to treatment (decrease in MUAC and WHZ (reaching
to SAM cut-off or presence of Edema) decide to refer to OPD-SAM.
7 Do appetite test
8 If child has improved, continue the treatment.
9 Collect empty sachets of RUSF and deduct from next ration if some sachets are
at home and child has not eaten still.
10 Give another ration of RUSF for two next weeks.
11 If the x does not attend in bi-weekly visits decide on home visit or follow up
through CHW to find the reason of absence and prevent his/her default.
5: Counselling during Provide counselling on proper complementary feeding using home available food
follow up Provide counselling on proper usage of RUSF and not sharing with others
Counsel the mother or carer on sensory stimulation and emotional support of the
child and convince them to play with child or let her/him to play with other
children.
Make an appointment for a follow-up visit biweekly and advice to have the follow
up card and empty sachets of RUSF with herself at each visit.
6: Discharge the child If MUAC reached to ≥ 12.5 Cm for two consecutive visits for children
from program who had admitted by MUAC criteria at admission time, or
W/H ≥-2SD for two consecutive visits for children who had admitted
1 by W/H-Zscore at admission time, and
Cured No Edema
Before discharge, provide counseling for mother on house care and
proper feeding the child.
51
2 Default: if child didn’t attend in two consecutive follow up visits.
3 Death: if child has dead because of any reason during treatment.
Refer to OPD-SAM: if child has weight loss and reached to SAM criteria during
treatment in OPD-MAM
4 In case of defaulting any child from program, share the detailed address and
information of child with CHS for follow up.
4. General case management of uncomplicated severe acute malnutrition in OPD-SAM for children aged 6-59
months
Location of action: OPD-SAM room
Responsible staff: Pediatrician and nutrition nurse
OPD-SAM usually receives those children who are detected as severely acute malnourished in screening section or referred from OPD-MAM,
Following on medical check-up by medical doctor, if there is no medical complication they can be treated in OPD-SAM services by giving specific
therapeutic food that is called RUTF. For proper management, below are the standard procedures

on status
Yes No
Greetings and 1 Welcome the client
4 Ask for the MCH handbook *
6 Complete the registration ( asking personal information of client)
If child is uncomplicated and you decided to admit in OPD-SAM, follow below commands:
1 Ask name, age and sex of the child
52
6-59 months SAM 2 Fill a patient card with detailed address and health information
children treatment in 3 Treat small associated illness (skin infection) which is manageable by home
OPD-SAM treatment.
4 Treat for presumptive infections with routine antibiotics (Amoxicillin or Table in
A) - (New Cases) or first Cotrimoxazole based on body weight) for five days. * annex
visit 5 Prescribe home amount of RUTF 200 Kcal/Kg/Day for 7 days (or use RUTF Table in
distribution table for calculation of number of RUTF sachets) annex
Refer to the child to vaccine section for measles vaccination
6 Counsel the mother or carer on feeding and care practices and the
use of RUTF at home.
7 Encourage the mother to continue breastfeeding.
Make an appointment for a follow-up visit every week.
8
9 Register the child and give a unique registration number.
10 Fill out a ration card that is kept by mother or carer.
11 Send the mother to pharmacy section to receive RUTF.
Counselling Explain the severity of the child’s condition; explain that the child can be treated
as an outpatient as long as he/she can comply with the treatment, come back
each week for follow-up to monitor progress until the child fully recovers
Continue to breastfeed the child on demand until the child reaches at least 2
years
Explain how to give the drugs (observe giving the first dose) and the RUTF
(observe and guide the mother during the appetite test) at home.
Wash the child’s hands and face and clean the RUTF sachet with soap before
feeding.
Give the daily-prescribed dose of RUTF to the child with sips of drinking water
after each mouthful. The first week, the child should not eat anything else
Do not mix RUTF with water or other fluids. Keep the RUTF sachet clean and
covered.
Do not share the RUTF with members of the family; RUTF is a treatment for the
malnourished child
Continue to feed the RUTF even if the child has diarrhoea. During illness, give
more food and fluids.
Ask mother or carer to bring back the RUTF empty sachets in each follow up visit.
53
1 Check loss of Edema
Follow up visits: 2 Check the weight,
3 Calculate weight gain and compare with last visit.
4 Check MUAC increasement and compare with last visit.
5 Ask the mother about health condition of child during last week
6 Check body temperature
7 Check Respiratory rate
8 Check pulse rate
9 Check appetite of the child
10 Absence of health problems or danger sings according to IMNCI
11 Check the empty sachets of RUTF to know the consumption of RUTF
12 Give RUFT for next week, considering the number of RUTF sachets that didn’t
consume by child. (*use RUTF distribution table)
13 Advise the mother to give all RUTF to malnourished child.
14 Treat for presumptive helminthiasis on 2nd visit or at admission time if child is

referred from IPD-SAM, as below:
- Single dose Mebendazole (250 mg for children 12–23 months of age
and 500 mg for children ≥ 2 years of age), or
- Albendazole (200 mg for children 12–23 months of age and 400 mg for children
≥ 2 years)
15 Make appointment for next visit.
Counselling on follow up All points indicated in first visit counselling above

visit From the second week, complementary food may gradually be offered after
taking the prescribed dose of RUTF
give age-specific counselling on feeding and care. Complementary feeding should
be gradually introduced alongside continued breastfeeding after the daily RUTF
dose is taken
B)- Referred IN from Check the referral sheet for child’s progress and treatments done in IPD-SAM.
IPD-SAM Check appetite, if maintained
Absence of health problems and danger signs
If child does not have improvement re-send to IPD-SAM
54
check the child, if Do not give routine antibiotics, unless any small issue needs antibiotic therapy
improved admit to OPD- (could be specified in referral sheet)
SAM If the child has been referred by your site, find the previous record and start
treatment from where he/she left in OPD-SAM
If the child is referred for first time to OPD-SAM site, handle him/her as child
come to OPD-SAM for first time (?)
C) Return after default: If child has SAM criteria, admit the child to OPD-SAM
Within 3 months after
defaulting Find the previous record in register and start treatment from where he/she left
the program
Refer to IPD-SAM, in 1 If there is no weight gain up to 5th visit or in 3rd visit weight is less than admission
follow up visits if weight, or
2 If Edema is present in 3rd visit, or
3 If appetite has lost, or
4 Presence of medical danger signs
END OF TREATMENT 1 Cured: use the If MUAC reached to ≥ 12.5 Cm for two consecutive visits
2 same criteria for If WHZ reached to ≥ –2, for two consecutive visits
3 admission and If Edema is absent, for two consecutive visits, and
4 discharge Child is alert and well
5 If the child is absent for two consecutive visits, record the
Default third missed visit as defaulting,
Give the list of defaulted children to CHS for further follow
and plan of home visit by CHW to inquire the reason of
defaulting.
6 Death If child dead at the result of any reasons, clinical or non-
clinical
7 Non cured If child didn’t achieve discharge criteria after 16
consecutive visits with full attention of involve staff.
8 Refer to IPD-SAM Mentioned above
55
5. Management of Complicated Severe Malnutrition in Children 6-59 Months of Age
Location of action: IPD-SAM section in the hospitals

Responsible staff: Pediatrics specialist, pediatrician & Nutrition Nurse
The child with Severe Acute Malnutrition must be treated differently because his physiology is seriously abnormal due to 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.
The main goal for admitting the complicated SAM children in IPD-SAM is to protect the child’s survival and prevent from death or disability. Hence,
precision in diagnosis of complications those which needs prompt action is the most important. Hence, management of children in this section
needs your cautiously feeding and treatment.
5.1- initial management:
The main goal of IPD-SAM management is to protect the child’s live and prevent from death. Hence, precision in diagnosis of complications those
which needs prompt action is most important.
on status
Yes No
4 Ask for the referral card if child is referred by other Health facility
5 Explain the processes and probable length of stay in IPD-SAM* *depend
to child’s
condition
Assess the child: 1 Ask age of the child, measure weight, length, edema and MUAC
Always use IPD-SAM sheet-1 during assessment and treatment
2 Ask the mother about medical history of her child and check the child physically
56
Based on ETAT 3 Check airway and breathing (Obstructed or absent breathing, cyanosis, or severe
principles (A,B,C,D) respiratory distress) and measure oxygen saturation
Check circulation (shock) and coma or convulsion now (cold extremities with
capillary filling>3 sec or weak and fast pulse)
Severe Dehydration with two of; (sunken eye by history, lethargy, inability to
drink/ poorly drink or slow skin pinch
5 Assess body temperature, if child has Fever (temperature ≥37.5oc) or
Hypothermia (temperature <35.5oc rectal or <35oc axillar)
6 Check the hypoglycemia (glucose<54 mg/dl or 3 mmol/lit)
7 Check consciousness of the child
9 Check for signs severe anemia, (Hemoglobin less than 4gr/dl)
11 Check skin of the child for lesions and determine grades of Dermatosis
12 Check for signs of eye problems like; corneal ulcer, clouding ….etc
14 Check for signs of CHF; (Increment in body weight, enlarging lever size, Rapid
increment in PR & RR, Enlarging jugular vein
Whenever you find sings of complications, give rapid response and start immediate treatment according to below
recommendations for each specific complication.
Treat airway problems Place the child on his/her side.
If the child has only respiratory distress, give oxygen supplementation at SpO2 <
90%.
If the child presents with other emergency signs with or without respiratory
distress, give oxygen therapy at SpO2 < 94%.
Start antibiotic; Chloramphenicol 25 mg/kg/day 3 times IV/IM
Or Ampicillin 50 mg/kg/day 4 times IM/IV for 2 days and follow by Amoxicillin 25
mg/kg/day 2 times orally for 5 days plus
Gentamycin 7.5 mg/kg/day one time IV/IM for 7 days
Treat the shock: Start O2 (Oxygen) 1-2 liters per minute and maintain the saturation at ≥94%.
Check vital sings particularly RR and PR and record as baseline.
whenever the child is Give 5 ml/kg of 10% glucose through IV as single dose.
lethargic, unconscious Keep the child warm
Give IV fluids, 15ml/kg/hour for one hour from below fluids:
57
and cold hands, has at - mixed Ringer Lactate with Glucose 5% (50% : 50%), or
least one of below sings: - mixed Half Saline (0.45%) with Glucose 5% (50% : 50%)
- Slow capillary fill (more Give antibiotics (IV) (*see annex for dose of antibiotics)
than 3 seconds), or Monitor the child’s condition and check RR & PR after each 10 minutes, compare
- weak and fast pulse with last records and record in patient file.
if Respiratory Rate (RR) and Pulse Rate (PR) decreases, it is sing of improvement,
then continue the IV fluids (15ml/kg) for one hour more
Do not give more IV fluid beyond second hour, shift IV fluid to ReSoMal 5-10 ml/kg
per hour for oral or nasogastric rehydration for 10 hours
If there was increment in RR 5 cycle in a minute and PR- 25 pulse in a minute and
it confirmed after 30 minutes. It is sings of overload, then stop the IV fluids
immediately and reassess after one hour.
If child’s condition did not improve after first hour treatment by IV fluids, then
assume that child has Septic shock and give order for fresh blood 10 ml/kg if there
is not sign of CHF. If, there is signs of CHF then order for Packed Cells 5-7ml/kg.
Until arrival of blood, continue IV fluids 3ml/kg/hour
When blood become ready, stope all IV and oral fluids.
Give Furosemide 1mg/kg
Apply blood 10ml/kg in 3 hours or packed cells 5-7ml/g in 3 hours.
Monitor the child each 10 minutes and record all findings in patient file.
Treat Dehydration 1 Don’t start IV route for rehydration
2 Don’t give standard WHO- ORS, because of high sodium content.
3 If child is unconscious and in shock due to dehydration, proceed with shock
treatment as above. If child is conscious with dehydration proceed with below
treatment steps
4 Start ReSoMal orally or by NG-Tube, by 5 ml/kg each half hour for first two hours
5 Record vital signs and progress of child after each 30 minutes during first two
hours (in sheet one)
6-a Regularly monitor weight gain, RR, PR, liver size stool and urine frequency.
Decreasing RR and PR is a positive sing and child has improved.
6-b if these sings increased as RR-5 in a minute and PR-25 in a minute at the same
time and confirmed after 30 minutes, its sing of overhydration. then stop ReSoMal
and re-assess after one hour.
58
7 After 2nd hour, continue the ReSoMal by 5-10ml/kg each hour for 10 intermittent
hours and start F-75
8 Give F-75 130ml/kg/day each two hours as intermittent doses with ReSoMal for
10 hours mentioned in above row.
9 Record all vital signs and progress of child after each hour during 10 intermittent
hours while you started F-75 (in sheet one)
10-a During the 10 hours, if there are signs of rehydration; RR and PR fall, urine started
to pass, tears appear, moist mouth and tongue, less sunken eyes and fontanelle
and improved skin turgor. Then, stop intermittent ReSoMal therapy and continue
feeding with F-75 and ReSoMal 50-100 ml after each stool pass or vomiting.
10-b If there is no sign of rehydration, then continue intermittent ReSoMal and F-75
therapy for 10 hours.
11 If rehydration takes 10 hours, by completion of period give ReSoMal 50-100ml
after each defecation or vomiting (as row ?)
Treat Hypoglycemia: 1/a Give immediately 50ml of 10% glucose or sacarose 10% (One rounded teaspoon
of Sugar in three tablespoon of water) oral or by NG-tube according to clinical
(when blood glucose is state and appetite of child.
less than 54mg/dl) 1/b If child is unconscious or has convulsion, treat with IV 10% glucose at 5ml/kg,
then give 50ml of the same solution by NT-tube.
2 Monitor blood sugar after 30 minutes; if blood glucose falls to below 54mg/dl *130x (Body
repeat 50 ml of 10% glucose by NG-Tube or orally. weight)÷12
If child condition improved and blood glucose raised above 54mg/dl, give F75 ÷4= amount
(130ml/kg/24hours) each half hours during first 2 hours. * of F75 for
each 0.5
hour
3/a After two hours check the blood Sugar, if it still below, then continue each half
hours F75 feeding for two hours more.
3/b If blood glucose has increased after two hours feeding by F75, then increase the
feeding interval from half hour to each two hours with same amount of F75 for
24hour which given at start time.
Treat hypothermia: 1 Give immediately 50ml of 10% glucose or sacarose 10% (One rounded teaspoon
of Sugar in three tablespoon of water) orally or by NG-tube according to clinical
(when BT is: state and appetite of child.
- Rectal < 35.5oc 2 Change the child’s cloths if cloths are wet.
59
- Axillar < 35oc) 3 Cover the child by a blanket or available cloth.
4 If child is smaller, put in skin to skin contact with mother as Kangaroo method to
All children with prevent losing body temperature.
Hypothermia should be 5 30 minutes after glucose, start F75 each 2 hours. * *130x (Body
treated routinely for weight)÷12
Hypoglycemia and (Dose of F75 is 130ml/kg/24hours) ÷4= amount
infection. of F75 for
each 0.5
hour
6 Let mother to sleep with her child in same bed and cover by same blanket, to
prevent loss of child’s body temperature.
7 Close the door and windows to keep the room warm.
8 Use heater with caution to keep the room’s temperature and indirect warming
the child.
9 Don’t use warm water bottle or fluorescent lamp for direct warming of the child.
10 If child has fever; Don’t give PARACETAMOL because of high risk of Liver
damage.
Treat anemia: 1 If HB below 4gr/dl, child is severely anemic, decide to transfuse blood.
2 Order for fresh blood 10ml/kg and if child has signs of heart failure order for
Whenever Hemoglobin Packed Cells 10ml/kg
is less than 4 gr/dl or 3 When blood achieved, Stop fluid intakes through IV, NG-tube and oral
Hematocrit less than 4 Record Respiratory Rate and Pulse Rate as baseline for further monitoring.
12% 5 Give Frusemide 1mg/kg IV.
6 Give blood 10ml/kg within 3 hours
Or: 7 Monitor the child and check RR and PR each 10 minutes and record in patient file.
Hb 4-6gr/dl with 8 If there is increase in RR by 5 breath and PR by 25 beats in minute, transfuse more
respiratory distress slowly.
9 If increase in RR by 5 breath and PR by 25 beats in minute confirmed after 30 CHF;
minutes stope transfusion and apply management of CHF. Congestive
Heart
Failure
10 If there are basal lung crepitations or enlarging of liver, then stop transfusion and
give 1mg/kg Frusemide IV.
11 Don’t repeat transfusion even if Hb is still low or within 4 dyas of last transfusion.
60
Treat CHF: 1 Start O2 (Oxygen) 1-2 liters per minute and maintain the saturation at ≥94%.
2 Stop IV fluids
In case if: 3 Give diuretic, preferably Frusemide 1mg/kg IV
- Increment in body 4 If there is no positive response by above management, start Digoxin 5µg/kg as
weight single dose.
- Enlarging lever size
- Rapid increment in PR &
RR
- Enlarging jugular vein
- Etc
Treat Corneal Ulcer and 1 Give Vit-A at 1st day and repeat at 2nd and 14th days of admission.
Corneal Clouding a. 50000IU for children <6 months
b. 100000IU for children 6-12 months
c. 200000IU for children older 12 months
2 Start drop Tetracycline 4 time in a day
3 Start drop Atropine 3 time in a day
4 In case of Corneal Ulcer; cover the affected eye with saline soaked pad and
bandage the eye.
Treat Convulsion: 1 Manage to keep open the airway

2 Give Diazepam, 0.5mg/kg (or 0.1ml/kg from 10mg/2ml Diazepam Injections),
preferably give it rectal.
3 For giving the Diazepam rectally, use 1ml syringes, remove the needle then insert
it up to 4-5cm in rectum, inject the diazepam solution then hold the buttocks
together for few minutes.
4 Give IV Glucose
5 Give a proper position to unconscious child to prevent aspiration
61
5.2- Feeding:
After covering and response to live threatening complications, its required to start feeding for admitted child. As nearly
all children with SAM have poor appetite when they admit to hospital. Hence, patience and coaxing is needed to
encourage the children to complete their each feed. Therefore, its required to start feeding gradually for children with
complicated SAM.
For children with, no appetite, shock status, mouth ulcers, unconscious state or if child is very weak, apply NG-tube and
feed them through tube until getting better and improvement of appetites.
Day-1 Do all anthropometric measurement and record them in

Phase -1 1 relevant sheet- Sheet 1 and sheet 2
24 hours If child doesn’t have +++ Edema start the feeding with F75
Stabilization 130ml/kg/day every two hours (12 times) to avoid
overloading.
If child has +++ Edema start the feeding with F75
100ml/kg/day every two hours (12 times) to avoid
overloading during whole phase-1 period
2 Apply NG tube if.
A: child is too poor to sallow
B: Child has oral trash
C: If child cannot take 80% of prescribed formula in 2 or 3
feeding times (applicable during phase 1)
If child has Hypoglycemia, feed him/her each half hours for
first two hours of admission, then, proceed with 2 hours
feeding as above
Encourage the mother to breastfeed the child between
feeding interval
62
Give formula by spoon, do not use bottle for feeding
Give 5 mg folic acid with F-75
3 Give all antibiotics on timely manner
Take care of skin lesions, oral trash, bath, and eye problems See annex
through giving relevant medicine (annex)
Record each day’s feeding information in sheet 2 properly
Day-2 Do the anthropometric measurement at the same time of
yesterday
Give F-75 130 ml/kg/day during whole phase-1
Remove NG tube when.
A: Child can take orally 80% of daily formula

B: Child can take all formula in two consecutive feeding time
4 Change the feeding interval to 8 times if child meet the
below criteria
A: No or mild vomiting
B: No diarrhea or less than 5 times per day
C: Child eats all formula in each feeding time
D: No need for NG tube
Otherwise, proceed with 12 times feeding if child does not
meet the criteria
Give 1 mg folic acid
feeding interval
Give all antibiotics on timely manner
5 Day-3 and so on Do all anthropometric measurement as the same time of
until transitional yesterday, record them in relevant sheets
phase Decide for feeding interval, check the criteria illustrated
above if child meet them change 8 times feeding to 6 times.
Otherwise, proceed with 8 time until child meet the criteria
in next 24 hours re-assessment
Give F-75 130 ml/kg/day
Give 1 mg folic acid
63
feeding interval
Give all antibiotics on timely manner
6 Continue this practice beyond day 3 if required until child is
stabilized or at least complications are controlled. (this will
take 3-7 days)
Phase Transitional 1 Transfer the child from phase one to transitional phase
Option 1 when.
- There are two options A: Good appetite, child can take at least 80% of formula
in transition phase 1: offered in each 4 hours
possibility treatment B: Edema reduced or resolved
with RUTF 2: RUTF is not C: All medical complications are treated or controlled
available and child D: NG tube is removed and not needed for feeding
should be treated in E: Child is alert and clinically well
IPD-SAM until full
recovery When the child meets the transition criteria (above) change
food formula to RUTF 25gr/kg/day in 6 times
If child cannot take the required amount of RUTF in each
feed top up F-100 or F-75 to fill the energy gap of RUTF
(1gr RUTF= 7.2 ml F-75 or 5.5 ml F-100)
if child refuses to take RUTF, give F-100 130 ml/kg/day in 6
times but offer RUTF first until the child take the RUTF in
proper quantity that can provide required energy
If child can’t completely eat the prescribed amount of RUTF.
Then, complete the required energy by F75 or F100
(100kcal/kg), each 4 hours
2 Day-2 Continue the same formula and amount as 1st day of
transition
3 Day-3 Increase the amount of RUTF gradually to 28gr/kg/day in
each 4 hours
Phase – 2 1 Change the formula to RUTF or increase the dosage of RUT if already child 200xBW÷5
tolerated with RUTF in Phase-T, to 200 Kcal/kg/day and prepare the child to refer 00=
if OPD-SAM is available to OPD-SAM for recovery and completion of treatment. number of
needed
64
(Option-1) RUTF
sachets in
a day
2 Continue this practice until child adapts himself with maximum dose of RUTF and
eat at least 80% of allocated amount of RUTF in a day
3 Then refer the child to OPD-SAM for further follow up and recovery.
Phase – 2 1 Continue feeding with F100, 150-220ml/kg/day, up to child get recovered and
if OPD-SAM is not achieve discharge criteria.
available *for discharge criteria see OPD-SAM section, chapter 4.
(Option-2)
65
6.Management of uncomplicated and complicated sever acute malnutrition in infants under 6 months of age
Location of action: OPD-SAM & IPD-SAM

Responsible staff: Pediatric specialist, pediatrician, and nutrition nurse
Severe acute malnutrition is less common in infants < 6 months than in older children. An organic cause for the
malnutrition or failure to thrive should be considered, and, when appropriate, treated. Infants less than 6 months of age
with severe acute malnutrition with any of the following complicating factors should be admitted for inpatient care:
This chapter provides guidance on management of uncomplicated and complicated severe acute malnutrition (SAM) in
infants under 6 months of age in Outpatient Department-SAM (OPD-SAM) and Inpatient Department-SAM (IPD-SAM) as
part of the Integrated Management of Acute Malnutrition (IMAM) approach.
The development of SAM in infants under 6 months commonly reflects suboptimal breastfeeding practices. Hence, re-
establishing satisfactory breastfeeding is at the core of treatment.
6.1- screening
Be careful that screening children in this category (<6months) is different with screening of children above 6-59 months
66
Intervention No Activity Objective: interve Remarks
ntion
status
Yes No

4 Ask for the MCH handbook for children below 24 months
Screening for 1 Ask name, sex and age of the child *. For details
Acute 2 Consider a row in register book and record personal information of the child. and procedure
Malnutrition, 3 Ask the mother to remove the cloths, socks and shows of her child and tell her the reason and why of
children 0-6 you are asking it. anthropometri
months 4-a Check pitting sign for diagnosis of Edema on both feet. c
4-b If you find Edema on feed. Then, assess for Edema on forelegs, arms and face of the child to measurements
determine the severity of Edema. (+, ++ or +++) please refer to
5 Measure the Weight of children by using UNISCALE or SECA Scale* GMP section.
Measure Length of the children by using standard height board*

Use Moyo chart to determine Standard Deviation of Weight and Height (Z-Score)
Record all measures and information in register book
Tell mother about nutrition status of her child
67
6.2- Classification of Malnutrition and Making Decision
Location of action: Nutrition Counselor Room

Responsible staff: Nutrition Counselor and Nutrition Nurse
Whenever screening competed and nutritional status of the child diagnosed, then make decision according to admit the
patient in OPD-SAM or refer to IPD-SAM. Use below table for decision making.
Child is Normal 1 When, nutritional edema is not present on feet, and

nourished 2 Weight for Length (W/L) is ≥-2SD and
3 No visible wasting found
4 Encourage the mother to continue excusive breastfeeding to her child.
Child is Moderately 1 If nutritional Edema is not present, but
acute malnourished 3 Weight for Length (W/L) is <-2SD and ≥-3SD
(MAM)
4 Encourage the mother to continue excusive breastfeeding to her child. And
5 Provide exclusive breastfeeding counseling for other.
6 Make an appointment for biweekly follow up visit and counselling
Child is Severely Acute 1 Weight for Length (W/L) is <-3 Zscore
Malnourished (SAM) 2 Moderate weight loss or recent (days-weeks) failure to gain weight, or
moderate drop across WAZ lines
Uncomplicated
3 Moderate, mild or possible breastfeeding difficulties, or
4 The infant is alert.
5 Social circumstances are adequate, and breastfeeding and IYCF support is
available.
5 Admit the child in OPD-SAM (Part 3.6)
1 The infant has bilateral pitting oedema, or
68
Child is Severely Acute 2 Weight for Length (W/L) < –3 Z-score
Malnourished (SAM) 3 Presence of general danger sign or serious associated disease, or
4 Severe breastfeeding difficulties, or
Complicated
5 Recent severe weight loss or prolonged (weeks-months) failure to gain weight,
or sharp drop across WAZ lines
6 Social circumstances are inadequate and breastfeeding or IYCF support is not
available.
7 Admit the infant to IPD-SAM (Part 4.6)
6.3--Management of uncomplicated infants less than 6 months of age in OPD-SAM
Location of action: Nutrition counselor’s room

Responsible staff: Pediatrician and Nutrition nurse
Previous recommendations advised inpatient management for all infants under 6 months of age with SAM. New
recommendations propose outpatient management of uncomplicated SAM in infants under 6 months of age.

on status
Yes No
4 Ask for the referral card
5 Ask for MCH-Handbook
69
Treatment 1 keep the infant warm. Cover the head and body to
prevent hypothermia.
2 Give routine, Amoxicillin 40 mg/kg/day two times per day for 5 days if child is ≥ 3
kg (BW)
3 If mother is available encourage the mother to continue breastfeeding and re-
lactate
4 If mother is not available recommend considering wet-nursing or accessing safe
expressed breastmilk.
5 If there is no realistic prospect of the infant being breastfeed, consider
appropriate replacement feeding with commercial infant formula. And
provide counseling on how to prepare the formula at home.
6 If swallowing of child matured or older infants, consider complementary foods
7 Record all information and actions in follow up card and OPD-SAM register.
8 Make an appointment for a follow-up visit every week.
Follow up visit: 1 Monitor weight and weight gain:
2 Identify danger signs and non-response to treatment:
3 Counsel mothers or carers on appropriate breastfeeding and
growth.
4 Guide mothers or carers to provide sensory stimulation and
emotional support for the infants.
5 Provide health and nutrition education for improved feeding
and care practices.
6 Provide psychosocial support to mothers or carers.
70
6.4 Management of complicated children <6 months of age in IPD-SAM
Infants with SAM with the prospect of breastfeeding should receive all support needed for the mother or carer to re-
establish breastfeeding and are given a supplement through supplementary suckling until full recovery.
Management of complicated SAM in infants under 6 months of age in IPDSAM is complementary to the care in IPD-SAM
for children 6–59 month of age discussed in Chapter 5.

on status
Yes No
Initial management: 1 Management of medical complications is the same as management of
complications in children 6-59 months in IPD-SAM in chapter 5.
1 keep the infant warm. Cover the head and body to prevent hypothermia.
Phase one or 2 Encourage breastfeeding immediately and then feed every 2–
stabilization 3 hours, day and night.
3 Place the infant in an adult bed to let the mother sleep with
the infant.
71
1 Breastfeed on demand or offer breast milk at least every 3 hours for at least 20
If breastmilk is not minutes
enough, support re- 2 Between ½ hour and 1 hour after a normal breastfeeding session, give
lactating by maintenance amounts of a milk supplement (DF100) at130 ml/ kg/ day –by SST
Supplementary Sucking 3 Infants without Edema; give Diluted F-100, 130ml/kg/day through SST each 3 130xBW÷8=
Technique (SST) hours (8 times a day) amount of
DF100 for
each 3 hours
4 Infants with Edema; give F-75 130ml/kg/day through SST each 3 hours (8 times a 130xBW÷8=
day) until resolving Edema. amount of
DF100 for
each 3 hours
Supplemental Suckling 1 Provide a cup (preferably not be plastic cup)
Technique (SST) 2 Provide Feeding tube or NG tube size 6-8
3 Prepare formula as per weight according to above
4 Put the formula in cup
5 Bind one side/end of tube on mother’s breast beside of nipple.
6 Put another side/end of the tube into formula cup
7 Put the cup about 10cm below than the head of child holding by mother
8 Advise the mother to keep the child straight and holding by one arm
9 Advice the mother to hold the cup by another hand and let the child to suck the
milk
10 Monitor the progress of the infant by daily weighing
11 If the infant loses weight or has a static weight over 3 consecutive days but
continues to be hungry and is taking all the milk, progressively add 5 ml extra to
each feed.
12 Weigh the infant daily with a scale graduated to within 10–20gr.
13 In general, do not increase the quantity of milk supplementation during the stay,
because the adequacy of the breastfeeding should improve.
14 If the infant starts gaining weight, decrease the milk supplement by one-third of
the maintenance intake
15 If the weight gain is sufficient and maintained for 2–3 days
(after gradual decrease of the milk supplement), stop the milk
supplement
72
16 If the weight gain is not maintained, re-increase the amount of milk supplement
to 75% of the maintenance amount for 2– 3 days
Phase Transition 1 Criteria for Retune of appetite
transition phase Edema starts resolving
2 Give expressed breast milk, or, infant formula or F100-Diluted at
This phase will continue 150–170 ml/kg/day each 3 hours or increased by one-third over the amount given
up to 3 days in the stabilization phase providing 110–130 Kcal/kg/day.
Rehabilitation phase: 1 Criteria to progress Good appetite (infant takes at least 90% of the infant
from Transition to formula milk or F100-Diluted prescribed for transition)
2 Rehabilitation Complete loss of bilateral pitting edema
phase
3 Minimum stay of 2 days in the transition
4 No other medical problem
1 Give expressed breast milk, infant formula milk or F100-Diluted
provided at 200 ml/kg/day, or twice the volume given during
stabilization, providing 150 Kcal/kg/day.
2 Continuous monitoring of key vital signs is daily care practice
3 Monitor weight and weight gain.
4 Involve the mother or carer in care of the infant
5 Counsel the mother or carer on appropriate breastfeeding and
growth.
6 Guide the mother or carer to provide sensory stimulation and
emotional support for the infant.
7 Provide health and nutrition education for improved feeding
and care practices.
8 Provide psychosocial support to the mother or carer if needed.
9 Provide health and nutrition support to the mother or carer
according to their health and nutritional status.
Referral to continued 1 All clinical complications including oedema are resolved
support in OPD-SAM: 2 Weight gain on either exclusive breastfeeding or replacement feeding is
satisfactory
Verify whether the 3 The immunization schedule and other routine interventions have been completed
infant has reached the 4 The infant has good appetite and is alert and well
following criteria 5 Advise the mother or carer on for safe feeding at home
73
6.5- Special support for low birth weight infants
Location of action: IPD-SAM section

Responsible staff: Pediatric specialist, pediatrician and nutrition nurse
Low birth weight (<2.5kg) infants, especially those born earlier than term or small for their gestational age, need
additional care to survive and stay healthy.
on status
Yes No
Management of 1 Management of medical complications is the same as management of
complications complication in children 6-59 months of age in IPD-SAM chapter-5.
Initial management 1 Keep the infant warm by skin-to-skin contact using Kangaroo technique, place the
child skin to skin on the mother’s chest between her breasts with infant head
If infant’s weight is <2.5 turned to one side and cover with mother’s cloths.
kg at birth time 2 initiating early breastfeeding, within the first hour after birth
3 Advise to mother to have extra attention to hygiene, especially hand washing for
prevention of infections
4 Advise to mother to extra attention to danger signs and the need for early care
seeking and referral to hospital.
If infant’s weight is <1.5 5 General management and warming procedure is the same as above.
kg at birth time 6 Feeding:
1st day: give 10ml/kg/day expressed breast milk with the remaining fluid
requirement 50ml/kg/day met by IV fluids.
74
If the infant doesn’t need IV fluids; give 2-4ml of expressed breast milk every two
hours through NG-tube
7 If the infant can not tolerate the enteral feeds, give IV fluids 60ml/kg/day for the
first day of live.
8 Check blood sugar each 6 hours, if child is Apneic, lethargic or convulsing, Use 10%
glucose solution.
9 Start enteral feed which infant’s condition is stable, there is no abdominal
distention or tenderness, bowel sounds are present, meconium is passed and no
apnea.
75
7. Involving Mothers in Care of malnourished children
Location of action: IPD-SAM section

Responsible staff: Nutrition nurse and nutrition counselor
Mothers and carers are the most useful resources in caring and taking part in management of
malnourished children. Technical staff can encourage and involve them in feeding practice,
sensory stimulations and physical and emotional supports during treatment and recovery period
of acute malnutrition and this an opportunity to their own health and wellbeing as well during
their children’s admission in program.
Hence, its important to involve them in management of their children from admission time till
recover.
Mothers’ health and 1 Control of maternal iron deficiency anemia with iron folate supplementation
response (60mg Iron and 400 µg (0.4mg) folic acid) tablets once in a day.
2 Increasing energy intake through two additional meals a day
3 Encourage mother to use birth spacing methods during lactation period
76
4 If you think mother need psychosocial supports, refer her to psychosocial
counselor
5 If child is prime, consult the on advantages of breastfeeding, attachment and
position.
Involving mothers to 1 Explain health status of child to mother and how many days they need to stay in
childcare IPD.
2 Explain the positive impacts of mother’s involvement on treatment of their
children
3 Teach the mother how to wash their and her child’s hands before feeding and
after toilet or changing child’s diapers.
4 Explain to mother that keeping clean herself and her child is important and can
protect them from illnesses.
5 Convince the mother continue breastfeeding for her child
6 Invite mother to take part in daily feeding of her child to learn how she can
continue.
7 Explain that feed according to ward’s schedule is important for recovery of
children and convince them to feed their children during the day and nighttime.
8 Explain for mother, how can they help each other for serving children at night and
convince them to sleep in rounds, not all mother sleep at same time.
9 Teach mother how to prepare toys for children from available waste materials at
home.
10 Explain how important are sensory and psychosocial stimulations for recovery of
her child.
8: management of Acute Malnutrition in Pregnant and Lactating Women (PLW) in OPD-MAM
Location of action: OPD-MAM section & MCH
77
Responsible staff: Nutrition Nurse, Midwives, Nutrition Counselor and Food distributer
Pregnant women and women with a breastfeeding infant under 6 months of age need additional energy requirements in addition to the on average
2,200–2,400 Kcal (depending on the basal metabolism and physical activities). OPD-MAM for PLW improves maternal nutrition during fetal
development and for the first 6 months of the infant’s life while the mother is breastfeeding the infant, and therefore is considered an essential
part of the IMAM approach

status
Yes No
4 Ask for the referral card has
Screening 1 Ask name and age of the mother
2 Ask if mother is pregnant or lactating
3 If mother is pregnant, determine gestational age
4 If mother is lactating, ask age of her child (“if child is older than 6months of
age, don’t screen the mother for acute malnutrition)
5 Check pettings sign on both feet of mother for diagnosis of Edema
6 Measure the MUAC (Med Upper Arm Circumference) of mother by standard
mothers’ MUAC. *
7 Register all information in register book
78
8.1- Classification of Malnutrition and Making Decision
Location of action: MCH & Nutrition Counselor Room

Responsible staff: Midwives, Nutrition Counselor and Nutrition Nurse
Whenever screening competed and nutritional status of the mother diagnosed, then make decision according to below
recommendations:
Normal Nutrition 1 If mother’s MUAC is ≥ 23 cm
2 Encourage the mother to continue her current feeding practice
Moderate 1 No Edema, and
Malnutrition 2 MUAC cut off ≥ 18.5 cm to < 23 cm
Severe Malnutrition 1 If Petting Edema is present on fee of the mother, refer her to hospital for
further investigation and treatment.
2 If only MUAC cutoff is <18.5cm admit the mother to OPD-MAM
Admit the mothers to 1 Lactating If MUAC is <23cm and of her child is less than 6 months Including
OPD-MAM, if: MUAC
<18.5cm
2 Pregnant If MUAC is <23 months and pregnancy confirmed Including
MUAC
<18.5cm
3.7- management of PLW in OPD-MAM
Location of action: OPD-SAM section
Responsible staff: Nutrition Nurse, Nutrition counselor and Midwives

status
Yes No
1 Welcome the client
79
Greetings and 2 Introduce yourself
4 Ask for the referral card if she has referred from other health facility
5 Ask for MHC Handbook
Treatment 1 Give a dry take-home fortified food supplement Super Cereal flour of 7.5 kg
for one month:
2 Ensure PLW receive iron folate supplementation as a routine MCH service
(60 mg iron + 400 mg folic acid)
3 Give counselling and health and nutrition cares at home
4 Make an appointment for follow up visit after one month
5 Record all information register and ration card
6 Give the prescription of food commodities and send her to Food distribution
point to receive the ration from food distributer.
Follow up visit 1 Check MUAC and monitor the progress of treatment
2 Continue nutrition counselling and education
3 Record information
End of treatment 1 Whenever MUAC reached to ≥ 230 mm for two
Cured consecutive visits, or
Infant reaches to 6 months of age
2 Default In case of absence in two consecutive visits,
3 Encourage the mother to attend the monthly FBNS and CBNS sessions
80
9.Treatment of Associated Medical Conditions in Children with Acute Malnutrition
Location: OPD
All children with SAM have moderate and severe anemia, oral candidiasis , esophageal or systematic candidiasis, acute watery diarrhea,
dehydration , dysentery, amoebiasis and giardiasis, Osmotic diarrhea caused by lactose intolerance, EYE infections , Helminthiasis, Strongyloidiasis
infection .malaria, Measles, Meningitis, otitis media, pneumonia, Bacterial skin infections, scabies, urinary tract infection and Vit A deficiency .
They need specific attention during treatment to cover the concomitant illnesses and let the child to utilize the given energetic food properly for
re-organizing the normal physiologic body function and weight gain. Some of the important diseases with treatment options are summarized as
below:
status
Treatment of moderate 1 Give routine antibiotic for SAM
anemia (Hb is ≥ 4 g/dl (or ≥ 6 2 Give oral antimalarial if malaria test is positive (refer to IMAM Guideline malaria
g/dl in the presence of treatment page 234)
respiratory distress) and < 3 Give mebendazole 100 mg twice per day for 3 days at second visit in OPD-SAM or in
9.3 g/dl) rehabilitation phase in IPD-SAM if child is 1 year or older and has not had a dose in the
previous 6 months
4 Tell the mother to more frequently breastfeed the child
5 If child get RUTF advise the mother to give prescribed amount daily. It contains enough
iron and no need to give extra iron for anemia treatment
6 If child is on F-75 diet that compiles WHO specification, give 5 mg folic acid orally once
at first day of admission
Severe Anemia: 1 Proceed with blood transfusion preparation
If Hb is < 4 gr/dl or 4-6 gr/dl 2 Stop all oral intake and IV fluids during transfusion.
with respiratory distress 3 Take blood sample for cross match from children.
4 Send blood to Lab to determine Blood Group.
5 Order to prepare fresh blood for transfusion.
81
6 Check the child for sign of heart failure.
Treatment and monitoring 1 Give furosemide, 1 mg/kg IV, at the start of the transfusion to make room for
of Severe anemia the blood.
2 Give 5–7 ml/kg of packed cells because whole blood is likely to worsen this
condition If the child has signs of heart failure
3 Give whole blood 10 ml/kg slowly over 3 hours, If packed cells are not available.
4 If no sign of heart failure gives whole blood as soon as possible (within the first
24 hours after admission)
• 10 ml/kg, slowly over 3 hours.
• The transfusion must be slower and of smaller volume than for a well-
nourished child.
5 Closely monitor the pulse and respiratory rates, listen to the lung fields,
examine the abdomen for liver size and check the jugular venous pressure
every 15 minutes during the transfusion.
In every 15 minutes during transfusion, monitor and check the below regularly.
A: Pulse
B: Respiratory rate
C: Listen to lungs files
D: Liver size
E: Jugular venous pressure
6 Look for signs of congestive heart failure such as:

• Fast breathing
• Respiratory distress
• Rapid pulse
• Engorgement of the jugular vein
Cold hands and feet or cyanosis of the fingertips and underside of the tongue.
82
7 If either breathing or heart rate or pulse increases, transfuse more slowly.
8 If there is basal lung crepitation or an enlarging liver, stop the transfusion and
give furosemide at 1 mg/kg by IV.
9 Do not repeat transfusion even if Hb is still low or within 4 days of the last
transfusion unless the child has life-threatening severe anemia or active
bleeding.
10 Do not give iron during stabilization of SAM even if the child is suspected to be
anemic because iron can make infections worse; iron can be given when the
child has a good appetite and starts gaining weight if fortified foods are not
given.
Treatment of oral 1 Give 100,000 units/ml of nystatin suspension 1–2 ml orally every 6 hours for 7 days
CANDIDIASIS
2 Apply half strengthen (0.25% gentian violet solution If nystatin suspension is not
available.
3 Apply 2% miconazole gel, 5 ml every 12 hours for 7 days If both these treatments are
ineffective.
Treatment of esophageal or 1 Difficulty or pain while swallowing, reluctant to take food, has excessive salivation or
systematic candidiasis cries during feeding”
2 Give fluconazole 3-6 mg/kg/day orally once per day for 7 days
3 If the child has active liver disease, no response to fluconazole or he is at risk of
disseminated candidiasis:
• Give amphotericin B 0.5 mg/kg by IV once a day for 10–14 days.
Management of Acute watery diarrhea
1 Examine the child for other infection (otitis media, measles and other)
83
1: Prevention of 2 Start feeding immediately
dehydration (child has AWD
3 Give routine antibiotic treatment for SAM
but no signs of dehydration
and being treated in OPD-
SAM)
2: Prevention of 1 Start feeding immediately with F-75 based on body weight.
dehydration (child is
2 Give ReSoMal 5 ml/kg after each loose stool to make up for the additional losses
admitted for other
complications in IPD-SAM 3 Give routine antibiotics to cover other infection as well.
with having AWD)
4 Do not give zinc supplementation if child take formula according WHO specification
Management of acute 1 Proceed with referral preparation to IPD-SAM site ASAP

watery diarrhea with sign of
2 Give first dose of antibiotic,
recent sunken eye in OPD-
SAM 3 Give 50 ml 10% sugar water (10 gr or two heaped teaspoon sugar in 100 ml of clean
water)
4 Tell mother to continue breastfeeding more frequently in the way to hospital
5 Advice to mother keep child warm and twisted in cloths
6 Fill the referral slip and mark the treatment given
Treatment of Dysentery 1 Give ciprofloxacin 30 mg/kg orally every 12 hours for 3 days as a first-line antibiotic.
2 Give ceftriaxone 80 mg/kg IV (or IM) once a day over 30 minutes for 3 days after 2 days
If there are no signs of improvement (no fever, fewer stools with less blood, improved
appetite).
3 Give ReSoMal 5ml/kg if the child losses electrolytes
4 Advice to Continues frequently breastfeeding.
1 Start treatment after laboratory confirmation
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Treatment of Amoebiasis 2 Give metronidazole 7.5 mg/kg orally every 8 hours for 5 days.
and Giardiasis
3 Tell the mother to breastfeed child more frequently
Treatment of Osmotic 1 Use a lower-osmolarity cereal-based starter F75 in the initial phase of the treatment.
diarrhea caused by
2 Introduce RUTF (or F100) gradually for catch-up growth.
carbohydrate intolerance
3 Consider treatment with metronidazole 5 mg/kg orally every 8 hours for 5 days if the
persistent diarrhea does not improve.
Treatment of Osmotic 1 Treat children for lactose intolerance only if the continuing diarrhea is preventing
diarrhea caused by lactose general improvement; starter F75 is a low lactose feed.
intolerance 2 In exceptional cases, substitute milk feeds with fermented milk such as yoghurt or with
a lactose-free infant formula.
Treatment of EYE 1 Wash the eyes by clean water or breast milk (after washing own hands with clean
INFECTIONS water), use a clean cloth to gently wipe away the pus.
2 Apply tetracycline eye ointment or chloramphenicol eye ointment
every 6 hours for 5 days.
3 Show the mother how to wash the eyes with water or breast milk and to put eye
ointment in the eyes and advise the mother to wash her hands before and after.
4 Review for improvement 48 hours after treatment or treat until redness is gone.
Treatment of Helminthiasis 1 Give routine anthelminthic in second visit of treatment to one-year above children.
with uncomplicated SAM
2 Mebendazole:
1. Age 12-23 months 250 mg single dose
2. Age 24 month and older 500 mg single dose
3 Or Albendazole:
1. 12-23 months 200 mg single dose
2. 23 months and older 400 mg single dose
1 Give:
85
Treatment of 1. Age: < 12 months or weight less 10 kg than give albendazole 200 mg orally
Strongyloidiasis infection by single dose for 3 days.
detecting typical larvae in 2. Age >1 year or ≥10 kg albendazole 400 mg orally single dose for 3 days or
the faces. Ivermectin 200 πg/kg orally single dose for 2 days.
2 Avoid tinidazole in SAM children, however, it is effective but dangerous in SAM
children due to causes sever anorexia.
Treatment of High fever 1 Sponge the child’s body with lukewarm water.
(body temperature 39.5° C)
2 Use paracetamol only in IPD-SAM if the fever causes the child
distress and be cautious of the risk of hepatic damage at normal doses:
3 Give Paracetamol syrup 120 mg/5 ml with bellow doses:
• Weight 4–< 6 kg give 2 ml
• Weight 6–< 10 kg give 2.5 ml
• Weight 10 < 12 kg give 5 ml
• Weight 12–< 14 kg give 7.5 ml
• Weight 14–19 kg gives 10 ml
Treatment of Malaria 1 Clinically diagnosed malaria:
(uncomplicated) • Give chloroquine 25 mg/kg (maximum 1500 mg) over 3 days and refer for
confirmation of diagnosis and follow-up treatment.
2 Confirmed malaria falciparum:
• Give sulphadoxine - pyrimethamine (SP) 25 mg/kg sulpha component
(maximum of 3 tablets) single dose plus artesunate (AS) 4 mg/kg (maximum
200 mg) daily for 3 days.
3 Confirmed malaria vivax:
• Give chloroquine 25 mg/kg (maximum 1500 mg) over 3 days plus primaquine
0.25 mg/kg (maximum 15 mg) daily for 14 days or 0.75 mg/kg (maximum 45
mg) weekly for 8 weeks.
Treatment of Severe malaria 1 Falciparum malaria
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• Give artesunate at 2.4 mg/kg IV or IM on admission, then at 12 h and 24 h,
then daily until the child can take oral medication. Should be continued at least
for 24 hours even if child can tolerate oral medication
2 Give artemether at 3.2 mg/kg IM on admission, then 1.6 mg/kg daily until the child
can take oral medication
3 Once tolerating oral medication, give:
• Complete treatment course of Artesunate +Sulphadoxine orally.
4 Quinine should be avoided to use in children with SAM:
• Because quinine is toxic
5 • Refer child with signs of very severe febrile disease or stiff neck for emergency
treatment in hospital,
6 Refer all pregnant women with severe malaria to hospital.
7 Give measles vaccine to all children with SAM who are 6 months of age and older
regardless of infection with measles now or within the last 3 months.
Measles prevention 1 Give a second dose of measles vaccine before discharge from hospital or at the end of
treatment.
2 At the end of treatment if an infant is under 9 months of age, make an appointment
for measles vaccination after the age of 9 months.
3 Give vitamin A on treatment dose (day 1,2,14)
Measle treatment (children 1 Vit A dosage based on Aged or weight

with SAM and active 1. Less than 6 months or 3-<6 kg give 50,000 IU
measles or happened in last 2. 6-<12 months or 6-<10 kg give 100,000 IU
3 months More than 1 year or 10-29 kg give 200,000 IU
2 3. Treat mouth ulcers with gentian violet if present
3 Give routine antibiotic for SAM.
4 Refer the child to IPD-SAM if the case is detected in OPD-SAM immediately
87
5 If meningitis is suspected and where possible, do a lumbar puncture to confirm
infection.
Treatment of Meningitis 1 Give ceftriaxone 50 mg/kg IM or IV every 12 hours
2 Or use Chloramphenicol+ Ampicillin If there is no known significant resistance,

chloramphenicol 25 mg/kg IM or IV every 6 hours and Ampicillin 50 mg/kg IM or IV
every 6 hours for 10 days.
3 Use a pulse oximeter to guide oxygen therapy.
4 If there are signs of hypoxemia or oxygen saturation is less than 90% give 0.5 to 1
lit/min oxygen (2 liter/min in severe respiratory distress)
5 Give oxygen flow regulated to maintain saturation of > 90%.
6 If there are convulsions/fits, give phenobarbital loading dose of 15 mg/kg.
7 If convulsion persists, give further doses of phenobarbital 10 mg/kg up to a maximum

of 40 mg/kg and watch for apnea.
8 If needed, continue with phenobarbital at a maintenance dose of 5 mg/kg per day.
9 Check for hypoglycemia and treat it
10 Check for tender swelling behind the ear.
Treatment of OTITIS MEDIA 1 Give the routine antibiotic treatment for SAM.
3 Use a cotton wick to dry any drainage from the ear at least three times per day.
4 Remove the wick when wet and replace it with a clean one, and repeat these steps
until the ear is dry.
5 In case of signs of mastoiditis refer the child to hospital immediately if the child has:
1. Ear pain
2. Pus drainage from the ear.
88
Ender swelling behind the ear.
No Pneumonia Cough or 1 Home care

cold 2 Soothe the throat and relieve cough with safe remedy. WHO
Pocket
book 2013
3 Advise the mother when to return.
4 Follow up after 5 days if not improving
5 If coughing lasts for more than 14 days thinking about chronic cough
6 Tell the mother to more frequently breastfeed the child
7 Advice Home care
Management of Pneumonia 1 Advice mother to continue breastfeeding
2 Give appropriate antibiotic
3 Advise the mother when to return immediately if symptoms of severe pneumonia
4 Follow up after 3 days.

5 If the child is coughing for more than 3 weeks or if having recurrent wheezing, refer
for assessment for TB or asthma.
3 in children who have SAM is manifested by fast breathing and chest in-drawing or
stridor in a calm child and need immediate referral and treatment in hospital
4 Admit to hospital.
Severe pneumonia Treat high fever if present.

Manage airway as appropriate.
Give recommended antibiotic.
Give oxygen if saturation< 90%.
Wash the affected area with soap and water and gently remove debris and crusts by
soaking in warm saline or clean warm water and Dry the child carefully.
1 Apply 10% polyvidone iodine ointment, or 5% chlorhexidine lotion to the affected area
89
Treatment of Bacterial skin
infections
2 Verify widespread superficial and deep-seated infections that could be a sign of
osteomyelitis that needs to be confirmed by X-ray and treat with:
1. Cloxacillin (250 mg capsule), 15 mg/kg orally every 6 hours.
2. or flucloxacillin 15 mg /kg every 6hours.
or oxacillin15 mg /kg every 6hours as staphylococcus aureus is a common cause of skin
infection.
3 3. Drain any abscesses surgically.
4 Apply 0.3% lindane lotion, once daily for 2 days to the affected areas.
Treatment of Scabies 1 Avoid 25% benzyl benzoate lotion, which is more irritating in children with SAM, unless
there is no alternative.
2 Treat family members to prevent infestation or re-infestation
3 Apply a barrier cream (zinc-oxide, castor oil ointment, petroleum jelly or tulle gras) to
the raw areas, and apply 1% gentian violet solution to skin sores to relieve pain and
prevent infection
4 Omit using nappies/diapers and leave the diaper area uncovered so that the perineum
can stay dry (atrophy of the skin in the perineum may lead to severe diaper dermatitis).
5 If the diaper area becomes colonized with candida sp., apply a barrier cream, or 1%
gentian violet solution, or miconazole gel or nystatin cream
6 Bathe or soak the affected areas daily for 10 minutes in 0.01% potassium
permanganate solution
Treatment of Skin lesions in 1 Give routine antibiotics to all children with SAM with or without kwashiorkor.
kwashiorkor
2 A 10% polyvidone iodine ointment can also be used.
90
3 Apply a barrier cream (zinc-oxide, castor oil ointment, petroleum jelly or tulle gras) to
the raw areas.
4 Apply 1% gentian violet solution to skin sores to relieve pain and prevent infection
5 Ignore using nappies/diapers and leave the diaper area uncovered so that the
perineum can stay dry (atrophy of the skin in the perineum may lead to severe diaper
dermatitis).
6 If the diaper area becomes colonized with candida sp. apply one of the bellow
1. barrier cream,
2. or 1% gentian violet solution.
3. or miconazole gel.
or nystatin cream.
7 4. Give a second-line antibiotic targeting Gram negative organisms
Treatment of Urinary tract 1 Prior to referral, give a first treatment dose of vitamin A according (to be repeated on
infection day 2 and 14).
Treatment of Vitamin A 1 If eye signs, apply 1% tetracycline eye ointment every 6 hours until all signs of
deficiency inflammation or ulceration resolve, and atropine eye drops 0.1% every 8 hours to relax
the eye and prevent the lens from pushing out.
2 Protect the eyes with pads soaked in 0.9% saline and bandage the affected eyes
(scratching it with a finger can easily rupture an ulcerated cornea).
3 Age:
1. < 6months give 50,000 IU
2. 6-12 months give 100,000IU
>1year give 200,000IU
4 3. Use a cereal-based starter F75, or, if necessary, a commercially available
isotonic starter F75.
MILK OR LACTOSE 1 Gradually introduce F100 or ready-to-use therapeutic food (RUTF) for catch-up
INTOLERANCE growth.
2
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10. Specialized Foods and Products for the Management of Acute Malnutrition
Location: IPD-SAM
This annex provides information on therapeutic foods and products specifications and safety, and their use in the treatment of severe acute
malnutrition (SAM): Therapeutic milk F75 and F100, and rehydration solution for malnutrition (ReSoMal). It also provides guidance on alternative
recipes.
status
F75 1 F75 is provided in inpatient care for stabilization ONLY.
2 The amount of F75 given during stabilization is 100 Kcal or 130 ml/kg/day.
3 Give F75 8-12 times per day or in 24 hours.
F100 1 Once the child is stabilized F75 is replaced by F100 135-150 ml /kg give during transition.
2 If the child is breastfed, breastfeeding should continue.
3 After transition phase refer the child to OPD_SAM.
4 if OPD_SAM is not present F100 maybe used in the rehabilitation phase.
5 F100 150–220 Kcal/kg/day with 4-6 g protein/kg/day
6 F100 may be used in inpatient care during transition and rehabilitation when RUTF is not
available.
7 Frequent feeds of F100 with added daily iron 3 mg/kg/day and continued folic
acid 1 mg/kg/day
8 If the child is breastfed, breastfeeding continues and is supported
9 Gradual introduction of family foods, but with the prescribed amounts of F100
take first
92
10 F100 should NEVER be given in outpatient care or for use at home.
F100-Diluted 1 For infants:

• Use Plan A, adequate breastfeeding is supported and restored. in case this is not
possible.
• Use Plan B, expressed breast milk, a wet nurse is sought. in case breast milk is not
available or insufficient,
• Use Plan C, F100-Diluted (an infant formula) is being used under strict control.
2 F100-Diluted is provided in inpatient care for infants < 6 months or infants > 6 months and
< 4 kg if no bilateral pitting edema.
3 Give the amount of F100-Diluted in small quantities (100 Kcal or 130 ml/kg/day) and
gradually increased to 150 Kcal or 200ml/kg/day for catch-up growth (weight gain).
In case of nutrition edema is present replace F100 by F75
Preparation of F75 and 1 Wash hands with clean water.
F100 feeds
2 Boil water 3-5 minutes and cool it to 70 degrees
3 Open a new tin and record the date of opening, If an open tin is used, verify the dates of
use.
4 prepare the milk with clean equipment in a clean environment.
5 Use the scoop that sits in the tin to reconstitute the milk, and verify the volumes of water
required per scoop, which are standard scoops.
6 Discard the prepared milk that is not used
7 Do not refrigerate the prepared milk (stored in refrigerate over 2 hours)
8 Do not mix milk powder of different tins therapeutic milk supplies from one supplier should
not be mixed with the therapeutic milk from another supplier.
Alternative Recipes for Therapeutic Milks refer to Annex xxx
93
11.Management of Severe Acute Malnutrition in other Age Groups
This annex provides guidance on the management of severe acute malnutrition (SAM) in school-age children, adolescents and adults in the
treatment of individual cases (which is not part of the Integrated Management of Acute Malnutrition (IMAM) approach)
location: OPD

Greeting and welcoming status
1 Welcome the client
4 Ask for chief complain
5 Explain and guide the processes for treatment
Screening of other age 1 Check edema in the same way as for under five children
groups
2 Examining the ankles and lower legs for bilateral pitting edema, including the severity of grade
(+), (++) and (+++).
3 Measure MUAC in the same way as for under five children but bellow MUAC cu-off shows severe
acute malnutrition:
1. MUAC < 130 mm in school-age children (5-9 years)
2. MUAC < 160 mm in adolescents 10-18 years).
3. MUAC < 185 mm in adults (>18 years).
94
4 Measure Weight and Height Z score cut-off shows Sever acute malnutrition
1. WHZ-for-age < –3 in school-age child (5-9 Years)
2. WHZ for age < -3 in adolescents (10-18 years)
3. BMI for age <16.0 in adult (over 18 years)
Diagnosis for SAM in 1 School age children (5-9 years)
other age groups 1. Presence of nutritional edema
2. MUAC < 130 mm, or
3. WHZ-for-age < –3, or
4. BMI-for-age z-score < –3
2 Adolescents (10–18 years)
1. Presence of nutritional edema, or
3. WHZ-for-age < –3, or
4. 4. BMI-for-age z-score < –3
3 Adults (over 18 years) excluding pregnant women
1. Presence of nutrition edema
3. BMI < 16
4 Pregnant and lactating women
1. Presence of nutritional edema
2. MUAC less than 185 mm
Case management of 1 Wash hands by clean water
other age groups
2 Check appetite test
3 If appetite test passed start RUTF:

1. 5-6 years the same as children under five (200 Kcal/kg)
2. 7-10 years 14.8 gr/kg (75 Kcal/kg)
3. 11-14years 11gr/kg (60 Kcal/kg)
4. 15-18 years 9.2gr/kg (50 Kcal/kg)
5. 19-75 years 7.4 gr/kg (40 Kcal/kg)
6. >75 years 6.4 g/kg (35 Kcal/kg)
95
4 Give routine antibiotic
5 Give anthelminthic in the second week of the treatment

• Mebendazole 100mg twice a day for 3 days.
• Albendazole 400 mg single dose.
6 If appetite test is not pass give Formula feed by Nasogastric tube as a:

1. 7-10 years F75 4.2 ml/kg in the stabilization phase than F100 3.0 ml/kg
2. 11-14 years F75 3.5 ml/kg in the stabilization phase than F100 2.5 ml/kg
3. 15-18 years F75 2.8 ml/kg in the stabilization phase than 2.0ml/kg
4. 19-75 years F75 2.2 ml/kg in the stabilization phase than 1.7ml/kg
5. >75years F75 2.0 ml/kg in the stabilization phase than 1.5 ml/kg
7 Treat all complication in the same way as for under five children
8 Monitor progress of the treatment

9 Introduce supplemented with a diet based on traditional foods.
Decide end of treatment 1 School-age children

1. MUAC is 165 mm, or
2. WHZ-forage –2, or
3. BMI-for-age z-score is –2.
4. Clinically well
2 Adolescents
1. MUAC 185 mm or
2. BMI-for-age z-score –2
3. Clinically well
3 Adults
1. MUAC 230 mm or
2. BMI 18.5, or
3. Clinically well
96
Section 3
Micronutrient supplementation and treatment SoPs
1.Iron folic acid deficiency and anemia

Iron is an essential mineral. It is a part of hemoglobin, the oxygen-carrying component in the blood. Iron is also part of myoglobin, which helps
muscle cells store oxygen. When iron is deficient, hemoglobin cannot be produced that causes anemia in individuals. When enough hemoglobin
is not available, the red blood cells formed are small and pale and unable to deliver adequate oxygen to the tissues. Considering the important
role of iron in human body, it is necessary to screen all children and women who attend the HFs for iron deficiency anemia. If any sign of iron
deficiency or anemia is determined the client should receive treatment in early stage. Below is the standard operation procedure for providing
iron to clients in HFs
Location: General OPD and MCH section
Responsible person: Medical doctor/ nurse and midwife
Intervention No Activity Objective: Intervention Remarks

status
Yes No
1-Greetings and 1 Welcome the client
2: Screening of iron 1 Ask for the symptoms of iron deficiency and induced anemia (fatigue,
deficiency anemia (all weakness, anorexia, sensitivity to cold, dizziness and headache, craving ice
children and adults) chips, pica and respiratory distress)
2 Observe the signs (nail shape, pallor in palm, inferior conjunctiva, and nail
bids)
3 Refer the patient to laboratory services to check the level of HB or hematocrit
if available in HFs
97
3: Decide for severity of 1 If HB is less than 7 gr/dl or hematocrit is less than 20% or clinically the
anemia and treatment conjunctiva, nail bids and palms are extremely pale consider the case as severe
setting anemia
2 Refer severe anemia for blood transfusion if.
A: Patient is pregnant women in 36 week of pregnancy or beyond
B: Any other patient with having respiratory destress or cardiac abnormalities
(laboured breathing at rest or oedema)
3 Except above two cases, treat other severe anemia patients in primary health
center by advising iron tablets
4 Treat all moderate anemia cases (HB<11-7 gr/dl in local setting by advising oral
IFA tablets
4: IFA dose for severe 1 A: Children< 2 year give 25mg iron+100-400 mcg folic acid daily for 3 months
and moderate anemia B: Children from 2-12 years give 60 mg iron+400 mcg folic acid daily for 3
treatment months
C: Adolescent and adults including pregnant women give 120 mg iron+400 mcg
folic acid daily in 2 divided doses for 3 months
5: Anemia prevention 1 Tell the mother to use locally available haem-iron food products such as meat,
and Iron folic acid liver, beans etc
supplementation 2 Start complementary feeding at age of six and give meat, eggs and other
animal products to children
3 Consume more Vit-C rich food that promote iron absorption
4 Do not use iron rich food together with team, yogurt and other phytates
having food items
5 Take much iron rich food during pregnancy and lactation
6 • Children, give iron as supplement:
• Low birth weight infants: 2 mg iron/kg from 2nd month to 23rd month
• 7Children aged 6-23 months: 2 mg iron/kg from 6 months to 23 onths
where iron prevalence is above 40%
• Children aged from 24 to 59 months: Iron 2 mg/kg/day up to 30
mg/day for 3 months where anemia prevalence is above 40%
• Children aged above 60 months: Iron 30 mg/day and folic acid 250
mcg/day for 3 months where anemia prevalence is above 40%
7 Women, give iron supplement;
98
• Adolescent girls (10-19 years): Iron 60 mg+ folic acid 400 mcg/week
continuously
• Women of child bearing age: Iron 60 mg+ folic acid 400 mcg/ day for 3
moths where anemia prevalence is above 40%
• Pregnant women: Iron 60 mg+ folic acid 400 mcg/ day as soon as
possible after gestation starts until end of pregnancy
• Lactating women: Iron 60 mg+ folic acid 400 mcg/ day during 3
months of post-partum where anemia prevalence is above 40%
2. Vit-A
it is a fat-soluble vitamin play different roles in body. It prevention cause different signs and symptoms with adults and children
Location: General OPD
Responsible person: Medical doctor/ nurse

status
Yes No
2: Screen the patient by 1 night blindness, Conjunctival xerosis, Bitot`s spots, xerophthalmia,
asking/observing these hyperkeratosis
Signs/ Symptoms
3 : Provide Vit-A for 1 Supplement Vit-A to children using NID campaign
prevention • Children aged 6-11 months give 100000 iu oral Vit-A
Children aged 24-59 months give 200000 iu oral Vit-A
2 If any child missed the campaign, give Vit-A as mentioned above in HFs when
come to contact
99
3 Vit-A supplementation is not recommended to women in post-partum period
or in routine ANC service to pregnant women
4: Advice Vit-A for 1 If child has Xeropthalmia, night blindness, keratomalacia, corneal ulcer and
treatment xerosis give Vit-A
• Children aged 0-5 months give 50000 iu oral Vit-A on first, second and
14th day
• Children aged 6-11 months give 100000 iu oral Vit-A on first, second
and 14th day
Children aged 12-59 months give 200000 iu oral Vit-A at first, second and 14th
day
2 If child has measles give Vit-A
• Children aged 6-11 months give 100000 iu oral Vit-A on first, second
and 14th day
Children aged 12-59 months give 200000 iu oral Vit-A at first, second and 14th
day
3 If child has chronic diarrheal diseases give Vit-A
• Children aged 0-5 months give 50000 iu oral Vit-A as single dose
• Children aged 6-11 months give 100000 iu oral Vit-A as single dose
Children aged 12-59 months give 200000 iu oral Vit-A as single dose
4 If child has acute malnutrition
• Do not give Vit-A if he/she take RUSF, RUTF or therapeutic milk,
because they have enough amount of Vit-A in combination
In case of eyes signs give Vit-A as indicated above
5: Give counselling to 1 Tell mother to continue breastfeeding with more frequencies
mother 2 If child aged 6 months tell her to give complementary feeding considering
FATVAH
3 Advice mother to give liver, meet, eggs, batter, carrot, pumpkin, green leaves
vegetables to child
4 Tell her to bring the child next week back to health facility for monitoring the
status
5 Tell mother to take care of hygiene, wash child hands frequently and use safe
water for food preparation
100
Zinc:
Zinc is an essential mineral that is a component of more than 300 enzymes needed to repair wounds, maintain fertility in adults and growth in
children, synthesize protein, help cells reproduce, preserve vision, boost immunity and protect against free radicals, among other functions.

status
Yes No
2: Give zinc 1 Give zinc if child has acute diarrhea, persistent diarrhea, dysentery
supplementation • For children 6-59 months old: 20 mg/ day for 10 days
For children under 6 months:10 mg / day for 10 days
3: Give counselling to 1 Tell mother to continue breastfeeding with more frequencies
mother 2 If child aged 6 months tell her to give complementary feeding considering
FATVAH
3 Advice mother to give meat, eggs, fish, dairy product to child because they are
good source of zinc. Secondly, whole grain product is also good source of zinc
especially when it is leavened with yeast
4 Tell mother to take care of hygiene, wash child hands frequently and use safe
water for food preparation
5 Advice mother to use iodized salt in prepared food
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4.Vitamin C
Vit-C is a water- soluble vitamin that has a number of biological functions. Its deficiency can cause various sings
and symptoms with children and adults. The below is standard procedure for Vit-C deficiency identification and
treatment
status
Yes No
2: Check the signs and 1 In adults and adolescents Internal Hemorrhage, Joint and muscle pain (legs &
symptoms of Vit-C feet), Joint swelling, Bleeding gum (can be swollen), Reduced mobility,
deficiency Reduced work capacity, Anemia
In children: General irritability, Tiredness in the limbs, especially the legs,
Pseudo paralysis (legs), hemorrhage around erupting teeth
3: Give counselling for 1 Eat as much fruit and vegetable as available.
prevention 2 Store fresh vegetables and fruit for as short a time as possible.
3 Vegetables should not be cut into small pieces before washing and cooking
4 Cook food for as short a time as possible
5 Cover pot with lid while cooking to reduce cooking time
6 Eat food soon after cooking, do not store cooked food
4: Give supplementary 1
Vit-C • Adult: 100 mg Vitamin C daily or 250 – 500 mg weekly, in 1 – 2 doses
Recommended when in for as long as serious risk exist.
situation where risk
factors for scurvy are Children: 30 - 50 mg Vitamin C daily or 100 mg weekly, in 1 – 2 doses for as
long as serious risk exists.
widely prevalent or
food-based measures
are not applicable
102
5: Give Vit-C for 1 When signs and symptoms of Vit-C deficiency observed
treatment • Adult: 500 –1000mg Vitamin C tablets daily divided over 3 doses for 2
– 3 weeks
• Children: 100 – 300 mg Vitamin C tablets daily divided in 3 doses for 2
– 3 weeks
5. Vitamin D
It is known as the sunshine vitamin because it can be produced in the skin by exposure to ultraviolet light

status
Yes No
2: Check the signs and 1 Rickets sings in babies
symptoms of Vit-D • The bones of the skull may be soft
deficiency • The fontanels (soft spot) takes a long time to close
• The chest may be deformed, and there may be swellings at the ends of
the ribs
• The baby may have repeated respiratory infections
Rickets Signs in children

• The skull may look enlarged
• The muscles are weak, and the child may learn to walk late
• The legs may bend, or the child has outward feet and walks like a duck
• Sometimes the legs are bent inwards, like “knock knees
Osteomalacia (in adults)

• Sever pain in the bones
• Muscle weakness
103
Broke bones, especially in people who are old or disabled
3: Prevention of Vit- D 1 adults are advised to take a supplement containing 800 international units of
Deficiency vitamin D per day
2 infants and children are advised to take a vitamin D supplement containing
400 international units of vitamin D
3 Sun exposure at least 15-30 minutes every day with the face and arms
uncovered
4 Advise the mother to give Vit-D rich food to child such as fish, meat, dairy
products, and oil
4: Treatment of Vit-D 1 Determine Vit-D level in blood by laboratory testing
deficiency 2 In adults whose 25-hydroxyvitamin D (25[OH]D) level is <10 ng/mL (25 nmol/L)
Give Vit-D2 or D3 50,000 iu orally once or more per week for six to eight
weeks, then 800 to 1000 (or more) iu of vitamin D3 daily thereafter.
3 In adults whose 25(OH)D is 10 to 20 ng/mL (25 to 50 nmol/L)
Give 800 to 1000 iu of vitamin D3 by mouth daily, usually for three-month.
Once a normal level is achieved, continued therapy with 800 iu of vitamin D
per day
4 treatment usually includes 800 to 1000 international units of vitamin D3 by
mouth daily, usually for a three-month period
5 Once a normal level is achieved, continued therapy with 800 international
units of vitamin D per day is usually recommended.
6 In adults whose 25(OH)D is 20 to 30 ng/mL (50 to 75 nmol/L)
Give 600 to 800 iu of vitamin D3 by mouth daily
7 Adults with normal Vit-D level (>30 ng/mL or75 nmol/L) are advised to take
orally 800 iu Vit-D daily
8 In infants and children whose 25(OH)D is <20 ng/mL (50 nmol/L)
Give 1000 to 5000 iu of vitamin D2 by mouth per day (depending on the age of
the child) for two to three months
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6. Calcium:
Calcium is an essential mineral found in great abundance in the body. Ninety-nine percent of all the calcium in the body is found in
the bones and teeth. The remaining one percent is in the blood

status
Yes No
2: Check Sings/Symptom 1 Hypocalcemia (Check for numbness and tingling in the fingers, muscle cramps,
of calcium deficiency convulsions, lethargy, poor appetite, and abnormal heart rhythms)
3: Prevention of calcium 1 All pregnant women should be supplemented with calcium where calcium
deficiency intake is low or existence of gestational hypertension
Give 1.5 to 2-gram elemental calcium daily in 3 doses effective from week 20th
until end of pregnancy
2 Tell mother to get calcium rich food such as dairy production and eggs
4: Treatment of calcium 1 Severe symptomatic hypocalcemia
deficiency • Give calcium gluconate 10 %(10-20ml) intravenously over 10-15
minutes
Then, give 10-15 mg/kg calcium gluconate in 1 litter glucose 5% over 4-6 hours
as infusion
2 Asymptomatic hypocalcemia
Give 1-2 gr calcium orally and Vit-D preparation
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7. Multiple Micronutrient Powders (MNP) for children
MNP is a new and innovative product designed to improve quality of diet of young children. It is increasingly being used for home fortification of
local complementary foods. MNP is powdered preparation of micronutrients, which is mixed into food while cooking or into food that is ready to
eat. WHO recommends use of MNPs containing iron, vitamin A and zinc, to reduce anemia among children aged 6-59 months Home fortification
of foods with multiple micronutrient powders is recommended to Improve iron status and reduce anemia among infants and children 6–23 months
of age MNP was originally developed to provide iron and other nutrients required for treating nutritional anemia, because iron and folic acid
tablets cannot be swallowed by young children and syrups had not been an effective intervention, likely because of poor acceptability related to
strong metallic taste, staining of teeth, bulky packaging and the potential for over-dosing. For this reason, the efficacy of MNP was evaluated
regarding its impact on anemia and iron deficiency
The below are the standard activities to be performed for MNP administration

status
Yes No
4 Ask child age
5 Inform mother for administration of MNP
2-Frequency 1 Give 1gr sachets MNP to children aged from 6-23 month in normal condition (One sachet per day/ total
and duration of 60 sachets for 2 months)
After 4 months re-start and give one sachet per day/60 sachets for 2 months (120 sachets for one year)
MNP
2 Give MNP 1gr sachets to children aged from 6-59 months in case of emergency and food insecurity (One
sachet per day/ total 60 sachets for 2 months)
After 4 months re-start and give one sachet per day/60 sachets for 2 months (120 sachets for one year)
3 Do not give MNP in case of emergency to those children who have already received MNP as a routine
program supplement.
3-Counseling for 1 Inform mother on the importance of MNP (vitamin and mineral deficiency affect cognitive and physical
MNP use (Main growth of your child. MNP is safe and can improve the quality of your child’s food and prevent the
disorder
106
messages for 2 Before preparing food and adding MNP to child’s food wash your hand with water/soap and tear the top
mothers or of MNP sachet with scissor
other care
3 Tell the mother to use clean utensil, dish, plates, and spoon for child feeding
givers on MNP Tell the mother to pour the entire contents of the package in amount of already cooked semi-liquid oily
4
use) food that child can consume it in single meal
5 inform mother/caregivers that The MNP should not be added to hot and liquid foods (tea, soup, milk,
water etc.).
6 Mix the food well after you have added the package of MNP and use it within 30 minutes
7 Give no more than one full package per day at any mealtime.
8 Tell the mother not share the food to which MNP is added with other household members since the
amount of minerals and vitamins in a single package of MNPs is just right amount for one child.
9 inform mother that MNP is not a substitute for feeding nutritious foods to their child and that they should
continue to feed their children a variety of good quality, nutritious foods
10 Inform mother that MNP should not be added to the food in front of the child who is eating the food, to
avoid refusal to eat by the child
11 Inform mother that Keep breastfeeding your child until two years of age.
12 Inform mother/caregiver that eat extra meat, eggs or fish, and dairy products such as yogurt, every day.
13 Inform mother/caregiver that give your child at least 3 meals a day plus 2 snacks that Every meal should
have 4 types of foods
14 Inform mother/caregiver that give no tea to your child while taking MNP.
15 Inform mother/caregiver about possible side effects of MNP and how to manage them
16 Inform mother/caregiver that the child’s stool will become dark when MNPs are ingested. This is a sign
that the MNPs are working. It is not an adverse side effect. Sometimes diarrhea happen which is not
matter of concern to discontinue the MNP. It subsides in few days or weeks
17 Inform mother/caregiver that If the side effects do not subside after a few days to a few weeks, use half a
package of MNPs added to complementary foods at 2 different mealtimes throughout the day ,for
example, if half a MNPs package is added to the complementary food in the morning, the other half
should be added at the next mealtime.
18 Inform mother/caregiver that If the side effects still do not subside, divide a MNPs package in 3 and feed
it throughout the day with complementary foods at 3 different mealtimes.
4: Micro nutrient 1 Give micronutrient supplementation to women (pregnant and lactating) whether the receive fortified
supplementation food ration or not
in emergency to 2 Give the micronutrient until the emergency is over
3 Tell mother to take one micronutrient tablet each day
107
pregnant and 4 Iron folic acid supplementation, where already provided, should be continued along with multiple
lactating women micronutrient supplementation
5 Counsel the mother to take extra food during pregnancy and lactation
8. Standard Operational Procedures ( SOP ) to Supporting Deworming
Background:
Large sectors of the Afghan population have limited access to safe water and sanitation, which increases the risk of transmission of
water- and food- borne diseases, including Soil-Transmitted Helminth (STH) infections. STHs interfere with the human host’s health
status, and their burden of disease is highest among children of school age.
Based on the results of a nationwide survey conducted in 2003, which showed an STH prevalence of 47.2%, and with the aim of
reducing morbidity among school children.
The absence of infections of moderate-to-heavy intensity after several yearly rounds of deworming and overall improvements in
provision of safe water and sanitation, indicates successful control of morbidity due to STH and, overall, their elimination as a public-
health problem from Afghanistan. Nevertheless, current levels of prevalence of infection still show persistence of active transmission
of STHs, thus justifying the continued implementation of mass deworming interventions among childrens.
Current Deworming Strategies:

The bellow strategies are available for deworming in the country:
1. Preschool aged children (24-59 months) deworming through NIDs.
2. School aged children (7-10 years) deworming in schools.
108
3. Adolescent girls (10-19 years) deworming through WIFS in schools.
4. Pregnant and lactating women deworming through HFs (ANC, PNC)
8.1 Supporting Deworming during pregnancy in Health Facility:

WHO recommends periodic treatment with anthelminthic(deworming) medicines, without previous individual diagnosis to all at-risk people
living in endemic areas. It defines at-risk people as pre-school-aged children, school-aged children, and women of childbearing age (including
pregnant women in their second and third trimesters and lactating women)
Location: Female OPD

Below are the standard activities to be performed to support Deworming of pregnant women during visiting HFs for ANC services.
Interventions Objective of activities Intervention Remarks

status
Yes No
1. Greetings and 1.1 Welcome the client and thank her for coming to HFs
welcoming 1.2 Introduce yourself
1.3 Show the client to have a set
1.4 Confirms woman’s name
1.5 Ask for the ANC card
1.6 Explain the processes
Complete the registration (record name and required information)
2. Identify the 2.1 Ask about the date of first day of her last menstrual period and regularity of menses
gestational age 2.2 Calculates expected date of delivery (EDD) and gestational age and records
2.3 Confirm she is in second or third trimester
3.4 WASH measures should be encouraged for improving sanitation & hygiene
3. Recommended 3.1 using single dose of albendazole (400 mg) or mebendazole (500 mg), for pregnant women
drugs to
109
deworming
during pregnancy
4. Recording 4.1 All pregnant women received deworming tablets should be recorded in ANC register book,
ANC cards and ticked in tally sheet
4.2 The health facility should follow the HMIS reporting procedures
8.2 Supporting Deworming in Children under five at HFs:

Location: OPD
The below are the standard activities to be performed for Deworming in Children under five at HFs
status
Yes No
1. Greetings and 1.1 Welcome the client
welcoming 1.2 Introduce yourself
1.3 Show the client to have a set
1.4 Ask the mother or caretaker for deworming in last round of NID campaign. If mother say that
there child not taked deworming tablets
1.5 Health care provider explain the processes
2. Identify the age 2.1 Ask the mother name of child and child age by months
of child 2.2 Record the name and age of child in register
2.3 Complete the general information part of registration
2.4 WASH measures should be encouraged for improving sanitation & hygiene
3. Treatment and Children aged 12-23 month Albendazole (200 mg) or Mebendazole (250 mg
3.1
dosages of drug
110
for different age Children aged from 24 to 59 months Albendazole (400 mg) or Mebendazole (500 mg
groups
3.2 Non-pregnant adolescent girls (10-19 year) and non-pregnant women of reproductive age
single-dose Albendazole (400 mg) or Mebendazole (500 mg), for all non-pregnant adolescent
girls and women of reproductive
4. Recording and 4.1 The health facility should follow the HMIS reporting procedures as below:
reporting
4.2 All child and adults received deworming tablets must be recorded the OPD register book and
ticked in tally sheet
4.3 In the end of month health care provider (HCP) will count up the number of tick marks in their
tally sheet and compile the data of children and adult dewormed in the HF
4.4 The mentioned compiled data through the platform of reporting format submit to the PPHD and
one copy will be kept at health facility
4.5 The PPHD team compiled all received reports from their HFs and will prepare two copies of
reporting; one copy will be submitted to MOPH while the second copy will be kept at provincial
office for record. The PPHD team to ensure that reported data is correct in all aspects (i.e.,
accuracy, completeness and timeliness).
111
Section 4
Community Based Nutrition Program
The community-based nutrition activities are part of the responsibility of Community Health Workers and Volunteers functioning in Health Post level,
and Community Based Nutrition package which is recently developed to be used as tool for easily implementing the nutrition activities at community
level to improve the nutrition status of families and communities.
The following SOPs should be used by CHWs and community volunteers (selected during 2 days Community Mobilization Session) while using
CBNP tools to preform nutrition activities, the SOPs are developed with consideration of nutrition activities listed in the BPHS guideline.
4.1 Growth monitoring and promotion (GMP) Sof under 2 year children (measuring weight for age)
Below are the standard activities to be performed for growth monitoring and promotion of children under 2 year of age living in the catchment area
of Health Post. Monthly Growth monitoring and promotion session for all children under 2 years of age living in the catchment area of the HP should
be conducted by the CHWs and volunteers at prescheduled days agreed with participation of a group of children under 2 year with their
mothers/caregivers in the HP.
1. Greetings 1 Welcome the client and thank she/he for bringing the child for weighing and growth If
and monitoring possible
welcoming 2 Introduce yourself ,
3 Ask the client to have a set develop
4 Explain the processes of weighting to mother/caretaker of the child pictorial
2. Registration 5 Register the child in tracking register (if the child not registered. SOP as
and Identify 6 Ask the mother/Care taker about the age of child (Dte of birth) well or
the age of 7 Record the child age in the tracking register and fill tracking sheet for the mentioned child put the
child in the tracking register book as well pictures
8 Tick the related cell of weighing session in the tracking register (the tracking register under
should be used as attendance sheet) each
9 step
1 If the child is already registered, mark the name of the child in tracking register along with
0 current month and mention the date of visit in tracking sheet
Consider the below recommended steps for weighing child by salter scale
1 Calibrate the scale at the starting of each working day with 3, 5 or 10 kg standard
1 weight or any other standard weight
112
3. Weight 1 Remove all cloths of the child as possible including shoes, hat
Measureme 2
nt 1 Put the child in trouser and hang him/her in the hook of scale
3
1 Let the scale hand to stand steady on one weight figure
4
1 Stand in front of scale hand at zero degree and read the indicated weight
5
1 Note the weight of the child
6
1 Release the trouser smoothly from hook and give the child to the mother
7
1 Write the weight of the child both in tracking sheet of the register and child growth
8 card (backside of the card)
1 Write the date of weighing & mark the status of child in tracking sheet and growth
9 card as he/she is in red, yellow or green zoon
4. Plotting the 2 Use blue color card for boys and violate color card for girls
GM card 0
2 Fill the card for general information (child name, father’s name, birth date, province,
1 district and HPs name)
The date of child weighing should be recorded in the child recording form (monthly GMP
card)
2 The child weight should be recorded in the related cell of the child recording
2 form (monthly GMP card) as well as tracking sheet
2 Plot on the GMP card based on the weight per age.
3
2 When points are plotted for two or more visits, connect adjacent points with a straight line
4 to better observe trends
5. Translat 2 If the child’s weight/age plot in the first visit located on the green zoon or its trend in
e the 5 continuous visits is go up, appreciate the mother and encourage her for continuation the
plots/trends same feeding and caring practices in the future
to decision 2 If the child’s weigh/age plot located on yellow/red zone or its trend go horizontally or down,
6 inform the mother about the situation, identify the problem and provide adequate
and action
counseling to the mother/caregiver based on the child age ( about exclusive
breastfeeding,complementary feeding with continuation of breastfeeding for children 6-24
months). Record the child nutrition status) and agreement with mother on actions to be
113
taken for improving the child nutrition status in columns both in the back side of the child
growth card and tracking sheet of the relevant child in tracking register.
Use CBNP related IEC material including Nutrition Flipbook, Pie-wheel Do and Don’ts
charts for complementary feeding and pregnant women while providing counselling to
mothers.
2 If the child’s weight/age trend is in the Yellow Zone of below the green zoon ( -2 to -3 Z
7 score) the child is moderately malnourished. Inform the mother about the situation, identify
the problem and provide adequate counseling to the mother/caregiver of the child
according to the age of the child. Record the date, weight of the child, nutrition status (mark
yellow zone) and agreement with mother on actions to be taken for improving the child
nutrition status in columns both in the back side of the child growth card and tracking sheet
of the relevant child in tracking register. Plan for follow up home visits of the child during
next two weeks. Using CBNP related IEC material including Nutrition Flipbook, Pie-wheel
Do and Don’ts charts for complementary feeding and pregnant women while providing
counselling to mothers.
2 If the child’s weight/age trend is in the Red Zone (severely malnourished), or Inform the
8 mother about the situation, identify the problem and provide adequate counseling to the
mother/caregiver of the child according to the age of the child. Prove the child a refer sheet
and refer her/his to near health facility for further investigation and follow up.
6. Follow 2 All children with steady or losing weight during last month, should be visited during two
up of 9 weeks after last growth monitoring session at their homes and check with the
children mother/caregiver the agreed points for improving the child nutrition status,
which are 3 If the agreed points were applied by the mother/caregiver, appreciate her work and tick the
0 relevant cell in the tracking sheet as well as in on the back of child growth card (GMP card)
prone to
malnutrition 3 If the agreed points were not followed by mother/caregiver, cross the relevant cell in the
through 1 tracking sheet as well as in on the back of child growth card (GMP card), ask for the reasons
and provide further counseling to mother/family member to take care and improve the child
conducting
nutrition situation
home visits All children with steady or losing weight during two consecutive growth monitoring visits,
the child is prone to malnutrition, should be referred to near health facility for further
investigation and follow up,
3 If the child was in red zone and provided refer sheet to visit near health facility for further
2 investigation should also be visited at their homes during next two week to ensure proper
use of therapeutic foods by the child and provide further counseling to mother/caregiver for
proper utilization of RUTF by the child
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4.2 Screening of children under 5 years of age (using MUAC and checking of edema)
Screening of children 6-59 month of age living in the catchment area of health post by measuring of mid upper arm circumference using MUAC tap
and checking of bilateral petting edema of children 0-59 months of age are solely the responsibility of Community Health Workers ,and each child
should be screened for assessing of acute malnutrition every 3 month by visiting at their homes.
The following standard steps should be considered while performing screening of children under five years of age.
1. Greetings 1 Greeting with mother/caretaker or family member of children under 5

2 Introduce yourself (even the community member knows CHWs)
3 Explain the processes of screening to mother/caregiver of the child
2. Check the 4 Remove footwear from child, if wearing
edema 5 Grasp the foot so that it rests in your hand with your thumb on top of the foot
6 Use moderately firm thumb pressure over a bony area just above the ankle or
the tops of both feet for approximately three seconds.
7 Release your thumb pressure
8 If an impression/indentation remains for at least a few seconds on both feet this
is identified as bilateral pitting edema and record it.
9 If edema detected in feet, check it in lower legs as well. In case it is positive in legs
observe it around the eyes’ orbits as well
3. MUAC 10 Ask the mother to unclothe the left arm of the child aged from 6-59 months of age
measurement 11 Ask the mother to bent left arm of the child
12 Measure the length of the child’s upper arm; between the bone at the top of the shoulder
and the tip of the elbow
13 Find the midpoint of the upper arm and mark it with a pen.
14 The child’s arm should then be relaxed, falling alongside his/her body.
15 Wrap the MUAC tape around the child’s arm, such that all of it is in contact with the
child’s skin.
16 feed the end of the tape down through the first opening and up through the third opening
17 Read the figure from the middle window where the arrows point inward. Record the number
with mm that meet sharply with arrows
18 Record the number in a paper or just see the color of MUAC tap presenting (red, Yellow
or green)
4. Translate 19 If there is no edema, and MUAC is more than 125 mm (green color area of the MUAC tap)
Edema and tell the mother that her child is not wasted or acutely malnourished. Encourage for
MUAC continuation good nutrition practices according to the age of the child.
measurement 20 If MUAC is less than 125 mm and between 125-115 mm (in the yellow area of the MUAC
tap) the child is moderately wasted. Inform the mother for this outcome, provide her
counselling on good feeding practices according the age of child and refer sheet, refer
115
to mother to near health facility if the health facility has OPD-MAM services for further
decision/action support. If the near health facility dose not the services, put the name of the child in weekly
follow up visits and provide follow up visits during next two weeks to provided further
counseling to mother and support to improve the nutrition situation of the child
21 If any grade of edema is observed or MUAC is less than 115 mm (in the red area of MAUC
tap) the child is severely malnourished. Inform the mother for this outcome, provide her
counselling on good feeding practices according the age of child and refer sheet, refer the
mother to near health facility for further diagnosis and support
5. Recording 22 All children under 5 participating in the screening should be tallied in HP tally sheet, a copy
and tallying of the refer sheet should be kept in the HP filling records
116
4.3 Food demonstration session
Food demonstration is part of the Community Based Nutrition activities which support/increase the capacity of mothers and family members on
preparing nutritious complementary foods for children 6-24 months of age from locally availed foods. The aim of the session is to share practices of
mothers with well-nourished children and proposes the preparation of diversified and balanced diet for children 6-24 months age. The session is
intended to be conducted at least once a month with participation all mothers with children under two years, especially those with malnourished
children. The number of participants in each session has depend on availability of space & cooking appliance in the HP. The food should be cooked
in the HP. The CHWs and volunteers should request mothers to bring a handful of whatever food items that they have at home with consideration
of foods listed in the Sessional Food Availability Calendar and seven food group categories with three functions (body protector, energy providers
and building our body) which are presented in nutrition Pie wheel. So that they could put all food items together and cook a wholesome meal for
children. Ask mothers to also bring a plate and spoon to feed their children. If the HP is not equipped with cooking utensils, stove, dishes, the items
should be provided by CHWs or volunteers. In each month new food recipe/menu should be selected from seven food categories available in the
community and ensure the prepared food has items from listed foods in seven food group to promote and demonstrate preparing of
balanced/diversified complementary foods for children 6-24 month of age.
The following steps should be considered while conducting food demonstration session
1. Greetings 1 Greeting and welcoming all mothers/ caregivers of children under two years of age in the
HP
2 Introduce yourself (even the community member knows CHWs & volunteers)
3 Request mothers to introduce himself to the session members
4 Explain the processes of food demonstration
5 Explain the recipe of meal planned to be prepared during the session
2. Preparation 6 Bring all needed appliances for cooking including stove, gas slander, pots, spoons for
for and cooking, a pitcher for water for cooking and drinking, a pot for water for washing, ---
cooking of 7 Explain to the mothers about complementary food, time of starting and its importance on
meal growth and health of children aged 6-24 months of age
8 use the information about complementary food mentioned in Dons and Don’ts charts for
children 6-24 months, pie wheel and Nutrition Flipbook, while explaining about
complementary and balanced food to mothers
9 Ensure that the food items selected for cooking has mixed food items from seven food
groups listed under three categories of foods mentioned in Pie wheel including1) energy
providing foods (Cereals and Tubers, Fats and Oils),2) protective food (
Vegetables and Fruits), and 3) body building foods (Dairy, Pulses, Nuts and Seeds, Meat,
Fish and eggs)
10 The food items should be selected from above mentioned categories of food with
consideration of seasonal and locally availability based on seasonal of the year
117
11 After selecting of food items and the recipe, the food items should be showed to mothers
and discuss about the role of each food items on producing energy, protection and growth
of body using Pie wheel, Don and Don’ts chart
12 Wash your hand and all cooking material with soap and water
13 Wash all vegetables prior of cutting them
14 Use iodized salt while cooking
15 Starting cooking of food items and request mothers to list the steps of cooking the recipe
16 Wait until the food is cooked and ready for serving
3. Serving 16 While the food is ready, ask mothers to wash their hands along with their children hand with
of cooked water and soap
food and 18 Ask mothers to wash palates and spoons of their children with water and soap as well
counseling to 19 Distribute the meal among all children participating in the session and request mothers to
mothers help/feed their children from the meal
20 Ask mother to taste the meal and provide their comments and suggestions for further
improvement the quality and taste of the food
21 Provide further counseling to mothers about complementary food, its importance and
benefit of balanced complementary food for children
22 At the end of session once again check with each mother to ensure, she received the
messages properly and understand the information about preparing and cooking of
balanced complementary foods
23 The CHWs and volunteers should select the date for next session
24 The CHWs and volunteers should further review messages and information about
preparation & use of balanced and mixed complement foods mentioned in Pie Wheel,
Dons & Don’ts charts and CBNP field manual
118
Annexes
e 4.2. Ro utine anthel Anthelminthic for children 12–59 months of age with MAM and SAM
Drug* Age Dose Prescription
12–23 months 250 mg
Mebendazole
24 months as older 500mg
12–23 months 200 mg Single dose orally
Albendazole
24 months and older 400mg
Pyrantel pamoate 12 months and older 10mg/kg
*Use only one of the anthelminthic.
Table 4.3. Dosage of routine antibiotic for children 6–59 months of age with uncomplicated SAM
Drug and dosage Dosage according to body weight
< 6kg 6 - <10 kg 10 - <15 kg 15 - < 20 kg

Amoxicillin 40 mg/kg orally two times per day for 5 days
Tablet 250 mg
Syrup 250 mg/5 ml 1 1½ 2 3
2.5 ml 7.5 ml 10 ml -
Cotrimoxazole (trimethoprim 4 mg/kg +
sulfamethoxazole 20 mg/kg) orally two times per day for
5 days
Adult tablet (T 80 mg + S 400 mg)
¼ ½ 1 1
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Pediatric tablet (T 20 mg + S 100 mg) 1 2 3 3
Suspension (T 40 mg + S 200 mg/5 ml) 2 ml 3.5 ml 6 ml 8.5ml
Table 5.5. Dosage of broad-spectrum antibiotic treatment for complicated SAM

Drug and dosage Dosage according to body weight
3- 6kg 6 - <10 kg 10 - <15 kg 15 - < 20 kg
Ampicillin 50 mg/kg IM or IV four times per day on days

1 and 2
1ml 2ml 3ml 5ml
Vial 500 mg mixed with 2.1 ml sterile water to give 500
mg/2.5 ml
1 1.5 2 3
250 mg tablet
120
Amoxicillin 40 mg/kg Syrup (containing 2.5ml 7.5ml 10ml --
orally two times per day 250mg/5ml)
on days 2–7 (5 days)
Vial containing 20 mg (2 ml at
Gentamicin 7.5 mg/kg 10 mg/ml) undiluted 2.25–3.75 ml 4.5–6.75 ml 7.5–10.5 ml --
IM or IV once a day on
days 1–7 (Vial Vial containing 80 mg (2 ml at --
containing 20 mg) 40 mg/ml) mixed with 6 ml 2.25–3.75 ml 4.5–6.75 ml 7.5–10.5 ml
sterile water
Vial containing 80 mg (2 ml at 0.5–0.9 ml 1.1–1.7 ml 1.9–2.6 ml 2.8–3.5 ml

40 mg/ml) undiluted
Table 5.6. Overview of Vit-A treatment in IPD/OPD-SAM for children 0–59 months of age
Age < 6 months 6−12 months > 1 year
Weight 3−< 6 kg 6−< 10 kg 10−29 kg
Vitamin A dosage 50,000 IU 100,000 IU 200,000 IU
121
Table 5.7. Overview of dietary treatment in IPD-SAM for children 6–59 months of age
Stabilization phase Transition Rehabilitation phase
Objective Stabilizing medical complication(s) Transitioning the feeding Restoring body function and catch up
and metabolism for electrolyte and protocol growth
micronutrient imbalances
Condition Child has poor appetite or isChild has returned appetite and Child gains weight
clinically unwell is alert and clinically well
Duration of stay 2–7 days 1–3 days 1–4 weeks
Child referred to OPD-SAM as Child continues treatment in OPD-
soon SAM; rare cases remain in IPD-SAM
as eats 75% of RUTF or two full until full recovery
meals
Therapeutic food F75 RUTF (if available and possible) RUTF or F100
topped up with F75 (or F100) inGradually introduce complementary
case home foods
needed*
F100 in case RUTF not available
or
not possible
Amount F75 130 ml/kg/day in 8–6 meals RUTF 27.6 g/kg/day RUTF 36.8 g/kg/day
F100 130 ml/kg/day in 8–6 F100 220 ml/kg/day in 6–5 meals
meals with daily increase of 10
ml per feed
Energy 100 Kcal/kg/day 150 Kcal/kg/day 200 Kcal/kg /day
Weight gain None ((weight gain is a danger sign) Average of 5 g/kg body Substantial, ≥ 10 g/kg body
weight/day weight/day
* RUTF can be topped up with F75 or F100 as follows: 25g RUTF (135 Kcal) = 180 ml F75 = 135 ml F100
20g RUTF (108 Kcal) = 144 ml F75 = 108 ml F100
18g RUTF (100 Kcal) = 133 ml F75 = 100 ml F100 = 1/5th of RUTF sachet (92g)
Table 4.5. Dosage of RUTF (92g) for children 6–59 months of age with uncomplicated SAM
122
Weight of child in kg Sachets per day Sachets per week
4-4.9 2 14
5-6.9 2.5 18
7-8.4 3 21
8.5-9.4 3.5 25
9.5-10.4 4 28
10.5-11.9 4.5 32
≥ 12 5 35
Indicator IPD-SAM^ IPD-SAM° OPD-SAM OPD-MAM
Cure rate / > 75% > 75% > 75%
Default rate < 15% < 15% < 15% < 15%
Death rate* < 10% < 10% < 10% < 3%
Average length of < 7 days < 30 days < 56 days < 56 days
stay
Average weight gain / > 5 g/kg/day > 5 g/kg/day > 5 g/kg/day
^ Option 1: IPD-SAM refers children to OPD-SAM after stabilization.

° Option 2: IPD-SAM retains children until full recovery
* Case-fatality rate during treatment
National standards of quality of IMAM services for children 6–59 months of age:
123
Boys’ weight (kg) Length 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
124
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
If a child is under 2 years of age or is less than 87 cm tall and his/her age is not known, measure length while the child is lying down (recumbent). Use the
weight-for-length look-up table.
Weight-for-Length Look-up Table Children 6–23 Months
Boys’ weight (kg) Length Girls’ weight (kg)

−3 SD −2 SD −1 SD Median (cm) Median −1 SD −2 SD −3 SD
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
125
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
126
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
Weight-for-Height Look-Up Table Children 24–59 Months

Boys’ weight (kg) Height Girls’ weight (kg)
−3 SD −2 SD −1 SD Median (cm) Median −1 SD −2 SD −3SD
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
127
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
Boys’ weight (kg) Height Girls’ weight (kg)
−3 SD −2 SD −1 SD Median (cm) Median −1 SD −2 SD −3SD
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
128
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
129
If child is 2 years of age or older, or if a child is at least 87 cm tall and his/her age is not known, measure standing height. If child 2 years of age or older or at least
87 cm tall is unable to stand, measure length while the child is lying down (recumbent) and subtract 0.7cm from the length to arrive at a comparable height. Use
the weight-for-height look-up table.
Volume of F75 for Children with Severe Wasting and Edema + and ++
Weight of Volume of F75 per feed (ml)a Daily total80% of daily total
Child (kg) Every 2 hoursb Every 3 hoursc Every 4 hours (130 ml/kg) a
(12 feeds) (8 feeds) (6 feeds) (minimum)
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
130
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
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
a Volumes in these columns are rounded to the nearest 5 ml.
b Feed two-hourly for at least the first day. Then, when the child has little or no vomiting, modest diarrhea (< 5 watery stools
per day), and is finishing most feeds, change to three-hourly feeds.
c After a day on three-hourly feeds: If no vomiting, less diarrhea, and finishing most feeds change to four-hourly feeds.
Volume of F75 for Children with Severe Bilateral Pitting Oedema (+++)
Daily total
Volume of F75 per feed (ml)a
Weight with (100
Every 2 hoursb Every 3 hoursc Every 4 hours ml/kg) 80% of daily totala
+++ oedema (kg) (12 feeds) (8 feeds) (6 feeds) (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
131
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
9.4 80 120 155 940 750
9.6 80 120 160 960 770
9.8 80 125 165 980 785
10.0 85 125 165 1000 800
a Volumes in these columns are rounded to the nearest 5 ml.
b Feed two-hourly for at least the first day. Then, when the child has little or no vomiting, modest diarrhea (< 5 watery stools per day), and is
finishing most feeds, change to three- hourly feeds.
c After a day on three-hourly feeds: If no vomiting, less diarrhea, and finishing most feeds, change to four- hourly
feeds.
132
Range of Volumes for Free Feeding with F100
Range of volumes per four-hourly feed of F100 (6 feeds daily)
Weight of Child Range of daily volumes of F100
(kg) Minimum (150 Maximum (220
Minimum (ml) Maximum (ml) a
ml/kg/day) 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
133
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
8.6 215 315 1290 1892
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
a Volumes per feed are rounded to the nearest 5 ml.
Look-up table for amounts of supplements of formula milk, F100-Diluted (severe wasting) or F75 (bilateral pitting edema)
for breastfed infants
Formula milk, F100- Diluted (or

F75 in case of oedema) (ml per
Infant’s weight (kg) Formula milk, F100-Diluted (or F75 in feed if 8 feeds per day)
case of oedema)
(ml per feed if 12 feeds per day)
< 1.3 20 25
1.3–1.5 25 30
134
1.6–1.8 30 35
1.9–2.1 30 40
2.2–2.4 35 45
2.5–2.7 40 50
2.8–2.9 40 55
3.0–3.4 45 60
3.5–3.9 50 65
4.0–4.4 50 70
Formula milk, F100- Diluted (or

Formula milk, F100-Diluted (or F75 in case of F75 in case of oedema)
Infant’s weight (kg)
oedema) (ml per feed if 8 feeds per day)
(ml per feed if 12 feeds per day)
< 1.3 20 25
1.3–1.5 25 30
1.6–1.8 30 35
1.9–2.1 30 40
2.2–2.4 35 45
2.5–2.7 40 50
2.8–2.9 40 55
135
3.0–3.4 45 60 Look-up
table for
3.5–3.9 50 65
amounts
4.0–4.4 50 70 of
formula
milk, F100-Diluted (severe wasting) or F75 (bilateral pitting edema) for non-breastfed infants in
stabilization
Look-up table for amounts of formula milk, F100-Diluted (severe wasting) or F75 (bilateral pitting edema)
for non-breastfed infants in transition and stabilization
Transition Rehabilitation
Infant’s Weight (kg) Formula milk, F100-Diluted (ml per feed if 8 Formula milk, F100-Diluted
feeds per day) (ml per feed if 6–8 feeds per day)
< 1.6 45 60
1.3–1.5 53 70
1.6–1.8 60 80
1.9–2.1 68 90
2.2–2.4 75 100
2.5–2.7 83 110
2.8–2.9 90 120
3.0–3.4 96 130
3.5–3.9 105 140
136
“This publication is made possible by the generous support of the American People through the United States Agency for International
Development (USAID). The contents are the sole responsibility of the Public Nutrition Directorate, Ministry of Public Health (MoPH), and do
not necessarily reflect the views of USAID or the United States Government.”

CBNP-Standard Operation Procedures

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CBNP-Standard Operation Procedures

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Islamic Republic of Afghanistan

Ministry of Public Health

Standard operation procedures for nutrition activities

1.1. Supporting nutrition of pregnant women

Intervention No Activity Objective: intervention Remarks

1.2. Supporting nutrition of Lactating women

Interventions 1 Objective of activities Intervent

2. Nutrition support of children 0-24 Months

2.1- Growth Monitoring/ screening of 0-24 Months children

Interventions Objective of activities Intervention

2.2. Screening of 24-59 months old children

Location: Screening room/nutrition counselor section

− Flat or inverted nipples, and long or big nipples.

Intervention No Objectives of activities Intervention Remarks

5. Refusal to breastfed and crying

Location of action: Nutrition counselor section

5 Compress and release the bulb again, several times

5 Release the outer cylinder, and then pull down again.

7. Not enough Milk

Location of action: Nutrition counselor section

8. Breastfeeding low birth weight and sick children

Interventions No Objective of activities Intervention Remarks

9. Increasing breastmilk and re-lactation

Location of action: Nutrition counselor section

10. Facility Based Food Demonstration

Integrated Management of Acute Malnutrition (IMAM SoPs)

1. Community Outreach for the Integrated Management of Acute Malnutrition

1.1. Principle of community outreach

Intervention No Activity Objective: interventi Remarks

1: Community Sensitization to Increase Awareness and Involvement

1.1 Understanding the 1. CBNP monthly meeting (gathering) :

1.2 Select the specific 1. Give the sensitization messages on.

2: Community Screening for Active Case Finding and Referral

Location of action: Nutrition counselor’s room

Intervention No Activity Objective: interventi Remarks

1. Greetings and 1 Welcome the client

Location of action: Nutrition Counselor Room

2.3.Emergency assessment and treatment:

1: Assis the general 1 Is the child able to drink or breastfeed?

Age / weight Good appetite Poor appetite

Child has MAM criteria

Intervention No Activity Objective: interventi Remarks

3 Death: if child has dead because of any reason during treatment.

Intervention No Activity Objective: interventi Remarks

14 Treat for presumptive helminthiasis on 2nd visit or at admission time if child is

Counselling on follow up All points indicated in first visit counselling above

Location of action: IPD-SAM section in the hospitals

5.1- initial management:

Treat Convulsion: 1 Manage to keep open the airway

Day-1 Do all anthropometric measurement and record them in

A: Child can take orally 80% of daily formula

Location of action: OPD-SAM & IPD-SAM

Greetings and 1 Welcome the client

Measure Length of the children by using standard height board*

Location of action: Nutrition Counselor Room

Child is Normal 1 When, nutritional edema is not present on feet, and

6.3--Management of uncomplicated infants less than 6 months of age in OPD-SAM

Location of action: Nutrition counselor’s room

Intervention No Activity Objective: interventi Remarks

Intervention No Activity Objective: interventi Remarks

Location of action: IPD-SAM section

Location of action: IPD-SAM section

8: management of Acute Malnutrition in Pregnant and Lactating Women (PLW) in OPD-MAM