Therapeutic Care

Session overview
• History of the treatment of acute malnutrition
• The rationale for home-based care
• The principles of community management of
acute malnutrition (CMAM)
• Components of CMAM
• Monitoring and evaluation
• Remaining challenges
 Learning objectives
By the end of this session, you should be able to:
• Explain the basic principles of therapeutic care and its role in
emergencies
• Describe the main protocols for the management of severe
malnutrition and how they are implemented in inpatient and
outpatient facilities
• List the key points in planning and implementing a therapeutic
care programme, including the standard criteria for opening
and closing a programme
• Assess the quality of therapeutic care programmes using
monthly reports, surveys and evaluations
 Background
• Traditionally, children with severe acute
malnutrition have been treated in centre-
based care:
– paediatric ward
– therapeutic feeding centre (TFC)
– nutrition rehabilitation unit (NRU)
– other inpatient care sites.
• The centre-based care model follows the
World Health Organization (WHO)
Guidelines for Management of Severe
Malnutrition.
Traditional Approach

Screening
Screening Many now advocate for
using MUAC alone, the
cluster recommends
continued use of W/H
 Traditional approach

No Malnutrition Screening

Moderate (70 - 80% Severe (<70%

Median)* Median/Oedema)*

Supplementary Therapeutic Care

Feeding
Recovered

Note: Standard screening protocols use percent

of the median – not z-scores
 Traditional approach
Phase II
Phase I Stabilization
Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.

Care Attend to complications (e.g. shock, hypoglycemia)
Feed F-75 Therapeutic Milk F-100 Therapeutic Milk
Quantity 135ml/kg/day 200ml/kg/day
Time 1-7 Days, 3 to 4 Weeks

See WHO, Management of Severe Malnutrition, 1999 for

further detail.
 The problem with in-patient care
Highly effective in reducing case specific mortality,
BUT…
• Low coverage leading to late presentation
• Overcrowding
• Heavy staff work loads
• Cross infection
• High default rates due to need for long stay
• Potential for mothers to engage in high risk
behaviours to cover meals
Potential for home-based care?
• As a result of the problems associated
with in-patient care, practitioners looked
at the potential for treating SAM in the
home
• The two developments that that enabled
this to happen were:
– Recognition that not all cases of SAM are the same
– The development of Plumpy’nut, a ready-to use
peanut-based product designed to treat SAM –
inspired by Nutella!
 Complicated
SAM with and without complications
 Ready-to-use therapeutic food
• Energy and nutrient dense: 500 kcal/92g
• Same formula as F100 (except it contains iron)
• No microbial growth even when opened
• Safe and easy for home use
• Is ingested after breast milk
• Safe drinking water should be provided
• Generally well liked by African children
• Can be produced locally
• Is not given to infants under 6 months
 Production of RUTF
• Ingredients for lipid-based RUTF:
– Peanuts (ground into a paste)
– Vegetable oil
– Powdered sugar
– Powdered milk
– Vitamin and mineral mix (special formula)
• Nutriset France produces ‘PlumpyNut®’ and has national
production franchises in DRC, Dominican Republic, Ethiopia,
India, Madagascar, Mozambique, Niger, Tanzania, USA and
Sierra Leone
• Valid Nutrition produces VN Peanut Formula in Malawi,
Zambia, Ethiopia and Kenya and Compact Foods produces
eeZeePaste Nut in Norway and India
Time for a taste test!
 The new approach >80% of severes
can be treated as
outpatients

Acute Malnutrition

Without Complications With Complications

Oedema (+++) OR
Marasmic-Kwashiorker
SAM and MAM with
<70% WHM, OR WHM <80% OR MUAC
70 - 80% WHM, complications
MAM
MUAC <125mm
MUACSAM
<110mm <125mm OR oedema
OR oedema AND illness*

Supplementary Outpatient
Therapeutic Care
Inpatient Care
Feeding

*Anorexia, LRI, High fever, Severe dehydration, anemia, not

alert, hypolglycaemia, or hypothermia
 The new approach
Acute Malnutrition

Without Complications With Complications

Oedema (+++) OR
Marasmic-Kwashiorker
-3 to <-2 <-3 / <70% SAM and MAM with
<70% WHM, OR WHM <80% OR MUAC
70 - 80% WHM, complications
70 to <80% MUAC <110mm
MUAC<115mm <125mm OR oedema
MUAC <125mm
MUAC 115-124 OR oedema
Oedema AND illness*

Supplementary Outpatient
Therapeutic Care
Inpatient Care
Feeding

*Anorexia, LRI, High fever, Severe dehydration, anemia, not

alert, hypolglycaemia, or hypothermia
 CTC, CMAM, IMAM
• There are various acronyms used to describe
home-based management of SAM:
– Community-based Therapeutic Care
– Community Management of Acute Malnutrition
– Integrated Management of Acute Malnutrition
• These are basically the same thing but are
used to refer to different modes of
implementation (emergency, non-emergency,
integrated as part of a health service)
 CMAM
• A community-based approach to treating SAM
– Most children with SAM without medical
complications can be treated as outpatients at
accessible, decentralised sites
– Children with SAM and medical complications are
treated as inpatients
– Community outreach for community involvement
and early detection and referral of cases
 Developments in CMAM
• 2000: 1st pilot programme in Ethiopia
• 2002: pilot programme in Malawi
• Scale up of programmes in Ethiopia (2003-4 Emergency),
Malawi (2005-6 Emergency), Niger (2005-6 Emergency)
• Many agencies and governments now involved in CMAM
programming in emergencies and non-emergencies
• Over 25,000 children with SAM treated in CMAM programmes
since 2001 (Lancet 2006)
 Evidence
• RUTF has been proven effective for the treatment of SAM
• Endorsed by WHO, UNICEF, WFP and SCN in a joint statement
published in May 2007

21 programmes in Ethiopia, Malawi, Sudan, Niger. 23,511

children with SAM treated and documented.
(results for com bined outpatient and inpatient)
3%
2%
4%

11% Cured
Defaulted
Died
Transferred
Non-cured

80%
Collins et al Lancet 06
Programme Outcomes for 21 Inpatient and Outpatient Care Programmes (2001-2006)
CMAM works in emergency contexts
100% Outcomes from CTC 2000 - 2003, (n = 7,408), & TFCs 1992-1998
(n= 11,287) against SPHERE minimum standards

75%

50%

25%

0%
recovered died default LTF
CTC 77% 5% 11% 7%
SPHERE 75% 10% 15% 0%
TFC 65% 12% 18% 5%
Core Components of CMAM

24
 Principles of CMAM
1. Maximum access and coverage
N Darfur 2001

Karnoi & Malha

Tina
Um Barow
Kutum

Mellit

Fata Barno Koma

El Sayah

Serif Korma
Kebkabiya El Fasher

Um Keddada

Tawila & Dar el Saalam

100 kms

Hospital TFC Taweisha

26
El Laeit
N Darfur 2001

Karnoi & Malha

Tina
Um Barow
Kutum

Mellit

Fata Barno Koma

El Sayah

Serif Korma
Kebkabiya El Fasher

Um Keddada

Tawila & Dar el Saalam

100 kms
Hospital with inpatient care
Taweisha
Outpatient care site
Inpatient care site El Laeit
27
 Principles of CMAM
2. Timeliness
 Complicated
Timeliness: late versus early presentation of SAM
 Timeliness
• Find children before SAM
becomes serious and
medical complications
arise
• Good community
outreach is essential
• Screening and referral by
outreach workers (e.g.,
community health
workers, volunteers)
 MUAC for screening
• Initially, CMAM used 2 stage screening process:
– MUAC for screening in the community
– Weight-for-height (WFH) for admission at a health facility
= Time consuming, resource intense, some negative
feedback, risk of refusal at admission
• MUAC for admission to CMAM (with presence of bilateral
pitting oedema, with WFH optional)
= Easier, more transparent, child identified with SAM in the
community will be admitted, thus fewer children are
turned away
 MUAC for screening
• A transparent and understandable measurement
• Can be used by community-based outreach workers (e.g.,
CHWs, volunteers) for case-finding in the community
• WHO now recommends use of <115mm for
SAM rather than <110mm
Inpatient Outpatient
SFP
care Care 33
 Principles of CMAM
3. Appropriate medical and nutrition care
Appropriate medical treatment and nutrition
rehabilitation based on need
 Principles of CMAM
4. Care for as long as needed
 Care for as long as needed
• Care for the management of SAM is provided
as long as needed
• Services to address SAM can be integrated
into routine health services of health facilities,
if supplies are present
• Additional support to health facilities can be
added during certain seasonal peaks or during
a crisis
 Principles of CMAM
1. Maximum access and coverage
2. Timeliness
3. Appropriate medical and nutrition care
4. Care for as long as needed

Following these steps ensures maximum

public health impact!
Core Components of CMAM

39
 1. Community outreach
• Community assessment (also assess IYCF)
• Community mobilisation and
involvement ( developing key messages/raising
community awareness)
• Community outreach workers:
– Early identification and referral of
children with SAM before the
onset of serious complications
– Follow-up home visits for
problem cases
– Community outreach to
increase access and coverage
 Community assessment
• Community perceptions of acute malnutrition
• Health seeking behaviour and decision makers for
accessing treatment
• Key community figures, and structures (administrative
and leadership)
• Existing community-based organisations and groups
• Potential candidates for case-finder role
• Existing links and communication systems between
health facilities and the community
• Formal and informal channels of communication
• Formal and informal health services
• Potential barriers for children with SAM to accessing
treatment
 1. Community outreach
• Key individuals in the community:
– Promote CMAM services
– Make CMAM and the treatment of SAM
understandable
– Understand cultural practices, barriers and
systems
– Dialogue on barriers to uptake
– Promote community case-finding and referral
– Conduct follow-up home visits for problem
cases
 2. Outpatient care
• For children with SAM without medical
complications:
– Initial medical and anthropometry assessment with
the start of medical treatment and nutrition
rehabilitation with take home ready-to-use
therapeutic food (RUTF)
– Weekly or bi-weekly medical and anthropometry
assessments monitoring treatment progress
– Continued rehabilitation with RUTF at home
It is essential to have a clear referral protocol for cases
that need to be treated in in-patient facilities
 2. Outpatient care
Acute Malnutrition

Without Complications With Complications

Oedema (+++) OR
Marasmic-Kwashiorker
SAM and MAM with
<70% WHM, OR WHM <80% OR MUAC
70 - 80% WHM, complications
MAM
MUAC <125mm
MUACSAM
<110mm <125mm OR oedema
OR oedema AND illness*

Supplementary Outpatient
Therapeutic Care
Inpatient Care
Feeding

*Anorexia, LRI, High fever, Severe dehydration, anemia, not

alert, hypolglycaemia, or hypothermia
 2. Outpatient care
• Medical Assessment
• Appetite Assessment
• Presumptive treatment:
– Antibiotic (amoxicillin), Anti-malarial, and Vitamin
A and/or Folic Acid in cases presenting with
deficiency symptoms
• Ready to Use Therapeutic Food (RUTF)
Clinic
Admission for
Outpatient Care

46
Appetite test
 RUTF supply
• Ensure understanding of
RUTF and use of medicines
• Provide one week’s supply
of RUTF and medicine to
take at home
• Request they return every
week to outpatient care to
monitor progress and assess
compliance
 Weekly follow-up
• Medical exam
• Provision of RUTF
• De-worming for children above 1 year of age
– Week 2
• Measles immunization for all children above 9
months of age
– Week 4
 3. Inpatient care
• For children with SAM with medical
complications or no appetite
– Child is treated in a hospital for stabilisation
of the medical complication
– Child resumes outpatient care when
complications are resolved

It is essential to have a clear referral

protocol to outpatient care
• Students can do Exercise 1 here if necessary
 3. Inpatient care
Acute Malnutrition

Without Complications With Complications

Oedema (+++) OR
Marasmic-Kwashiorker
SAM and MAM with
<70% WHM, OR WHM <80% OR MUAC
70 - 80% WHM, complications
MAM
MUAC <125mm
MUACSAM
<110mm <125mm OR oedema
OR oedema AND illness*

Supplementary Outpatient
Therapeutic Care
Inpatient Care
Feeding

*Anorexia, LRI, High fever, Severe dehydration, anemia, not

alert, hypolglycaemia, or hypothermia
 3. Inpatient care
• SAM with medical complications or no appetite:
– Anorexia, LRI, High fever, Severe dehydration
– Anemia, Child not alert, Hypolglycaemia
– Hypothermia
• Medical treatment according to WHO and/or national
protocols
• Return to outpatient care after complication is resolved,
oedema reduced, and appetite regained
• All infants under 6 months with SAM receive specialised
treatment until full recovery
Care of infants with SAM , 6
months
 Inpatient to outpatient care
Phase II
Phase I Stabilization
Trans/Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.

Outpatient Care
Care Attend to complications (e.g. shock, hypoglycemia)

Feed F-75 Therapeutic Milk RUTF

Quantity 135ml/kg/day 200ml/kg/day

Time 1-7 Days, 3 to 4 Weeks

WHO, Management of Severe Malnutrition, 1999
Relationship between outpatient care and
inpatient care
• Complementary
– Inpatient care for the management of SAM with medical
complications until the medical condition is stabilised and
the complication is resolving
• Different priorities
– Outpatient care prioritises early access and coverage
– Inpatient care prioritises medical care and therapeutic
feeding for stabilisation
 4. Management of MAM
• Supplementary feeding
• Alternative?
• Other activities
– Routine medication
– Basic preventive health care and
immunisation
– Health and hygiene education; infant and
young child feeding (IYCF) practices and
behaviour change communication (BCC)
 Discharge
• For admissions on low MUAC as the
evidence on % weight gain is still being
collected, some agencies also promote:
• Minimum length of stay of 2 months, MUAC
≥ 11.5cm,
 Sustained weight gain and
 Clinically well
• And others, alternatively, use MUAC
≥12.5cm for two consecutive weeks
regardless of the total length of stay.
•  
IYCF integrated with CMAM
• Assessment – part of community
mobilisation investigation.
• Counselling/Reaching an agreement with 
mother/carer (Assess,Analyse,Act)–
Admission/follow up/Discharge planning 
• Points of Contact
• Action orientated group sessions
• IYCF support groups
• Home visits
Global commitments for CMAM
• WHO consultation (Nov 2005) – agreement by WHO to
revise SAM guidelines to include outpatient care and
endorse MUAC as entry criterion for programmes
• United Nations Children’s Fund (UNICEF) accepted
CMAM globally (2006)
• United Nations (UN) Joint Statement on Community-
Based Management of Severe Acute Malnutrition (May
2007) – support for national policies, protocols,
trainings, and action plans for adopting approach: e.g.,
Ethiopia, Malawi, Uganda, Sudan, Niger
 Global commitments for CMAM
• Collaboration on joint trainings between
WHO, UNICEF, United Nations High Council for
Refugees (UNHCR), and United States Agency
for International Development (USAID)
• Donor support for CMAM development,
coordination and training
• Several agencies supporting integration of
CMAM into national health systems
 CMAM in different contexts
• Extensive emergency experience
– Some transition into longer term programming, as in the
cases of Malawi and Ethiopia
• Growing experience in non-emergency or
development contexts
– e.g., Ghana, Zambia, Rwanda, Haiti, Nepal
• Growing experience in high HIV prevalent areas
– Links to voluntary counselling and testing (VCT) and
antiretroviral therapy (ART)
 Integrated approach
Shock/crisis
Emergency Levels
GAM and SAM above seasonal norms
Transition

Non-Emergency
e with increased numbers Emergency Levels Post emergency

Capacity to manage severe acute (Exceed MoH capacity) High numbers reducing
malnutrition strengthened in ongoing Facilitate MOH to cope with MoH resumes normal
health and nutrition programs within increased numbers programming within
existing health system (in-country rapid response) existing health system
))capacity)
Community based prevention based Link outpatient and
nutrition programs. SAM identified in inpatient care with
GM and screening through MUAC health/nutrition community
based programming
Suggested New Design Framework for CMAM Programming. Field Exchange.Issue 39. Sep 2010
Suggested New Design Framework for CMAM Programming. Field Exchange.Issue 39. Sep 2010
Suggested New Design Framework for CMAM Programming. Field Exchange.Issue 39. Sep 2010
 Monitoring and evaluation
Sphere standards:
• Coverage (measured using various methods):
– >50% rural areas
– >70% urban areas
– >90% camps
• Proportion of children discharged who have:
– Died <3% for outpatient, <10% for inpatient
– Recovered >80%
– Defaulted <15%
• Number of children stabilized in inpatient care
• Mean length of stay
 CSAS
• Centric Systematic Area Sampling
 Map area to be covered and divide into
squares
 Active case finding – in all the squares.
How many covered out of total found
 Questionnaire for those not covered –
why did they not access service.
 CSAS maps coverage in detail usually
within a service delivery unit
 SQUEAC
• Semi Quantatitive Evaluation Access and
Coverage
 Identification of factors affecting coverage and possible
areas of low and high coverage.Estimation of possible
coverage (prior)
 Confirmation of coverage of these areas –ie; obtaining
the evidence (likelihood)
 Combining the prior and likelihood – Bayesian* analysis
to get an estimated coverage(posterior)
(*Method of statistics where some kinds of observations and evidence
are used to calculate the probability that a hypothesis may be true)
 Remaining challenges
• Admission/discharge protocol (use of
W/H, MUAC, weight gain?)
• Reporting formats
• Practicalities of integration:
– Cost/availability of RUTF – locally produced RUTF is
more expensive
– Acceptability of RUTF – less well accepted by children
in Asia, controversies in India
– Emergency versus non-emergency funding for CMAM
– Management of MAM
• Students can do Exercise 2 here if
necessary
 Any questions?
Points for evening discussion