Integrated Management of Acute Malnutrition

Diagnosis of Acute Malnutrition

Anthropometric Measurement Techniques

Before admission into therapeutic/supplementary feeding programs, it is common
practice to retake anthropometric measurements for every child referred by the
community and/or primary health care settings. This is called a two-stage
process. This ensures more control by the treatment-facility but may lead to
children being referred but not admitted.

Some programs are introducing the one-stage process, in which referral from
community/primary health care settings entitle a child to admission without
retaking anthropometric measurements. This enables the treatment-facility to
function more efficiently by reducing delays and overcrowding but may have
implications for the size of the program (particularly for supplementary feeding).

Before admission into therapeutic/supplementary feeding programs, it is common

practice to take all the following anthropometric measurements:

• Mid-Upper Arm Circumference (MUAC) screening (for children with length

> 65 cm).

• Weigh-for-Height (W/H) or Weigh-for-Length (W/L).

• Bilateral oedema.

However, some treatment-facilities are using only Mid-Upper Arm Circumference

(MUAC) screening and bilateral oedema to confirm admission into
therapeutic/supplementary feeding programs.
Mid-Upper Arm Circumference (MUAC) screening and bilateral oedema are
explained in the Early Detection and Referral of Children with Acute Malnutrition
section.

Screening for Acute Malnutrition

Acute malnutrition is a result of recent (short-term) deficiency of protein, energy
together with minerals and vitamins leading to loss of body fats and muscle
tissues. Acute malnutrition presents with wasting (low weight-for-height) and /or
presence of pitting oedema of both feet.
Screening for Acute Malnutrition should be done at any contact points;
children wards, immunization points, community out-reaches, ART sites, young
child clinics, counselling units and psycho social groups. Community-based
service providers can also perform malnutrition screening provided that they are
adequately trained and equipped.

Screening for acute malnutrition includes

1. Use and interpretation of Mid-Upper Arm Circumference (MUAC) Tape

2. Checking for bilateral pitting oedema

NOTE: Children with confirmed bilateral oedema are directly identified to be

severely malnourished and are recorded has having nutritional oedema.
Recognizing Visible clinical Signs
Marasmus signs
• Prominent bones (ribs)

• Skinny limbs

• Loose skin (on lifting)

• Loose skin around the buttocks (buggy

pants)

Kwashiorkor
 • Presence of bilateral pitting oedema

• Hair changes (brownish, scanty, straight)

• Skin changes (dermatosis)

• A large, protuberant belly

Checking for Bilateral pitting oedema

Apply gentle thumb pressure to both feet for 3 seconds. If a shallow print or pit
remains on both feet when the thumb is lifted, then the child presents oedema.
Only children with bilateral oedema are recorded as having nutritional oedema.
These children are at high risk of mortality and need to be treated in a
therapeutic feeding program urgently.
Nutritional oedema always starts from the feet and extends upwards to other
parts of the body.
Nutritional oedema can only be
confirmed by testing with finger
pressure.

You can not tell by just looking

Correct testing for oedema with finger

pressure

Normal thumb pressure should be applied

to both feet for three seconds

(Source: Protocol for the management of

Severe Acute Malnutrition, Ethiopian
Federal MOH, February 2007)

How to classify oedema

 • No oedema: 0
• Oedema below the ankles: +
• Odema in both feet and legs, below the knees: ++

• Odema on both feet, legs, arms and sacral pad and

eye lids:+++

Mid-upper Arm Circumference (MUAC) for children 12-59 months

MUAC is a quick and simple way to determine whether or not a child is
malnourished using a simple colored plastic strip. MUAC is suitable to use on
children from the age of 12 months up to the age of 59 months. However, it can
also be used for children over six months with length above 65 cm.
Steps for taking the MUAC measurement of a child

• Determine the mid-point between the elbow and the shoulder (acromion
and olecranon) as shown on the picture below.

• Place the tape measure around the LEFT arm (the arm should be relaxed
and hang down the side of the body).

• Measure the MUAC while ensuring that the tape neither pinches the arm
nor is left loose.

• Read the measurement from the window of the tape or from the tape.

• Record the MUAC to the nearest 0.1 cm or 1mm.

• If using a 3-colour tape:

a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of
malnutrition;
a measurement in the red zone means that the child is acutely
malnourished.

If using a 4-colour tape:

a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of
malnutrition;
a measurement in the orange zone means that the child is moderately
malnourished;
a measurement in the red zone means that the child is severely
 malnourished.

• Repeat the measurement two times to ensure an accurate

interpretation.

4-colour Mid-Upper Arm Circumference (MUAC) tape

click here for a larger image
Interpretation of Anthropometric Indicators

Moderate Acute Malnutrition (MAM):

• If Weight-for-Height/Length is less than 80% or less than '-2 SD' of the

median reference population (NCHS/WHO table)

OR

• If Mid-Upper Arm Circumference (MUAC) is less than 125mm (12.5 cm),

RED COLOUR (3-colour Tape) OR ORANGE COLOUR (4-colour Tape)

AND

• If there is no bilateral oedema evident

Severe Acute Malnutrition (SAM):

 • If Weight-for-Height/Length is less than 70% or less than '-3 SD'
(marasmus) of the median reference population (NCHS/WHO table)

OR

• If bilateral oedema is evident

OR

• If Mid-Upper Arm Circumference (MUAC) is less than 110mm (11.0 cm),

RED COLOUR (3-colour Tape and 4-colour Tape).

Decision-making at a glance
1. A child with Severe Acute Malnutrition (SAM) with medical
complications and NO APPETITE (based on appetite test) should be
admitted for In-patient Care:

Medical conditions include:

• Gross oedema (+++)

• High or low body temperature

• Acute or prolonged respiratory infection

• Watery diarrhoea - vomiting

• Extensive oral thrush

• Very pale eyes and palms (severe anaemia)

• Irritability or loss of consciousness

2. A child with Severe Acute Malnutrition (SAM) can be admitted as an

Out-patient with Ready-to-Use-Therapeutic-Feeding (RUTF) if there
are NO medical complications and if the child has a GOOD APPETITE
(based on appetite test).

3. A child with Moderate Acute Malnutrition (MAM) should be referred to

Supplementary Feeding Programs (if program available).
Management of Severe Acute Malnutrition in Children
Under Five Years
• Introduction
 • Admission
• In-patient Treatment Phase 1
• In-patient Treatment Transition
• In-patient Treatment Phase 2
• Out-patient Treatment Phase 2
• Discharge and Follow-up
• Special Cases

Introduction
Acutely malnourished children lack growth nutrients that are required to build
new tissues. These nutrients aid weight gain after illness, repair damaged tissues
and help replace the rapid turn-over of cells (intestine and immune cells). Correct
replenishment of nutrients like essential amino acids (protein), potassium,
magnesium and zinc (among other minerals) is essential for recovery from
malnutrition.

This section addresses the treatment of Severe Acute Malnutrition (SAM)

characterized by severe wasting (W/H < 70% NCHS median or Mid-Upper Arm
Circumference (MUAC) < 11.0). Oedematous cases are always classified as
severe.

Children with severe acute malnutrition need to be treated with specialized

therapeutic diets (F75 and F100 formula; RUTF) alongside the diagnosis and
management of complications during in-patient care.

The standard treatment for complications like dehydration or severe anaemia

given to non-malnourished children can lead to death through heart failure if the
patient is severely malnourished because of temporary electrolyte disequilibrium.

Note: Stunting is due to chronic malnutrition. Discharged children have to be

adequately supported at home through an improved quality diet. Families that are
not able to meet the minimum requirements for a healthy diet should be assisted
through targeted food aid or cash-transfer safety-net programs.

The principles of management of Severe Acute Malnutrition, whatever the

program setting, are based on three phases:

Phase 1:
Patients that have not passed the appetite test and/or have a major medical
complication should be admitted to an in-patient facility for phase 1 treatment.
The F75 formula is used during this phase to promote recovery of normal
metabolic function and nutrition-electrolytic balance. The duration in this Phase is
2-7 days until the child is stabilized.
Rapid weight gain at this stage is dangerous, which is why F75 is formulated so
that patients do not gain weight during this stage.

F-75 contains 75 kcal of energy and 0.9 g protein per 100ml.

Transition Phase: In-patients transferred from Phase 1 are introduced to F100

formula or RUTF and start to gain weight. The Transition Phase is crucial to
monitor an in-patient’s adjustment capacity to a sudden change of diet as this
may lead to electrolyte disequilibrium. The expected weight gain should be
around 6g per kg per day. The duration in this phase is 1-3 days.

F-100 contains 100 kcal of energy and 2.9g proteins per 100ml.

Phase 2: In-patients transferred from Transition Phase may continue to use F100
formula or RUTF in the facility-setting until discharged or they may be transferred
to out-patient treatment where they are given RUTF only.

Patients that have passed the appetite test and/or do not have a major medical
complication can be admitted directly to an out-patient facility for Phase 2
treatment using RUTF. The expected weight gain should be 8g per kg per day.

Program settings may depend on national guidelines and facilities available. The
following are the most common types of services for treatment:

In-patient treatment: Management of severe malnutrition in facilities should

ideally be only for Phase 1 and the Transition Phase.

Patients that are admitted can be treated on a 24 hour basis with full medical
surveillance and treatment of complications. They would receive 6-12 meals of
F75 per day during Phase 1 followed by 6 meals of F100 per day during the
Transition Phase.

Patients may also be treated on a Day Care basis. In this case they would have
to receive the 5-6 meals of F75 within 12 hours making this option not one that is
recommended for Phase 1. Day Care is suitable for in-patient treatment during
Phase 2 but it places a burden on the caregiver who has to come in on a daily
basis. In general, the continuation of this treatment as in-patients for Phase 2
may increase the economic burden on the caregivers as well as on the facility.

All in-patients that regain their appetite and have successfully passed the
Transition Phase should continue treatment as out-patients if there is a service in
place and if the caregivers agree.

Out-patient treatment is normally organized from the same facilities that have
in-patients. However, out-patient treatment can also be arranged from peripheral
health units bringing the service closer to the community. Most patients can be
admitted directly as an out-patient and can receive the treatment on a weekly
basis. For each in-patient facility there should be many satellite sites providing
out-patient treatment programs.

A strong communication and referral system needs to be in place to allow in-

patients to move from in-patient (Phase 1 and Transition Phase) to out-patient
treatment (Phase 2). The opposite applies if out-patients do not respond
appropriately or if they develop complications. If this occurs they should be
transferred immediately from out-patient to in-patient treatment.

Patients attending TB and ART services are at high risk of malnutrition and
should be systematically screened for severe malnutrition using the Mid-Upper
Arm Circumference (MUAC) tape and checking for oedema so that they can be
promptly referred and admitted if needed.

Mobile clinics should incorporate the management of severe acute malnutrition.

Screening could be done using Mid-Upper Arm Circumference (MUAC) tape and
checking for oedema. Enrolled patients based on admission criteria are given a
weekly RUTF ration if they pass the appetite test and/or do not have medical
complications. Transport is important for patients referred for in-patient care.

Note: The link between malnutrition and HIV/AIDS is acknowledged. For this
reason, it is recommended to make available HIV Individual Counselling and
Testing (ICT) services at in-patient and out-patient treatment sites. If this is done
so HIV-exposed or HIV-positive children can access appropriate support and
care at an early stage.

Feeding formulas: What are F-75 and F-100?

F-75 is the "starter" formula used during initial management of malnutrition,
beginning as soon as possible and continuing for 2-7 days until the child is
stabilized. Severely malnourished children cannot tolerate normal amounts of
protein and sodium or high amounts of fat. They may die if given too much
protein or sodium. They also need glucose, so they must be given a diet that is
low in protein and sodium and high in carbohydrate. F-75 has is specially mixed
to meet the child's needs without overwhelming the body's systems in the initial
stage of treatment. Use of F-75 prevents deaths. F-75 contains 75 kcal and 0.9 g
protein per 100 ml.

As soon as the child is stabilized on F-75, F-100 is used as a "catch-up" formula

to rebuild wasted tissues. F-100 contains more calories and protein: 100 kcal and
2.9g protein per 100 ml.
The table below shows a number of recipes. The choice of recipe may depend
on the availability of ingredients, particularly the type of milk, and the availability
of cooking facilities.

The principle behind the recipes is to provide the energy and protein needed for
stabilization and catch-up. For stabilization (F-75), it is important to provide a
formula with the energy and protein as shown (no less and no more). For catch-
up (F-100), the recipes show the minimum energy and protein contents needed.

The first three recipes given for F-75 include cereal flour and require cooking.
The second part of the table shows recipes for F-75 that can be used if there is
no cereal flour or no cooking facilities. However, the recipes with no cereal flour
have a high osmolarity (415 mOsmol/l) and may not be tolerated well by some
children with diarrhoea.

The F-100 recipes do not require cooking as they do not contain cereal flour.

It is hoped that one or more of the recipes can be made in your hospital. If your
hospital cannot use any of the recipes due to lack of ingredients, seek expert
help to modify a recipe using available ingredients.

Recipes for F-75 and F-100

If you have cereal flour and cooking facilities, use one of the top three
recipes for F-75:

Alternatives Ingredient Amount for F-

75

Dried skimmed milk 25 g

Sugar 70 g
Cereal flour 35 g
If you have dried
Vegetable oil 30 g
skimmed milk
Mineral mix* 20ml
Water to make 1000 ml 1000 ml**
Dried whole milk 35 g
Sugar 70 g
Cereal flour 35 g
If you have dried
Vegetable oil 20 g
whole milk
Mineral mix* 20 ml
Water to make 1000 ml 1000 m/**
 Fresh cow's milk, or full-
cream 300ml
If you have fresh (whole) long life milk
cow's milk, or Sugar 70 g
full- Cereal flour 35 g
cream (whole) Vegetable oil 20 g
long life milk Mineral mix* 20 ml
Water to make 1000 ml 1000 ml**

If you do not have cereal flour, or there are no cooking No cooking is

facilities, use one of the following recipes for F-75: required
for F-100:

Alternatives Ingredient Amount for F- Amount for F-100

75

Dried skimmed milk 25 g 80 g

Sugar 100 g 50 g
If you have dried Vegetable oil 30 g 60 g
skimmed milk Mineral mix* 20 ml 20 ml
Water to make 1000 ml 1000 ml** 1000 ml**
Dried whole milk 35 g 110 g
Sugar 100 g 50 g
If you have dried Vegetable oil 20 g 30 g
whole milk Mineral mix* 20 ml 20 ml
Water to make 1000 ml 1000 ml** 1000 ml**
Fresh cow's milk, or full-
cream 300 ml 880 ml
If you have fresh (whole) long life milk
cow's milk, or Sugar 100 g 75 g
full-
Vegetable oil 20 g 20 g
cream (whole)
long life milk Mineral mix* 20ml 20ml
Water to make 1000 ml 1000 ml** 1000 ml**

*Check contents of mineral mix or alternatively use ready-made Combined

Mineral Vitamin Mix (CMV).

** Important note about adding water: Add just the amount of water needed to
make 1000 ml of formula. (This amount will vary from recipe to recipe, depending
on the other ingredients). Do not simply add 1000 ml of water as this will make
the formula too dilute. A mark for 1000 ml should be made on the mixing
container for the formula so that water can be added to the other ingredients up
to this measure.
 Add water just up to 1000 ml mark

Mineral mix

The mix contains potassium, magnesium and other essential minerals. It must be
included in F-75 and F-100 to correct electrolyte imbalance. The mineral mix may
be made in the pharmacy of the hospital or a commercial product called
Combined Mineral Vitamin Mix (CMV) may be used to provide the necessary
minerals.

Vitamins

Vitamins are also needed in or with the feed. Children are usually given
multivitamin drops as well. The multivitamin preparation should not include
iron.

If available, CMV may be used to provide the necessary vitamins. If CMV is used
separate multivitamin drops are not needed.

Correct position to feed a severely malnourished child with F75

and F100
(Source: Protocol for the management of Severe Acute Malnutrition, Ethiopian
Federal MOH, February 2007)

Tips for correct preparation of F75 and F100 using other

ingredients

• Apply hygiene at all levels

• Mix oil well so that it does not separate. If oil floats to the top of the
mixture, there is a risk that some children will get too much and others too
little. Use a long hand whisk to thoroughly mix the oil.

• Be careful to add the correct amount of water to make up 1000 ml of

formula. If 1000 ml of water is mistakenly added, the resulting formula will
be about 15% too dilute.

• Required equipment include: hand whisk (rotary whisk or balloon whisk), a

1-litre measuring jug, a cooking pot, and a stove or hot plate.

• Amounts of ingredients are listed in the table above. Cereal flour may be
maize meal, rice flour or millet.
 • It is important to use cooled, boiled water even for recipes that involve
cooking. The water should be cooled because adding boiling water to the
powdered ingredients may create lumps.

• The cooking time will depend on the type of cereal flour to be used and
the nature of the heat source.

For cooking:

1. Mix the flour, milk or milk powder, sugar, oil, and mineral mix in a 1-litre
measuring jug (If using milk powder, this will be a paste).

2. Slowly add cooled, boiled water up to 1000 ml.

3. Transfer to cooking pot and whisk the mixture vigorously.

4. Boil gently for 4 minutes, stirring continuously. Maize-flour based recipe

should be boiled for longer periods.

5. Some water will evaporate while cooking, so transfer the mixture back to
the measuring jug after cooking and add enough boiled water to make
1000 ml. Whisk again.

Pre-packed F75 and F100

These are commercially available and include already all required nutrients.
Preparation:

• Add one large packet of F75 or F100 to 2 litres of water.

• Where very few children are being treated, smaller volumes can be mixed
using the red scoop (20 ml water per red scoop or F75/F100 powder)

• Close the F75 / F100 sachet appropriately by rolling down the top.

The Appetite Test

Why do the appetite test?

• Malnutrition changes the way infections and other diseases express

themselves – children severely affected by the classical IMCI diseases,
who are malnourished, frequently show no signs of these diseases.
However, the major complications lead to a loss of appetite. Most
importantly, the signs of severe malnutrition itself are often interpreted as
dehydration in a child that is not actually dehydrated. The diagnosis and
 treatment of dehydration are different in these patients. Giving
conventional treatment for dehydration to the severely malnourished is
very dangerous.

• Even though the definition and identification of the severely malnourished

is by anthropometric measurements, there is not a perfect correlation
between anthropometric and metabolic malnutrition. It is mainly metabolic
malnutrition that causes death. Often the only sign of severe metabolic
malnutrition is a reduction in appetite. By far the most important
criterion to decide if a patient should be sent to in- or out- patient
management is the Appetite Test. A poor appetite means that the child has
a significant infection or a major metabolic abnormality such as liver
dysfunction, electrolyte imbalance, cell membrane damage or damaged
biochemical pathways. These are the patients at immediate risk of death.
Furthermore, a child with a poor appetite will not take the diet at home and
will continue to deteriorate or die. As the patient does not eat the special
therapeutic food (RUTF) the family will take the surplus and get used to
share it.

How to do the appetite test?

1. The appetite test should be conducted in a separate quiet area.

2. Explain to the mother/caregiver the purpose of the appetite test and how it
will be carried out.

3. The mother/caregiver, where possible, should wash her/his hands.

4. The mother/caregiver should sit comfortably with the child on her/his lap
and either offer the RUTF from the packet or put a small amount on
her/his finger and give it to the child.

5. The mother/caregiver should offer the child the RUTF gently, encouraging
the child all the time. If the child refuses then the mother/caregiver should
continue to quietly encourage the child and take time over the test. The
test usually takes a short time but may take up to one hour. The child must
not be forced to take the RUTF.

6. The child needs to be offered plenty of water to drink from a cup as he/she
is taking the RUTF.

The result of the appetite test

Pass:
 1. A child that takes at least the amount shown in the table below passes the
appetite test.

Fail:

1. A child that does not take at least the amount of RUTF shown in the table
below should be referred for in-patient care.

2. Even if the caregiver/health worker thinks the child is not taking the RUTF
because s/he doesn’t like the taste or is frightened, the child still needs to
be referred to in-patient care for least a short time. If it is later found that
the child actually takes sufficient RUTF to pass the test then they can be
immediately transferred to the out-patient treatment.

The following table gives the MINIMUM amount of RUTF that should be taken.

Important considerations:

• The appetite test should always be performed carefully. Patients who fail
their appetite tests should always be offered treatment as in-patients. If
there is any doubt then the patient should be referred for in-patient
treatment until the appetite returns (this is also the main criterion for an in-
patient to continue treatment as an out-patient).

• The patient has to take at least the amount that will maintain body weight.
A patient should not be sent home if they are likely to continue to
deteriorate because they will not take sufficient therapeutic food. Ideally
they should take at least the amount that children are given during the
transition phase of in-patient treatment before they progress to Phase 2
(good appetite during the test).

• Sometimes a child will not eat the RUTF because he is frightened,

distressed or fearful of the environment or staff. This is particularly likely if
there is a crowd, a lot of noise, other distressed children or intimidating
health professionals (white coats, awe-inspiring tone). The appetite test
 should be conducted a separate quiet area. If a quiet area is not possible
then the appetite can be tested outside.

• The appetite test must be carried out at each visit for out-patients. Failure
of an appetite test at any time is an indication for full evaluation and
probably transfer for in-patient assessment and treatment.

• During the second and subsequent visits the intake should be very good if
the patient is to recover reasonably quickly.

• If the If the appetite is good during the appetite test and the rate of
weight gain at home is poor then a home visit should be arranged. It
may then be necessary to bring a child into in-patient care to do a simple
“trial of feeding” to differentiate i) a metabolic problem with the patient from
ii) a difficulty with the home environment; such a trail-of-feeding, in a
structured environment (e.g. TFU), is also frequently the first step in
investigating failure to respond to treatment.

Medical Complications
If there is a serious medical complication then the patient should be referred for
in-patient treatment – these complications include the following:

• Bilateral pitting oedema Grade 3 (+++)

• Marasmus-Kwashiorkor (W/H<70% with oedema or MUAC<11cm with

oedema)

• Severe vomiting/ intractable vomiting

• Hypothermia: axillary’s temperature < 35°C or rectal < 35.5°C

• Fever > 39°C

• Number of breaths per minute:

o 60 resps/ min for under 2 months

o 50 resps/ minute from 2 to 12 months

>40 resps/minute from 1 to 5 years

o 30 resps/minute for over 5 year-olds or

o Any chest in-drawing

 • Extensive skin lesions/ infection

• Very weak, lethargic, unconscious

Fitting/convulsions

• Severe dehydration based on history & clinical signs

• Any condition that requires an infusion or NG tube feeding.

• Very pale (severe anaemia)

• Jaundice

• Bleeding tendencies

• Other general signs the clinician thinks warrants transfer to the in-patent
facility for assessment.

Note: Always explain to the mother/caregiver the choices of treatment option and
decide with the mother/caregiver whether the child should be treated as an out-
patient or in-patient despite the decision and advice of the health worker.

Source: Protocol for the management of Severe Acute Malnutrition (Ethiopia

MOH)

Ready-to-Use Therapeutic Food (RUTF)

• Local production of RUTF
• Commercial pre-packed Plumpy'Nut

Local production of RUTF

There are four basic ingredients in RUTF:

• Sugar

• Dried Skimmed Milk

• Oil

• Vitamin and Mineral Supplement (CMV)

In addition, up to 25% of a product’s weight can come from oil-seeds, groundnuts
or cereals like oats.
As well as containing the necessary proteins, energy and micronutrients, RUTF
should also have the following attributes:

• Taste and texture suitable for young children

• No need for cooking before consumption

• Resistant to contamination by micro-organisms and long shelf-life

without sophisticated packaging. Product should be oil-based

WHO/UNICEF/WFP/SCN DRAFT specifications for RUTF

Ready-to-Use Therapeutic Food
High energy, fortified ready to eat food suitable for treatment of severely
malnourished children.

This food should be soft or crushable, palatable and easy for children to eat
without any preparation. At least half of the proteins contained in the product
should come from milk products.

Nutritional composition

Moisture content 2.5% maximum

Energy 520-550 Kcal/100g
Proteins 10 to 12 % total energy
Lipids 45 to 60 % total energy
Sodium 290 mg/100g maximum
Potassium 1100 to 1400 mg/100g
Calcium 300 to 600 mg/100g
Phosphorus (excluding phytate) 300 to 600 mg/100g
Magnesium 80 to 140 mg/100g
Iron 10 to 14 mg/100g
Zinc 11 to 14 mg/100g
Copper 1.4 to 1.8 mg/100g
Selenium 20 to 40 µg
Iodine 70 to 140 µg/100g
Vitamin A 0.8 to 1.1 mg/100g
Vitamin D 15 to 20 µg/100g
Vitamin E 20 mg/100g minimum
Vitamin K 15 to 30 µg/100g
Vitamin B1 0.5 mg/100g minimum
Vitamin B2 1.6 mg/100g minimum
Vitamin C 50 mg/100g minimum
Vitamin B6 0.6 mg/100g minimum
Vitamin B12 1.6 µg/100g minimum
Folic acid 200 µg/100g minimum
Niacin 5 mg/100g minimum
Pantothenic acid 3 mg/100g minimum
Biotin 60 µg/100g minimum
n-6 fatty acids 3% to 10% of total energy
n-3 fatty acids 0.3 to 2.5% of total energy

Commercial Pre-packed Plumpy'Nut

Plumpy’Nut is a ready-to-use therapeutic spread produced by Nutriset and
presented in individual sachets. It is a paste of groundnut composed of vegetable
fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar, mineral
and vitamin complex.

Plumpy’Nut is specifically designed to treat acute

malnutrition without complications and has the
following characteristics:

• It is nutritionally equivalent to F-100

(therapeutic milk used for in-patient care in
Phase 2)

• One sachet has an energy value of 500Kcal

• One sachet has a weight of 92 g

• Each carton of Plumpy'Nut contains 150

 sachets (around 15.1 kg)

Benefits and composition of Plumpy'Nut

• The quantity distributed to each child is easy to calculate based on the

weight

• One simply needs to open the sachet by cutting one corner and eat the
paste

• No preparation or cooking is necessary

• Does not need to be diluted with water. This eliminates risk of

contamination

• Can be used at home with supervision from the health centre

• Reduces length of stay in hospital or Therapeutic Feeding Centre

• Reduces number of staff necessary for preparation and distribution of

therapeutic food

• Has a faster recovery rate and higher acceptability than F100

• Can be stored at room temperature for long periods of time

• Has a long shelf life, even without refrigeration (24 months)

Nutrients and Energy Composition of Plumpy'Nut

Nutrient Per sachet of 92 g Nutrient Per sachet of 92 g

Energy 500 kcal Vitamin A 840 mcg

Proteins 12.5 g Vitamin D 15 mcg
Lipids 32.86 g Vitamin E 18.4 mg
Calcium 276 mg Vitamin C 49 mg
Phosphorus 276 mg Vitamin B1 0.55 mg
Potassium 1 022 mg Vitamin B2 1.66 mg
Magnesium 84.6 mg Vitamin B6 0.55 mg
Zinc 12.9 mg Vitamin B12 1.7 mcg
Copper 1.6 mg Vitamin K 19.3 mcg
Iron 10.6 mg Biotin 60 mcg
Iodine 92 mcg Folic acid 193 mcg
Selenium 27.6 mcg Pantothenic acid 2.85 mg
Sodium < 267 mg Niacin 4.88 mg

Management of Plumpy'Nut
Who should receive Plumpy'Nut?
A child over six months and/or an adolescent according to the following criteria:

• Severely malnourished without medical complications, have passed the

appetite test, and have been enrolled in outpatient care.

• HIV positive, moderately malnourished without medical complications,

have passed the appetite test, and have been enrolled in outpatient care.

• Can drink liquids.

• Not allergic to milk or nuts.

What should be the dosing for Plumpy'Nut be?

The number of packets per day to be given to a child/adolescent depends on the
weight of the child. The table below provides the accurate dosing based on the
weight range of the child/adolescent:

Weight (kg) Packets / day Packets / w

3.5 - 3.9 1.5 11

4.0 - 5.4 2 14
5.5 - 6.9 2.5 18
7.0 - 8.4 3 21
8.5 - 9.4 3.5 25
9.5 - 10.4 4 28
10.5 - 11.9 4.5 32
12.0-13.5 5 35
>13.5 200kcal/kg/day 200kcal/kg/day

How should Plumpy'Nut be administered?

• The Plumpy'Nut should be given to the child in small amounts and

frequently (e.g. ½ sachet * 8 times per day) provided that the daily amount
is according to prescription.
 • Always have safe drinking water nearby whenever the child is eating
Plumpy'Nut.

• Make sure that the child consumes and finishes the Plumpy'Nut before
eating their porridge.

• A family food meal can be gradually introduced as the child's health

improves.

• Children should be supervised while they consume their Plumpy'Nut and

meals.

Allergic Reaction to Plumpy'Nut:

Although it is unlikely, there is a small chance of a child having an allergic
reaction to the peanut butter in Plumpy'Nut. It is important to ask for a history of
allergy to the ingredients in Plumpy'Nut.
The allergy may cause reactions in the form of:

• Skin changes: hives, rashes and infections

• Body swelling

• Shortness of breath

• Anaphylactic shock

If the child develops any of these symptoms, discontinue administering

Plumpy'Nut. The child should be treated for allergic reaction in the nearest health
facility immediately.
Messages for caregivers on Plumpy'Nut
Plumpy'Nut

• Is only for malnourished children and should not be shared with other
members of the family who are hungry.

• Should be kept in a secure place and out of reach of children in the

house. It should be kept away from the sun to preserve nutrients.

• Should be given soon after a feed if the child breastfeeds.

• Should always be given before any other family food.

 • Should be given to the child in small amounts and frequently.

• After eating, the remaining amount in the sachet should be kept for the
next feed. The top of the sachet should be rolled down for safety.

• May cause chocking. Therefore, a generous amount of clean water must

always be given to the child, at least 1 cup (100ml) of clean water for each
dose of Plumpy'Nut. If choking persists the child should be taken to the
nearest health facility.

• A balanced, nutritious meal can be given after the correct amount of

Plumpy'Nut.

• May cause complications such as diarrhoea, vomiting, fevers, swelling,

rashes, hives, skin infections, and shortness of breath or shock. If these
symptoms are present, the caregiver must stop giving Plumpy'Nut and
take the child to the OTC or nearest health facility.

• Empty sachets should be kept and presented at each bi-weekly visit.

Key Message
:
Plumpy'Nut is a treatment for malnourished children. Only the
malnourished children should eat it.

Admission
Every opportunity should be taken to identify and refer severely malnourished
patients at all available contact points within the health system, including Out-
Patient Departments (OPD), mobile clinics and community-based services.
Malnutrition screening would be made using Mid-Upper Arm Circumference
(MUAC) tape and by checking for oedema (see Early Detection and Referral).

Check Admission Procedures

Summary of key steps for admission (in-patient - out-patient treatment):

• On arrival, patients should be given sugar water immediately - 10 gr of

sugar per 100 ml of water. Patients in clear need of medical attention
should be "fast tracked" to have their anthropometric measurements
checked so that they can start treatment as soon as possible.
• The following anthropometric measurements should be taken before
admission:

o Mid-Upper Arm Circumference (MUAC) screening (for children with

length > 65 cm)

and/or

o Weight-for-Height (W/H) or Weight-for-Length (W/L).

o Bilateral oedema

• The following criteria should be present for admission:

Children aged 6 months to 18 years:

o W/H or W/L < 70% (WHO/NCHS table)

or

o Mid-Upper Arm Circumference (MUAC) < 110 mm (11.0 cm)

with a length > 65 cm

or

o Presence of bilateral oedema

• Patients that have been referred by the community or by peripherals

health units but do not fulfil the criteria for SAM should be referred to
supplementary feeding programs (if available) or counselled on available
nutritional support programs. It is important that caregivers receive some
tangible benefit - like a "protection ration" - from coming to the treatment-
centre.

• Patients that do fulfil the criteria for SAM and do not require "fast tracking"
should perform the appetite test so that further decisions can be made if
they will need to commence in-patient or the out-patient treatment.

Check the Summary of Criteria for admission to in-patient or out-patient

care

• At admission, it is crucial to explain to the mother/caregiver about the

nutrition status of their child and the implications for his/her life.
Admission Room - what you need at a glance

Anthropometric equipment (Oxfam Kit 1):

• Infant/child length-height measuring board

• Scale, infant spring-type 25 kg x 100g

• Weighing trousers

• Mid-Upper Arm Circumference (MUAC) tape

• Scale, infant, clinic beam type, 16kg x 10g

• W/H wall-chart

Registration and recording equipment (Oxfam Kit A4):

• Record book

• Multichart

• Identification bracelet

• Milk cards

• Stationary

RUTF for appetite test

Job aids:

• Summary Admission Criteria Table for in-patient or out-patient

• NCHS/WHO W/H and W/L reference table

Early Detection and Referral of Children with

Malnutrition

Home » Early Malnutrition Detection and Referral

This section looks at feasible ways to timely detect and refer children with
malnutrition from primary health care units and communities. It is intended
mainly for practitioners and program managers to increase coverage through
active case finding and referral of children with malnutrition at all contact points
before the onset of life threatening complications.

Growth Monitoring Chart

• Plotting the Weight on the Growth Monitoring Chart
• Interpretation of good or bad Growth
• Challenges with the Growth Monitoring Chart

Growth Monitoring Chart

Plotting the weight on the Growth Monitoring Chart

Growth Monitoring Chart

Click for larger images:

Small | Medium | Large

A high standard example of a Growth Monitoring Chart from India

Three steps for appropriate plotting include:

1. Find the child's age on the chart

The first box called "Born" on the horizontal axis should be filled
with the name of the month the child was born (i.e. March). All the
other boxes should be filled with the subsequent months (i.e. April,
May, June, etc). Based on the month, mark a straight dotted line
up the middle of the column.

2. Find the child's weight on the chart.

The vertical axis of the growth chart indicates the weight of the child
in kilos. Based on the child weight, follow the horizontal faint line
across corresponding to the child weight (to the nearest 100g)
across the card until it crosses the right month column. Put a dot in
the middle of the column representing the month of weighing.
 3. Draw the Growth Curve.

Draw a line from the previous dot, if any, to the new one to make
the child's growth curve.

Growth Monitoring Chart

Interpreting Good or Bad Growth

Child Growth Monitoring Chart Table of Minimum Expected Weight

Explanation Gain for Children Less than 2 Years

Click here for a large image of this chart Click here for a large image of this chart

Good Growth

The child has gained enough weight if the curve is going up and the slope is
parallel to one of the reference curves.

Even if the child is small, the growth curve should still go up and should be
parallel to one of the reference curves to show the child is growing well.
If the child has missed one growth monitoring session, the "At 60 days" column
of the Table of Minimum Expected Weight Gain should be used to calculate the
child's expected weight, based upon his/her weight of two months before. The
child's growth will be classified as adequate or inadequate.

If the child has missed two or more growth monitoring sessions, the child's weight
should be plot on the growth card but it can not be joint with the previous dot.
The "Adequate growth" can be assessed only in the next month.

Bad Growth

The child growth is static if the curve is flat. This is a dangerous sign that need to
be further investigated.

The child has lost weight if the child's growth curve shows a downward direction.

The child's growth is slowing and the weight gain is less than expected if the
curve is less steep than the reference curve.

Using the Table of Minimum Expected Weight Gain

Every child, whether big or small, should gain a known amount of weight each
month if she/he is growing well.

The table of expected minimum weight gain gives the expected weights after one
month and after two months. It is useful to check on a child's growth to determine
whether a child has gained an adequate amount of weight or not.

Children should be referred for suspected acute malnutrition in the following

cases:

• They do not gain weight for more than two months.

• They are losing weight.

• They are falling below the bottom line:

o A child below 2 years of age with plotted weight below the "low-
weight-for-age" curve

o A child two years old and above with plotted weight below the
"very-low-weight-for-age" curve
Note: None of the above indicators are recognized by international
standards as diagnostic criteria for admission in acute malnutrition
treatment programs.

Challenges with the Growth Monitoring Chart

• The birth weight is recorded for delivery at health facilities but seldom for
home delivery.

• The date of the weighing and the weight of child are not always recorded.

• The weight is not always plotted in the chart.

• Special events witch may affect children growth are not recorded.

• After the immunization cycle is completed, children are not taken anymore
on a monthly / two monthly bases making it difficult to plot their growth.

• Very often nutrition counselling and health education is not given along the
weighing session due to lack of time and personnel.

• Even if the weight-below-the-curve indicates suspicion of acute

malnutrition, it is not a diagnostic feature.

Detection and Referral of Children with Acute

Malnutrition
• Screening for Acute Malnutrition
• Interpretation of Mid-Upper Arm Circumference (MUAC) indicators
• Setting up a referral system for Acute Malnutrition (community and facility
level)

Screening for Acute Malnutrition

Acute malnutrition is a result of recent (short-term) deficiency of protein, energy
together with minerals and vitamins leading to loss of body fats and muscle
tissues. Acute malnutrition presents with wasting (low weight-for-height) and /or
presence of pitting oedema of both feet.

Screening for Acute Malnutrition should be done at any contact points;

children wards, immunization points, community out-reaches, ART sites, young
child clinics, counselling units and psycho social groups. Community-based
service providers can also perform malnutrition screening provided that they are
adequately trained and equipped.

Screening for acute malnutrition includes

1. Use and interpretation of Mid-Upper Arm Circumference (MUAC) Tape

2. Checking for bilateral pitting oedema

NOTE: Children with confirmed bilateral oedema are directly identified to be

severely malnourished and are recorded has having nutritional oedema.
Recognizing Visible clinical Signs
Marasmus signs
• Prominent bones (ribs)

• Skinny limbs

• Loose skin (on lifting)

• Loose skin around the buttocks (buggy

pants)

Kwashiorkor
 • Presence of bilateral pitting oedema

• Hair changes (brownish, scanty, straight)

• Skin changes (dermatosis)

• A large, protuberant belly

Checking for Bilateral pitting oedema

Apply gentle thumb pressure to both feet for 3 seconds. If a shallow print or pit
remains on both feet when the thumb is lifted, then the child presents oedema.
Only children with bilateral oedema are recorded as having nutritional oedema.
These children are at high risk of mortality and need to be treated in a
therapeutic feeding program urgently.
Nutritional oedema always starts from the feet and extends upwards to other
parts of the body.
Nutritional oedema can only be
confirmed by testing with finger
pressure.

You can not tell by just looking

Correct testing for oedema with finger

pressure

Normal thumb pressure should be applied

to both feet for three seconds

(Source: Protocol for the management of

Severe Acute Malnutrition, Ethiopian
Federal MOH, February 2007)

How to classify oedema

 • No oedema: 0
• Oedema below the ankles: +
• Odema in both feet and legs, below the knees: ++

• Odema on both feet, legs, arms and sacral pad and

eye lids:+++

Mid-upper Arm Circumference (MUAC) for children 12-59 months

MUAC is a quick and simple way to determine whether or not a child is
malnourished using a simple colored plastic strip. MUAC is suitable to use on
children from the age of 12 months up to the age of 59 months. However, it can
also be used for children over six months with length above 65 cm.
Steps for taking the MUAC measurement of a child

• Determine the mid-point between the elbow and the shoulder (acromion
and olecranon) as shown on the picture below.

• Place the tape measure around the LEFT arm (the arm should be relaxed
and hang down the side of the body).

• Measure the MUAC while ensuring that the tape neither pinches the arm
nor is left loose.

• Read the measurement from the window of the tape or from the tape.

• Record the MUAC to the nearest 0.1 cm or 1mm.

• If using a 3-colour tape:

a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of
malnutrition;
a measurement in the red zone means that the child is acutely
malnourished.

If using a 4-colour tape:

a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of
malnutrition;
a measurement in the orange zone means that the child is moderately
malnourished;
a measurement in the red zone means that the child is severely
 malnourished.

• Repeat the measurement two times to ensure an accurate

interpretation.

4-colour Mid-Upper Arm Circumference (MUAC) tape

click here for a larger image
Interpretation of Mid-Upper Arm Circumference MUAC
indicators
• MUAC less than 110mm (11.0cm), RED COLOUR, indicates Severe Acute
Malnutrition (SAM). The child should be immediately referred for
treatment.

• MUAC of between 110mm (11.0cm) and 125mm (12.5cm), RED COLOUR

(3-colour Tape) or ORANGE COLOUR (4-colour Tape), indicates
Moderate Acute Malnutrition (MAM). The child should be immediately
referred for supplementation.

• MUAC of between 125mm (12.5cm) and 135mm (13.5cm), YELLOW

COLOUR, indicates that the child is at risk for acute malnutrition and
should be counselled and followed-up for Growth Promotion and
Monitoring (GPM).

• MUAC over 135mm (13.5cm), GREEN COLOUR, indicates that the child
is well nourished.
 4-colour Mid-Upper Arm Circumference (MUAC) tape
click here for a larger image

Advantages of Mid-Upper Arm Circumference (MUAC) screening

• It is simple and cheap. It can be used by service providers at different

contact points without greatly increasing their workload and it can be
effectively used by community-based people for active case finding.

• It is more sensitive. MUAC is a better indicator of mortality risk

associated with malnutrition than Weight-for-Height. It is therefore a better
measure to identify children most in need of treatment.

• It is less prone to mistakes. Comparative studies have shown that

MUAC is subject to fewer errors than Weight-for-Height (Myatt et al,
2006).

• It increases the link with the beneficiary community. MUAC screening

allows service providers from peripheral health units and from the
community to refer children with acute malnutrition to therapeutic or
supplementary feeding programs. The MUAC colour coding is easy to
understand for the child's care-taker.

Challenges

• It is common practice to have the child's Weight-for-Height measurement

taken to confirm admission into a therapeutic or supplementary feeding
program. Particularly for supplementary feeding programs, this may lead
to children being referred from the community or peripheral units but not
admitted. In these cases, counselling and compensation (e.g. a "protection
ration" or soap) should be offered to care-givers turned away so that the
visit to the site is still worthwhile.

• Using a MUAC cut-off of less than 125 mm for referral and admission in
supplementary feeding programs can have implications for the size. Cut-
offs for supplementary feeding programs can be adjusted (e.g. reduced to
120mm) based on capacity and resources so that priority is given to
 identifying children most at risk of death and therefore most in need of
treatment.

Setting up a referral system for Acute Malnutrition

1. Underlying principles:

Child acute malnutrition can be identified in primary health centers

and in the communities before the onset of complications. Workers
at facility and community level can be trained on the use of Mid-
Upper Arm Circumference (MUAC) tape and on recognition of
bilateral pitting oedema.

Whenever referred, it is crucial that caregivers understand the life

saving importance of going immediately to the recommended
facility where their children will be fully assessed to determine the
type of care they should receive.

Early detection and referral, coupled with decentralized

treatment makes it possible to start management of acute
malnutrition before the onset of life-threatening complications.

Detecting and referring children with acute malnutrition are the

foundation for integrated management of malnutrition at facility and
community level.

2. Division of roles for malnutrition screening and assessment:

Community:

• Taking Mid-Upper Arm Circumference (MUAC).

• Checking presence of oedema.

• Referring children with acute malnutrition to sites with

treatment services.

All functional Health Centers:

• Taking Mid-Upper Arm Circumference (MUAC).

• Checking presence of oedema.

• Referring children with acute malnutrition to sites with

treatment services.
 Health Centers with treatment services (therapeutic and
supplementary feeding programs):

• Taking anthropometric measurements (W/H and W/L,

presence of oedema and Mid-Upper Arm Circumference
(MUAC))

• Diagnosis and decision on type of treatment.

3. Referral forms for children with acute malnutrition

It is crucial that trained workers at facility and community level

locate the nearest facilities to refer cases with Severe/Moderate
Malnutrition.

Referral should be done in writing using the Format below

wherever possible. Caregivers must take the referral form with
them to the recommended facility and present it on arrival.

A referral letter/form must contain the following essential

elements:

Referral Form for children with Acute Malnutrition

Date
screened:_______________________________________________________

Parent's name:
_______________________________________________________

Child's name:
________________________________________________________

Age: _____________________________ Sex:

______________________________

Village: ___________________________
Taluka:____________________________

MUAC: (mm/cm or colour) ____________ Oedema:

___________________________

Facility referred to: _________________________________ (indicate nearest

centres)
Other observations:
____________________________________________________

Treatment provided (if any):

______________________________________________

Detection and Referral of Micronutrient Deficiencies

• Clinical Signs of Iron Deficiency Anaemia, Vitamin A Deficiency and Iodine
Deficiency Disorders
• Detection and Referral of Severe Anaemia

Clinical Signs of Iron Deficiency Anaemia, Vitamin A

Deficiency and Iodine Deficiency Disorders
Source: Sphere Project

Iron Deficiency Anaemia

• Pale conjunctivae (inner eyelid),

nailbeds, gums, tongue, lips and
skin

• Tiredness

• Headaches

• Breathlessness

Iodine Deficiency Disorders - Goitre and Cretinism

Goitre:
 • Grade 0: No palpable (can't feel) or
visibly enlarged thyroid.

• Grade 1:A palpable but not visibly

enlarged thyroid with neck in normal
position.

• Grade 2: A palpably and visibly enlarged

thyroid with neck in normal position.

Cretinism:

• Neurological cretinism:

o Mental deficiency

o Deaf mutism

o Spasticity

o Ataxia (lack of muscular coordination)

• Hypothyroid cretinism:

o Dwarfism

o Hypothyroidism

Vitamin A Deficiency - Xerophthalmia

• Night blindness

• Eye dryness accompanied by foamy accumulations on the conjunctiva

(inner eyelids), that often appear near the outer edge of the iris (Bitot's
spots)

• Eye dryness, dullness or clouding (milky appearance) of the cornea

(corneal xerosis)
 • Eye softening and ulceration of the cornea (keratomalacia). This is
sometimes followed by perforation of the cornea, which leads to the loss
of eye contents and permanent blindness.

Bitot's spots Corneal ulceration (Keratomalacia)

Detection and Referral of Severe Anaemia

Severe anaemia is defined clinically as a low hemoglobin concentration leading
to the point that the heart cannot maintain adequate circulation of the blood. A
common complaint is that individuals feel breathless at rest.

Severe anaemia may be defined by using a hemoglobin or hematocrit cutoff or

by extreme pallor.

First choice: If the hemoglobin or hematocrit can be determined, cutoffs of

hemoglobin below 7.0 g/dL or hematocrit below 20% should be used to define
severe anaemia.

Second choice: a method is available for evaluating the color of a drop of blood
on a special filter paper. This method (formerly called the Talqvist method)
requires standard blotting or filter paper and color comparison charts, which are
available from the World Health Organization (Haemoglobin Colour Scale).

Third choice: assessment of pallor. Three sites should be examined: the inferior
conjunctiva of the eye, the nail beds, and the palm. If any of these sites is
abnormally pale, the individual should be considered to be severely anemic. This
method will detect most but not all of people who are truly severely anemic (i.e.,
hemoglobin below 7.0 g/L) and will rarely identify a healthy person as severely
anemic.

Iron deficiency is not the only cause of severe anaemia. Other possible causes
include malaria, folate deficiency, hemoglobinopathies such as sickle cell
anaemia or thalassemias, and the anaemia of chronic disorders such as HIV
infection, tuberculosis, or cancer.
In primary health care settings, health care workers should know when to refer
individuals who do not respond to oral iron therapy or who are at urgent risk of
serious complications.

The following categories of people need to be timely referred to hospitals or

facilities with appropriate treatment in place:

• Children with severe malnutrition

• Pregnant women in the last month of pregnancy

• People with respiratory distress or cardic abnormalities

• People that have started the oral iron and folate therapy but have their
conditions worsening at the first follow-up visit

• People that are doing the oral iron and folate therapy but show no
improvement at 4-week follow-up visit.

Management of Iron Deficiency Anaemia (IDA)

Key steps:

• All patients with clinical signs of Iron Deficiency Anaemia should receive
iron and folic acid supplementation according to their age for 3
months.

Group Iron Folic Acid Dose of Comment

Syrup /
tablets
 4 ml syrup
< 2 years 25 100-400
once a day Exact dose is 3-6
mg\kg\day. Giving the
8 ml syrup syrup in doses between
2-12 years 60 400
once a day ½ to 1 times of weight in
ml will give the exact
quantity. Hence dose
Adolescents
should not exceed weight
and adults
of the child. eg 8 kg
including 1 tablet
120 400 should not receive more
pregnant a day
than 8 ml.
mothers

In-patient Treatment Phase 1

1) Phase 1

Use only F75 Formula

Summary of key steps for Phase 1:

• Admitted patients should be registered and all information recorded in the

Multichart including the target weight for discharge (WHO/NCHS table).

• Admitted patients should be provided with a systematic medical

examination and given routine medicine

• Children in Phase 1 should be together in a separate room or space and

NOT mixed with other patients because of their special diet requirements.
Use identification bracelets if you do not have a separate room or space.

• It is important to provide mother/care givers with all necessary equipment

at admission: blanket, mug, plate, etc.

• F75 is the starter formula to use during initial management. Severely

malnourished children cannot tolerate usual amounts of protein and
sodium at this stage, or high amounts of fat. They may die if given too
much protein or sodium. They also need glucose, so they must be given a
diet that is low in protein and sodium and high in carbohydrate. F-75 is
specially made to meet the child's needs without overwhelming the body's
systems in the initial stage of treatment. Use of F-75 prevents deaths.
• Children in Phase 1 need to receive daily surveillance:

o Weight is measured, entered and plotted on the Multichart.

o The degree of oedema (0 to +++) is assessed and noted in the

Multichart.

o Body temperature is measured twice a day and noted in the

Multichart.

o Standard clinical signs (stool, vomiting, dehydration, cough,

respiration and liver size) are assessed and noted in the Multichart.

o A record is taken if the patient is absent, vomits or refuses a feed

and whether the patient is fed by naso-gastric tube or is given I-V
infusion or transfusion (e.g. under "Observation" or other
appropriate spaces in the Multichart).

• Breastfeeding children should always get the breast milk before the diet
and on demand.

• Preparation of feeds:

o Amounts of F75 to give during Phase 1 is based on the class of

weight (Kg)

o Frequency of feeds per day needs to be based on the functionality

of the service. If there is no sufficient staff to prepare and distribute
the feeds at night, it is advisable to consider 6 feeds during the day
only and not at night.

o Use the WHO Feeding Table

o Preparation of feeds: Pre-packaged F75 or On-site prepared F75

o Organization of feeds: Daily instructions need to be left for the

staff in charge of preparing and distributing the feeds with the
required amount for each child. Individual milk cards are a good
practice for this. F75 can not be kept in liquid form at room
temperature for more than a few hours before it is consumed.

• Supervision of feeding: Sharing of the mother's meal with the child can
be very dangerous for the malnourished child. Peer supervision among
mothers should be encouraged to promote appropriate feeding practices.
The meals for mothers should never be taken beside the patient because
 it is almost impossible to stop a child demanding some of the mother's
meal. If the mother's meal has added salt or condiment it can be sufficient
to provoke heart failure in the malnourished child.

• Feeding technique: The child should be on the mother's lap against her
chest, with one arm behind her back. The child should never be force fed.
Naso-gastric tube (NGT) feeding is used when a patient is not able to take
sufficient diet by mouth (that is defined as an intake of less than 75% of
the prescribed diet). Other reasons for using NGT include: 1) Pneumonia
with a rapid respiration rate; 2) Cleft palate or other physical deformity; 3)
Painful lesions of the mouth and 4) Disturbances of consciousness. The
use of NGT should not normally exceed three days and should only be
used in Phase 1.

• Treatment of medical complications for severely malnourished children

should follow standard WHO protocols for the seven steps of initial phase
care taking into account national policy.

Note 1: Careful diagnosis of dehydration (history and clinical signs) need

to be done BEFORE using a rehydration solution like Resomal and should
be accompanied by hourly monitoring.

Note 2: The routine use of IV fluids is discouraged and should only be

used to resuscitate severely acutely malnourished children from shock.

• Criteria to progress from Phase 1 to Transition

Follow the two criteria:

1. Return of appetite

and

2. Evidence of loss of oedema (this is normally judged by an

appropriate and proportionate weight loss as the oedema
starts to subside).

Children with gross oedema (+++) should wait in Phase 1 until their oedema has
reduced to moderate oedema (++).

In-patient Treatment Unit - What you need at a glance

Sleeping space
Note: Keep children in Phase 1, Transition and Phase 2 in a separate space

• Beds and blankets - adult beds are preferable to children beds

• Table or trolley for the distribution of feeds

Kitchen

Note: if you are using the common kitchen, keep the products, equipment and
utensils for the therapeutic feeding separated from the rest.

• Oxfam Kit 1

• F75, F100 and RUTF

• Mugs and saucers for the child

Medicine supplies

• Routine medicines

• Essential medicines for opportunistic infections

• Medicines for medical complications

• Medical equipment for medical complications

Job Aids (Phase 1)

• Routine medicine table

• Table for the F75 amounts to be given during Phase 1

• Antibiotics reference card

• Treatment of medical conditions reference card

In-patient Treatment Phase 1

2) Transition Phase

Use only F100 formula

Summary of key steps for Transition Phase:

• Daily surveillance of the child remains exactly the same in Transition

phase as it was in Phase 1. The expected rate of weight gain is about
6g/kg/day if all the food is taken by the patient and there is not excessive
malabsorption.

• Breastfeeding children should always get the breast milk before the diet
and on demand.

• Preparation of feeds

o Amounts of F100 given during the Transition Phase are based on

class of weight (Kg)

o Frequency of feeds should normally be 6 per day.

o Use the WHO Feeding Table

o Preparation of feeds: Pre-packaged F100 or On-site prepared

F100

o Organization of feeds: Daily instructions need to be left for the

staff in charge of preparing and distributing the feeds with the
required amount for each child. Individual milk cards are a good
practice for this. F100 can not be kept in liquid form at room
temperature for more than a few hours before it is consumed.

• Routine antibiotics should be continued after transferred from Phase 1

for another four days.

• Move the child back to Phase 1:

o If the child gains weight more rapidly than 10g/kg/day.

o If there is increasing oedema

o If child suddenly develops oedema

o If liver size increases rapidly

o If child develops signs of fluid overload

o If child develops signs of abdominal distension

 o If child gets significant re-feeding diarrhoea so there is weight loss

Note: Several loose stools without weight loss is not a criterion to

move the child back to Phase 1

o If naso-gastric tube is needed

o If complication arise that necessitates an intravenous infusion

• Progress the child to Phase 2:

o If child has a good appetite. Taking 90% of the prescribed F100.

o If child has lost the oedema entirely.

Job aids (Transition Phase):

• Table for F100 amounts to be given during Transition Phase

F-75 Reference Card

Volume of F-75 to give for children of different weights

Weight of Volume of F-75 per feed (ml) a Daily total 80% of daily
child (kg) (130 total a
Every 2 Every 3 Every 4 Ml/kg) (minimum)
hours b (12 hours c (8 hours (6
feeds) feeds) feeds)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
 4.8 55 80 105 624 500
5.0 55 80 110 650 520
5.2 55 85 115 676 540
5.4 60 90 120 702 560
5.6 60 90 125 728 580
5.8 65 95 130 754 605
6.0 65 100 130 780 625
6.2 70 100 135 806 645
6.4 70 105 140 832 665
6.6 75 110 145 858 685
6.8 75 110 150 884 705
7.0 75 115 155 910 730
7.2 80 120 160 936 750
7.4 80 120 160 962 770
7.6 85 125 165 988 790
7.8 85 130 170 1014 810
8.0 90 130 175 1040 830
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 2-hourly for at least the first day. Then, when little or no vomiting, modest
diarrhoea <5 watery stools per day), and finishing most feeds, change to 3-hourly
feeds.
c
After a day on 3-hourly feeds. If no vomiting, less diarrhoea, and finishing most
feeds, change to 4-hourly feeds.

Click here for a larger version of the image below

Click here for a larger version of the image above
F-100 Reference Card
Range of Volumes for Free-Feeding with F-100

Weight of Range of volumes per 4-hourly Range of daily volumes of F-

Child (kg) feed of F-100 (6 feeds daily) 100
a
Minimum (ml) Maximum (ml) Minimum (150 Maximum (220
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
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.

In-patient Treatment Phase 2

3) Phase 2

Use F100 or RUTF

Summary of key steps for Phase 2:

• Surveillance of the child:

o 3 times per week, weight is measured, entered and plotted on the

Multichart.

o 3 times per week, the presence of bilateral oedema is assessed

and noted in the Multichart.

o Every morning, body temperature is measured and noted in the

Multichart.

o Every morning, standard clinical signs (stool, vomiting,

dehydration, cough, respiration and liver size) are assessed and
noted in the Multichart.

o Every week, Mid-Upper Arm Circumference (MUAC) is taken.

o Every 3 weeks height/length is taken.

o For every feed intake record is noted in the Multichart.

• F100 or RUTF are used in Phase 2. Never give F100 for home use,
provide RUTF as take-home therapeutic food. RUTF can be started in the
in-patient treatment to assess the tolerance of the child to the product.
• Breastfeeding children should always get the breast milk before the diet
and on demand

• Preparation of feeds

o Amounts of F100 or RUTF to give during Phase 2 are based on

class of weight (Kg)

o Frequency of F100 feeds should normally be 5-6 times per day.

One portion of porridge may be given for patients who are more
than 8 kg (24 months of age). Frequency of RUTF should be 5-6
times per day. Clean water should be offered to drink while giving
RUTF.

o Use the WHO F100 Feeding Table or M. Golden RUTF Feeding

Table

o Preparation of feeds: Pre-packaged F100 or On-site prepared

F100 and RUTF

o Organization of feeds: Daily instructions need to be left for the

staff in charge of preparing and distributing F100 feeds with the
required amount for each child. Individual milk cards are a good
practice for this. F100 can not be kept in liquid form at room
temperature for more than a few hours before it is consumed.
RUTF can be kept safely and the amount for several feeds can be
given to the patient at one time.

• Children should be able to take as much F100 or RUTF they want if they
feed quickly and easily. They must not be force fed.

• Iron needs to be added to the F100 in Phase 2:

o For 2 to 2.4 liters of F100: Add 1 crushed tablet of ferrous

sulphate (200 mg).

o For 1 to 1.2 liters of F100: Dilute 1 tablet of ferrous sulphate (200

mg) in 4ml water first then add only 2ml of the solution in the F100.

o For 500-600 ml of F100: Dilute 1 tablet of ferrous sulphate (200

mg) in 4ml water first then add only 1ml of the solution in the F100.

• De-worming tablet (Albendazole) is given at the start of Phase 2 for

patients over 1 year.
 • Health and nutrition education including cooking demonstrations
should be made available on site to show the components of a balanced
meal, the cooking time and the consistency of the porridge.

• Move the child back to Transition Phase or to Phase 1:

o If the child develops a significant "re-feeding oedema" (grade ++ or

grade +++)

o If the child develops a major illness

o If the child develops "re-feeding diarrhoea" leading to weight loss.

• Move the child to out-patient treatment when:

o There is a good supply of RUTF

o An out-patient treatment service is close to the patient's home

o The child has good appetite and no medical complications

o The caregiver has the motivation and capacity to continue the

treatment at home

Note: this is not a "discharge" from the in-patient treatment but a

transfer to another part of the same program.

Job aids (Phase 2):

• Table for F100 and RUTF amounts to be given during Phase 2

Out-patient Treatment Phase 2

Summary of Key Steps for Out-patient treatment:

• Patients from admission that fulfil the criteria for SAM, do not have any
medical complications and have passed the appetite test can go directly to
Phase 2 and be registered as "new admission". All their information should
be recorded in the Client Card [Front | Back] including the target weight for
discharge (WHO/NCHS table).

• Patients that are admitted directly to Phase 2 as out-patients should be

provided with a systematic medical examination and given routine
medicine. Note: they will be given the same routine medicines as those
 provided in Phase 1 as in-patient.

• Patients transferred from in-patient treatment should be registered as

"transferred from". All their information should be recorded in the Client
Card including the target weight for discharge (WHO/NCHS table).

• Surveillance of the child:

o Every week, weight is measured, entered and plotted on the Client

Card.

o Every week, the presence of bilateral oedema is assessed and

noted in the Client Card.

o Every week, body temperature is measured and noted in the Client

Card.

o Every week, standard clinical signs (stool, vomiting, dehydration,

cough, respiration and liver size) are assessed and noted in the
Client Card.

o Every week, Mid-Upper Arm Circumference (MUAC) is taken.

o Every month or as required height/length is taken.

o Every week, appetite test is done and intake record is noted in the
Client Card.

• RUTF is provided as take-home therapeutic food for malnourished

children only. RUTF are usually oil-based with little available water and,
therefore, resistant to bacterial growth. This allows them to be safely used
at home even where hygiene conditions are not optimal. It is important
that caregivers are provided with comprehensive information on the use of
RUTF.

• The amount of RUTF provided to the caregiver is based on the class of

weight and on the necessary quantity required to last until the next visit to
the out-patient site.

• Use the RUTF Feeding Table

 • Breastfeeding children should always be given Breast-Milk before the
RUTF.

• Caretakers should give small and regular meals of RUTF and encourage
their children to eat as often as possible (every 3-4 hours). RUTF should
not be shared with other family members even if the child does not
consume all the diet offered. Leftovers can be kept safely and eaten at a
later time.

• RUTF is the only food the child needs to recover. It is not necessary to
give other foods as they do not have the equivalent of nutrients contained
in RUTF and may interfere with the recovery of the child. If other foods are
given, always give RUTF before other foods. While giving RUTF, always
offer plenty of clean water to drink.

• Move the child to Phase 1 (in-patient):

o If the child develops any of the medical complications that demand

in-patient treatment.

o If the child has severely reduced appetite.

o If the child increases/develops oedema.

o If the child develops "refeeding diarrhoea" sufficient to lead to

weight loss.

o If the child does not respond to the treatment.

o If there is a weight loss for 2 consecutive weighing sessions.

o If there is a weight loss of more than 5% of body weight at any visit.

o If the weight stays static for three consecutive weighing sessions.

Out-patient Treatment Site - What you need at a glance

Anthropometric equipment:

• Infant/child length-height measuring board

• Scale, infant spring-type 25 kg x 100g

• Weighing trousers
 • Mid-Upper Arm Circumference (MUAC) tape

• Scale, infant, clinic beam type, 16kg x 10g

Registration and recording equipment:

• Record book

• Client Card [Front | Back]

RUTF for appetite test

Routine medicines
Job aids:

• Routine medicine table

• Summary Admission Criteria Table for in-patient or out-patient

• NCHS/WHO table

Discharge and Follow-up

The discharge criteria for severely malnourished children is applicable for
both in-patient and out-patient treatment programs.

Note: Any transfer from in-patient to out-patient treatment and vice-versa should
always be recorded as "transfer from" and never as "discharge" or "new
admission"

• Discharge criteria for children aged 6 months to 18 years:

o Weight-for-Height (W/H) and Weight-for-Length (W/L) > = 85%

(WHO/NCHS table) on at least two weighing sessions

or

o No oedema for 14 days

• Follow-up after discharge:

 o Patient should be enrolled in a nutritional support program for
another four-six months. For the first two months, they should
attend every two weeks and than once per month if progress is
satisfactory.

o Patient and family should be prioritized in accessing food rations

from public distribution systems.

o If there is no nutritional support program near the patients' home,

they should be referred to the nearest health centres or linked up
with mobile clinics for continuous growth monitoring and support.

Check the table* giving the Target weight for discharge for patients
admitted with various admission weights when no height is available -
used for patients admitted on MUAC alone.

*The table is constructed so that a person admitted with a weight-for-

height of 70% (NCHS median) will be discharged when they reach 85%
weight-for-height (NCHS Median). Those admitted at 65% weight-for-
height will reach 79% weight-for-height at the target weight. Most patients
below 65% will be treated as in-patients and will have their height
measured and an individual target weight calculated.

Failure to Respond
It is usually only when children fulfil the criteria for “failure to respond” that they
need to have an extensive history and examination or laboratory investigations
conducted. Most patients are managed by less highly trained staff (adequately
supervised) on a routine basis. Skilled staff (nurses and doctors) time and
resources should be mainly directed to those few children who fail to respond to
the standard treatment.

Failure to respond to standard treatment is a “diagnosis” in its own right. It should

be recorded on the chart as such and the child then seen by more senior and
experienced staff. For out-patients this diagnosis usually warrants referral to a
centre for full assessment; if inadequate social circumstances are suspected as
the main cause in out-patient management a home visit can be performed before
transfer to the in-patient treatment facility.
When a child fails to respond then the common causes must be investigated and
treated appropriately according to the manual.

Every child with unexplained primary failure to respond should have a detailed
history and examination performed. In particular, they should be checked
carefully for infection as follows:

1. Examine the child carefully. Measure the temperature, pulse rate and
respiration rate.

2. Where appropriate, examine urine for pus cells and culture blood.
Examine and culture sputum or tracheal aspirate for TB; examine the fundi
for retinal tuberculosis; do a chest x-ray. Examine stool for blood, look for
trophozoites or cysts of Giardia; culture stool for bacterial pathogens. Test
for HIV, hepatitis and malaria. Examine and culture CSF.

Secondary failure to respond (deterioration/regression after having progressed

satisfactorily to Phase 2 with a good appetite and weight gain in Transition Phase
for in-patients and deterioration after an initial response in out-patients), is
usually due to:

• Inhalation of diet into the lungs. There is poor neuro-muscular coordination

between the muscles of the throat and the oesophagus in malnutrition. It is
quite common for children to inhale food into their lungs during recovery if
they are: 1) force fed, particularly with a spoon or pinching of the nose; 2)
laid down on their back to eat, and 3) given liquid diets. Inhalation of part
of the diet is a common cause of pneumonia in all malnourished patients.
Patients should be closely observed whist they are being fed by the
caretaker to ensure that the correct technique is being used. One of the
advantages of RUTF is that it is much less likely to be force fed and
inhaled.

• An acute infection that has been contracted in the centre from another
patient (called a “nosocomial” infection) or at home from a visitor/ sibling/
household member.

• Sometimes as the immune and inflammatory system recovers there

appears to be “reactivation” of infection during recovery; acute onset of
malaria and tuberculosis (for example sudden enlargement of a cervical
abscess or development of a sinus) may arise several days or weeks after
starting a therapeutic diet.

• A limiting nutrient in the body that has been “consumed” by the rapid
growth and is not being supplied in adequate amounts by the diet. This is
very uncommon with modern diets (F100 and RUTF) but may well occur
with home-made diets or with the introduction of “other foods”. Frequently,
introduction of “family plate”, UNIMIX or CSB slows the rate of recovery of
a malnourished child. The same can occur at home when the child is
 given the family food (the same food that the child was taking when
malnutrition developed) or traditional “weaning” foods.

• With out-patients, traditional medicines, other treatments and a change in

home circumstances can significantly affect the recovery of the
malnourished child.

Action required when failure to respond is commonly seen in a programme.

• The common causes listed in the box should be systematically examined

to determine and rectify the problems.

• If this is not immediately successful then an external evaluation by

someone with experience of running a programme for the treatment of
severe malnutrition should be involved in the organisation and application
of the protocol.

• Review staff performance with refresher training if necessary.

For out-patient treatment:

• Follow-up through home visits by outreach workers/volunteers to check

whether a child should be referred back to the in-patient facility between
visits.

• Discuss with mother/caregiver on aspects of the home environment that

may be affecting the child’s progress.

• At health facility carry out medical check and Appetite test

• A follow-up home visit is essential when:

o Mother/caregiver has refused admission to in-patient care despite

advice

o Patient fails to attend appointments at the out-patient programme

Source: Protocol for the management of Severe Acute Malnutrition, Ethiopia

Federal Ministry of Health, February 2007 (based on the Guideline for the
management of the severely malnourished, Michael Golden and Yvonne Grellety,
September 2006)