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 Bilateral oedema. (W/H) or Weigh-for-Length (W/L).

• •

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 High Acute Watery Extensive Very pale eyes or or

oedema low prolonged diarrhoea oral and palms (severe body respiratory -

(+++) temperature infection vomiting thrush 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 inpatients 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 catchup (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 F75 25 g 70 g 35 g 30 g 20ml 1000 ml** 35 g 70 g 35 g 20 g 20 ml 1000 m/**

Dried skimmed milk Sugar Cereal flour If you have dried Vegetable oil skimmed milk Mineral mix* Water to make 1000 ml Dried whole milk Sugar Cereal flour If you have dried Vegetable oil whole milk Mineral mix* Water to make 1000 ml

Fresh cow's milk, or fullcream If you have fresh (whole) long life milk cow's milk, or Sugar Cereal flour fullcream (whole) Vegetable oil long life milk Mineral mix* Water to make 1000 ml

300ml 70 g 35 g 20 g 20 ml 1000 ml** No cooking is required for F-100:

If you do not have cereal flour, or there are no cooking facilities, use one of the following recipes for F-75:

Alternatives

Ingredient

Amount for F- Amount for F-100 75 25 g 100 g 30 g 20 ml 1000 ml** 35 g 100 g 20 g 20 ml 1000 ml** 300 ml 100 g 20 g 20ml 1000 ml** 80 g 50 g 60 g 20 ml 1000 ml** 110 g 50 g 30 g 20 ml 1000 ml** 880 ml 75 g 20 g 20ml 1000 ml**

Dried skimmed milk Sugar If you have dried Vegetable oil skimmed milk Mineral mix* Water to make 1000 ml Dried whole milk Sugar If you have dried Vegetable oil whole milk Mineral mix* Water to make 1000 ml Fresh cow's milk, or fullcream If you have fresh (whole) long life milk cow's milk, or Sugar fullVegetable oil cream (whole) long life milk Mineral mix* Water to make 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 3. Transfer add to cooled, cooking pot boiled and water whisk up the to mixture 1000 ml.

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 inpatient 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 Hypothermia: Fever Number
o o

• • • •

vomiting/ axillary’s temperature > of resps/ min breaths for from from for chest <

intractable 35°C or rectal <

vomiting 35.5°C 39°C

per under 2 1 5 to to 2 12 5 year-olds

minute: months months years or

60 50 >40 30 Any

resps/ minute resps/minute resps/minute

o o

over

in-drawing

• •

Extensive Very weak, Fitting/convulsions Severe Any Very Jaundice Bleeding dehydration that

skin

lesions/ lethargic,

infection unconscious

• • • • • •

based requires

on an

history infusion (severe or

& NG

clinical tube

signs feeding.

condition

pale

anaemia)

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 outpatient 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 Oil Vitamin and Mineral Supplement (CMV) Skimmed Milk

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 No

and need

texture for

suitable cooking

for before

young

children 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 Energy Proteins Lipids Sodium Potassium Calcium Phosphorus (excluding phytate) Magnesium Iron Zinc Copper Selenium Iodine Vitamin A Vitamin D Vitamin E Vitamin K Vitamin B1 2.5% maximum 520-550 Kcal/100g 10 to 12 % total energy 45 to 60 % total energy 290 mg/100g maximum 1100 to 1400 mg/100g 300 to 600 mg/100g 300 to 600 mg/100g 80 to 140 mg/100g 10 to 14 mg/100g 11 to 14 mg/100g 1.4 to 1.8 mg/100g 20 to 40 µg 70 to 140 µg/100g 0.8 to 1.1 mg/100g 15 to 20 µg/100g 20 mg/100g minimum 15 to 30 µg/100g 0.5 mg/100g minimum

Vitamin B2 Vitamin C Vitamin B6 Vitamin B12 Folic acid Niacin Pantothenic acid Biotin n-6 fatty acids n-3 fatty acids

1.6 mg/100g minimum 50 mg/100g minimum 0.6 mg/100g minimum 1.6 µg/100g minimum 200 µg/100g minimum 5 mg/100g minimum 3 mg/100g minimum 60 µg/100g minimum 3% to 10% of total energy 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 Energy Proteins Lipids Calcium Phosphorus Potassium Magnesium Zinc Copper Per sachet of 92 g 500 kcal 12.5 g 32.86 g 276 mg 276 mg 1 022 mg 84.6 mg 12.9 mg 1.6 mg Nutrient Vitamin A Vitamin D Vitamin E Vitamin C Vitamin B1 Vitamin B2 Vitamin B6 Vitamin B12 Vitamin K Per sachet of 92 g 840 mcg 15 mcg 18.4 mg 49 mg 0.55 mg 1.66 mg 0.55 mg 1.7 mcg 19.3 mcg

Iron Iodine Selenium Sodium

10.6 mg 92 mcg 27.6 mcg < 267 mg

Biotin Folic acid Pantothenic acid Niacin

60 mcg 193 mcg 2.85 mg 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 Not allergic to milk or nuts. drink liquids.

• •

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) 3.5 - 3.9 4.0 - 5.4 5.5 - 6.9 7.0 - 8.4 8.5 - 9.4 9.5 - 10.4 10.5 - 11.9 12.0-13.5 >13.5 Packets / day 1.5 2 2.5 3 3.5 4 4.5 5 200kcal/kg/day Packets / w 11 14 18 21 25 28 32 35 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 Body Shortness

changes:

hives,

rashes

and

infections swelling

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 Should be given soon be after a feed if any the child breastfeeds. family food.

• •

always

given

before

other

• •

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 OutPatient 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 o

Weight-for-Height Bilateral

(W/H)

or

Weight-for-Length

(W/L). oedema

The

following

criteria 6

should

be

present to

for 18

admission: years:

Children
o

aged

months

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 treatmentcentre. 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 Explanation Table of Minimum Expected Weight 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 They They
o

do

not

gain are

weight

for

more losing

than

two

months. weight.

are

falling

below

the

bottom

line:

A child below 2 years of age with plotted weight below the "lowweight-for-age" curve A child two years old and above with plotted weight below the "very-low-weight-for-age" curve

o

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 malnutrition, it is not a diagnostic feature. suspicion of acute

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. Cutoffs 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 MidUpper 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 Checking

Mid-Upper

Arm

Circumference of

(MUAC). oedema.

presence

Referring children with acute malnutrition to sites with treatment services.

All functional Health Centers:
• • •

Taking Checking

Mid-Upper

Arm

Circumference of

(MUAC). oedema.

presence

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 o o o

Mental deficiency Deaf mutism Spasticity Ataxia (lack of muscular coordination)

Hypothyroid cretinism:
o

Dwarfism Hypothyroidism

o

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 Pregnant People women with

with in the

severe last month or cardic of

malnutrition pregnancy abnormalities

respiratory

distress

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 Syrup / tablets

Comment

< 2 years

25

100-400

4 ml syrup once a day 8 ml syrup once a day

2-12 years Adolescents and adults including pregnant mothers

60

400

120

400

1 tablet a day

Exact dose is 3-6 mg\kg\day. Giving the syrup in doses between ½ to 1 times of weight in ml will give the exact quantity. Hence dose should not exceed weight of the child. eg 8 kg should not receive more than 8 ml.

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
o o

in

Phase

1

need

to

receive

daily

surveillance:

Weight is measured, entered and plotted on the Multichart. The degree of oedema (0 to +++) is assessed and noted in the Multichart. Body temperature is measured twice a day and noted in the Multichart. Standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in the Multichart. 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).

o

o

o

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

of

feeds:

Amounts of F75 to give during Phase 1 is based on the class of weight (Kg) 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. Use the WHO Feeding Table

o

o o o

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

of

feeds

Amounts of F100 given during the Transition Phase are based on class of weight (Kg) Frequency Use of the feeds should WHO normally be 6 per day. Table

o o o

Feeding

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

o

Routine antibiotics should be continued after transferred from Phase 1 for another four days. Move
o o o o o o

the If If If If If If child child the child

child gains

back weight is suddenly size more

to rapidly increasing develops increases

Phase than

1:

10g/kg/day. oedema oedema rapidly overload distension

there child liver develops develops

signs signs of

of

fluid

abdominal

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 o •

If

naso-gastric

tube

is

needed

If complication arise that necessitates an intravenous infusion the child to Phase 2:

Progress
o o

If child has a good appetite. Taking 90% of the prescribed F100. 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 child (kg)

Volume of F-75 per feed (ml) a Every 2 hours b (12 feeds) 20 25 25 30 30 35 35 35 40 40 45 45 50 50 Every 3 hours c (8 feeds) 30 35 40 45 45 50 55 55 60 60 65 70 70 75 Every 4 hours (6 feeds) 45 50 55 55 60 65 70 75 80 85 90 90 95 100

Daily total (130 Ml/kg)

80% of daily total a (minimum)

2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0 4.2 4.4 4.6

260 286 312 338 364 390 416 442 468 494 520 546 572 598

210 230 250 265 290 310 335 355 375 395 415 435 460 480

4.8 5.0 5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0 8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0
a

55 55 55 60 60 65 65 70 70 75 75 75 80 80 85 85 90 90 90 95 95 100 100 105 105 110 110

80 80 85 90 90 95 100 100 105 110 110 115 120 120 125 130 130 135 140 140 145 145 150 155 155 160 160

105 110 115 120 125 130 130 135 140 145 150 155 160 160 165 170 175 180 185 190 195 200 200 205 210 215 220

624 650 676 702 728 754 780 806 832 858 884 910 936 962 988 1014 1040 1066 1092 1118 1144 1170 1196 1222 1248 1274 1300

500 520 540 560 580 605 625 645 665 685 705 730 750 770 790 810 830 855 875 895 915 935 960 980 1000 1020 1040

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 FChild (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 9.0 9.2 9.4 9.6 9.8 10.0
a

220 225 230 235 240 245 250

325 330 335 345 350 360 365

1320 1350 1380 1410 1440 1470 1500

1936 1980 2024 2068 2112 2156 2200

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
o

of

the

child:

3 times per week, weight is measured, entered and plotted on the Multichart. 3 times per week, the presence of bilateral oedema is assessed and noted in the Multichart. Every morning, body temperature is measured and noted in the Multichart. Every morning, standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in the Multichart. Every week, Mid-Upper Arm Circumference (MUAC) is taken. Every 3 weeks height/length is taken.

o

o

o

o o 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
o

of

feeds

Amounts of F100 or RUTF to give during Phase 2 are based on class of weight (Kg) 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. Use the WHO F100 Feeding Table or M. Golden RUTF Feeding Table Preparation of feeds: Pre-packaged F100 or On-site prepared F100 and RUTF 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.

o

o

o

o

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
o

needs

to

be

added

to

the

F100

in

Phase

2:

For 2 to 2.4 liters of F100: Add 1 crushed tablet of ferrous sulphate (200 mg). 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. 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.

o

o

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 +++) If the child develops a major illness

o o •

If the child develops "re-feeding diarrhoea" leading to weight loss. the There child is a to out-patient good treatment of when: RUTF

Move
o o o o

supply

An out-patient treatment service is close to the patient's home The child has good appetite and no medical complications 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
o

of

the

child:

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

o

o

Every week, standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are assessed and noted in the Client Card. Every week, Mid-Upper Arm Circumference (MUAC) is taken. Every month or as required height/length is taken.

o o 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
o

the

child

to

Phase

1

(in-patient):

If the child develops any of the medical complications that demand in-patient treatment. If If the the child has child severely reduced appetite. oedema.

o o o

increases/develops

If the child develops "refeeding diarrhoea" sufficient to lead to weight loss. If the child does not respond to the treatment.

o o o o

If there is a weight loss for 2 consecutive weighing sessions. If there is a weight loss of more than 5% of body weight at any visit. 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
o

criteria

for

children

aged

6

months

to

18

years:

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. Patient and family should be prioritized in accessing food rations from public distribution systems. 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.

o

o

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-forheight of 70% (NCHS median) will be discharged when they reach 85% weight-for-height (NCHS Median). Those admitted at 65% weight-forheight 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 A
o

• •

health

facility

carry home

out

medical visit

check is

and

Appetite

test when:

follow-up

essential

Mother/caregiver has refused admission to in-patient care despite advice Patient fails to attend appointments at the out-patient programme

o

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)