Presentation Outline

1. History of CMAM in Malawi

2. Policy and Strategic Environment
3. Overview of CMAM: Components and the
Continuum of Care
4. Updates in the 2016 CMAM Guidelines
1) History of CMAM in Malawi

• Hunger Crisis
2001
• CMAM in emergency and operational research in
Dowa
2002 • Research Projects by College of Medicine

• Scale up to one more district for further

operational pilot
2003 • Local small scale RUTF production
History of CMAM in Malawi
• CMAM National dissemination workshop
• More interest generated among DHOs, partners, and
2004 NGOs

• Another food crisis

• Three additional districts to pilot CMAM
2005 • Second dissemination and consensus meeting

• Adopted as a national strategy

• Integration of CMAM into PHC
• Formation of the CTC Advisory Service
• Interim guidelines
2006 • Intensive advocacy for buy-in within MOH Mgt, DHOs, NGOs,
and partners
• CTC scaled up to 12 districts
2) Policy & Strategy Environment
• Political commitment and leadership
• Inclusion of nutrition in National Development policies—
MGDS, EHP, ACSD
• Development of guiding operational tools such as National
Nutrition Policy and Strategic Plan, CMAM Guidelines,
CMAM M & E tools, CMAM Training Manual
• Setting up committees to guide scale up and quality
implementation—CMAM Steering Committee, CAS, TNP,
CMAM Stakeholders Committee, CMAM Taskforce
• Local Production of RUTF
Policy & Strategy Environment (continued)

• Partnership in financing CMAM program

• Procurement of Supplies: MoH, UNICEF, WFP, Irish Aid,
CIDA, CHAI
• Other core CMAM activities: MoH, FANTA, SSDI, UNICEF,
WFP, WHO, CHAI
• Coordination
• CMAM Steering committee, CAS, TNP, CMAM Stakeholders
Committee
• Linkages
• CMAM integrated with other Child Survival Programmes
such as IMCI, HTC/ART, IMCI, PMTCT, IYCN
Coordination and Networking

CMAM
Steering
Committee

CMAM
Learning
Forum CMAM Stakeholders
Committee

Targeted
Nutrition
Programme
3) Overview of CMAM & Rationale
Advantages of CMAM
• Decentralised to health centre level
• Active case-finding through volunteers
• Lower caseload in NRU
Comparison with classical approach
• Higher coverage
• Acceptable cure, default, and death rates
• Earlier presentation of cases
• Less intensive medical care
• Reduces cross infections
• Care giver not removed from the family
 CMAM Components
SCREENING
No Home
Community/Health Facility
wasting/No WHZ> -3.0 <
Oedema -2.0
(No acute MUAC 11.5 -
Malnutritio 12.5cm
n PLM <22cm
MAM

NRU/
SFP WHZ < -3.0 OTP Inpatient
Bilateral Pitting Care
Oedema WHZ <-3.0
MUAC<11.5cm Bilateral Pitting
SAM without Medical Oedema
Complications MUAC<11.5cm
Good Appetite SAM with Medical
Complications or No
Appetite
Components of CMAM (1)

1) Community Outreach
• Community assessment
• Community mobilisation and involvement
• 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 10

coverage
Component of CMAM (2)

2) Outpatient care for children with SAM without medical

complications at decentralised health facilities and at home
• 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 nutrition rehabilitation with RUTF at home
ESSENTIAL: a good referral system to inpatient care,
11
based on Action Protocol
Components of CMAM (3)

3) Inpatient care for children with SAM with medical

complications or no appetite
• Child is treated in a hospital to stabilise the
medical complication
• Child resumes outpatient care when
complications are resolved

ESSENTIAL: A good referral system to outpatient care

12
Components of CMAM (4)

4) Services or programmes for the management of

moderate acute malnutrition (MAM)
• Supplementary Feeding

13
CMAM Emphasis on Service Linkages

LOCAL RUTF AGRICUTURE SUPPORT IGA

PRODUCTION PROGRAMMES MICROFINANCE

Services and
In-patient care programmes to
for SAM with prevent malnutrition
complications CMAM
Services & Outpatient care for
GMP / CHD
programees SAM without MCHN
HEALTH & HYGIENE
for MAM complications U5 CLINIC
PROMOTOION

COMMUNITY
MOBILISATION

IYCN / ENA /
HTC/ PMTCT
MATERNAL
ART/ TB
NUTRITION
4) Highlights of updates in the 2016 CMAM Guidelines

• Low coverage and poor outcomes

• Limited pre-service training and orientation

• Service standards and guidelines

• Global (WHO) and national updates

 Admission Criteria
2012 Protocol WHO 2013 update Malawi 2016 update
Includes older children Older children and The inclusion of older children .
>59mo and adolescents not 59mo and adolescents has been
adolescents. included or discussed. retained in the revision.

Includes older children Excluded. Retained older children and

and adolescents. adolescents.
Includes pregnant and Excluded. Retained pregnant and lactating
lactating women. women.
Did not include a A section has been Section on infants < 6mo has
section on infants < 6 added to the 2013 been added to the new
mo. WHO guidelines. guidelines.
Include use of BMI as Uses WHZ &MUAC. BMI dropped from the criteria.
admission criteria.
 HIV
Current Protocol WHO 2013 update
Does not mention All HIV-infected infants and
when to start ARTs children < 2 yrs should be
in children. initiated with ART, irrespective
of clinical staging and CD4
count.
All HIV-infected children > 2 yrs
and <5 yrs should be started on
lifelong antiretroviral drug
treatment based on their CD4
count (≤750 cells/mm3) or CD4
percentage (≤25%), or if they
have WHO clinical staging 3 or
4 (including severe acute
malnutrition).
Malawi 2016 update
• All HIV positive children should
start on ARVs irrespective of
staging and CD 4 count (2016
Clinical HIV guidelines).
• Examine all infants less than
12months of age with confirmed
HIV antibodies for PSHD.
• All children < 2 yrs who start ART
should be referred for a new
confirmatory DNA-PCR DBS
sample. This can be collected on
the day of starting ART.
 HIV & TB
Current Protocol
Does not guide the health
worker on when to suspect
TB in HIV infected children .
Does not mention when to
start ARTs in HIV infected
children.
WHO 2013 update Malawi 2016 update
Children living with HIV who This has been added as part of the
have any one of the following assessment for treatment failure (in
symptoms—poor weight gain, conformity with the 2016 Clinical
fever, current cough, or contact HIV guidelines).
history with a TB case—may
have TB and should be
evaluated for TB and other
conditions.
Children with SAM who are HIV Added to guidelines in section 5.4
infected and qualify for ART on in- patient treatment page 54. (In
should be started on ART after conformity with the 2016 Clinical
stabilization of metabolic HIV guidelines)
complications and sepsis
(indicated by return of appetite
and resolution of severe
oedema). (Same ART regimens,
and doses, as children with HIV
without SAM.)
 Micronutrient Supplementation: Vitamin A
Current protocol
Give high dose vitamin A on
admission except in children
with oedema—page 73
(Annex 4-2 Routine
Medicines for SAM in OTP/
NRU) and page 81 (Routine
Daily treatment and
Prophylaxis, Vitamin A) .
 
WHO 2013 update Malawi 2016 update
Give low-dose (5000 There is no clear rationale for
IU) vitamin A giving a single high-dose vitamin A
supplementation daily supplement, unless children have
from the time of eye signs of vitamin A deficiency or
admission until have had measles recently.
discharge from
treatment. (The vitamin A intake of children
  who are fed therapeutic food [F-
75, F-100, or ready-to use
therapeutic foods] that complies
with WHO specifications exceeds
the recommended nutrient intake
for well-nourished children and
seems adequate for malnourished
children.)
 Micronutrient Supplementation: Vitamin A and
Measles

Current Protocol WHO 2013 update Malawi 2016 update

The section on measles on A high dose (50 000 IU,
page 82 in the current 100 000 IU or 200 000 IU,
Malawi CMAM Guidelines depending on age) of
discusses giving measles vitamin A should be given
vaccines but not high dose to all children with severe
vitamin A acute malnutrition with
recent measles on day 1,
with a second and a third
dose on day 2 and day 15
(or at discharge from the
programme), irrespective
of the type of therapeutic
food they are receiving.
Added to the guidelines.
(High-dose vitamin A
supplementation reduces
mortality in children with
severe acute malnutrition
complicated by measles-
specific respiratory
infections.)
 Micronutrient Supplementation:
Zinc
Current Protocol
Page 97: If clinically
indicated add zinc: 0-6
months: 10 mg (1/2 tablets)
daily for 10-14 days and >
6months give 20 mg (1
tablet) daily for 10-14 days.
Page 99: For infants < 6
months or > 6 months but
<3kgn (breastfed), the
current Malawi guideline is
silent on the use of F-75 in
edematous breastfed young
infants. It only discusses the
use of F100-D.
WHO 2013 update Malawi 2016 update
If children with SAM are admitted Added to the
to hospital and treated with F-75 guideline.
and subsequently with ready-to-
use therapeutic food, they should
not receive oral zinc supplements
in addition to F-75 or RUTF as
these therapeutic foods contain
the recommended amounts of zinc
for management of diarrhea
Recommendation 8.2 (bullet 3):
For infants with severe acute
malnutrition and oedema, infant
formula or F-75 should be given as
a supplement to breast milk.
 Antibiotics
Current Protocol
Routine amoxicillin used in
ambulatory care
Table 16, Page 82: Give benzyl
penicillin 50,000iu/kg 6 hourly
IV/IM for 48 hours then oral
amoxicillin 15mg/kg 8 hourly
for 5 days AND if the child fails
to improve within 48 hours add
Gentamycin 7.5mg/kg once a
day IV/IM for 7 days or
Chloramphenicol 25mg/kg
IM/IV 8 hourly for 5 days
WHO 2013 update Malawi 2016 update
Routine use of Retained use of amoxicylin
ambulatory antibiotics (CT used in HIV programme)
recommended using for ambulatory care of SAM.
either Cotrimoxazole or
Ampicillin
Antibiotics for the Give benzyl penicillin 50,000
management of iu/kg 6 hourly IV/IM for 48
complicated malnutrition hours then oral amoxicillin
has not been discussed in 25–40 mg/kg 8 hourly for 5
the 2013 WHO updates. days PLUS  Gentamycin 7.5
mg/kg once a day IV/IM for
7 days.
 
(WHO Paediatric Hospital Care 2013, page 207)
Malaria Treatment
Current Protocol WHO 2013 update Malawi 2016 update
Intravenous infusion of Artesunate should be used
quinine should be used for for the treatment of
severe malaria but severe malaria.
with caution in severe
malnutrition. (Page 83) Malawi 2013 Edition of
Malarial treatment
Guidelines (page 10).
Thank You