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MINISTRY OF HEALTH
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITIONIN UGANDAJanuary 2016
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION
IN UGANDA
MINISTRY OF HEALTH
January 2016
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA4 JANUARY 2016
Foreword ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 11
Acknowledgements ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 12
Acronyms And AbbreviAtions .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 14
glossAry oF terms .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 16
CHAPTER ONE 19introdUction ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 191.0 OverviewofMalnutritioninUganda .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 191.1 AcuteMalnutritionasaformofunder-nutrition... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 191.2 ComponentsofIntegratedManagementofAcuteMalnutrition(IMAM). ..... ..... ..... ..... . 201.3 PrinciplesofIMAM .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 211.4 PurposeoftheIMAMguidelines .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 221.5 IntegratingIMAMintotheExistingHealthStructureofUganda. ..... ..... ..... ..... ..... ..... . 22
CHAPTER TWO 25commUnity involvement .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 252.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 252.1 StepsincommunityMobilisationandInvolvement ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 26
CHAPTER THREE 31nUtrition Assessment And clAssiFicAtion oF AcUte mAlnUtrition .. .... 313.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 313.1 Wheretheassessment/screeningshouldbedone. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 313.2 NutritionAssessment ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 333.3 Classificationofacutemalnutrition ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 37
CHAPTER FOUR 43SUPPLEMENTARY FEEDING PROGRAMME FOR MANAGEMENT OF MODERATE ACUTEMALNUTRITION ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 434.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 434.1 OpeningandClosingaSupplementaryFeedingProgramme . ..... ..... ..... ..... ..... ..... ..... . 534.2 RequirementsandProcessforSettingUpaSupplementaryFeedingSite . ..... ..... ..... ..... . 54
contents
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 5
CHAPTER FIVE 59oUtpAtient therApeUtic cAre For the mAnAgement oF AcUte mAlnUtrition with no medicAl complicAtions. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 595.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 595.1 AdmissionCriteriaforOTC .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 605.2 AdmissionprocessandactivitiesinOTC . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 615.3 DischargeProcedures ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 685.4 ProcessandRequirementsforSetting-upanOTC . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 69
CHAPTER SIX 73inpAtient therApeUtic cAre For mAnAgement oF AcUte mAlnUtrition with medicAl complicAtions . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... 736.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 736.1 AdmissionCriteria ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 736.2 AdmissionProcess ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 746.2 StabilisationPhase/Phase1 .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 766.4 RehabilitationPhase/Phase2 .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 926.5 CriteriatomovefromPhaseIIbacktotheStabilisationPhase(Phase1) .. ..... ..... ..... ..... . 94
CHAPTER SEVEN 97inpAtient mAnAgement oF inFAnts less thAn siX months with sAm.. .... 977.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 977.1 AdmissionCriteria ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 987.2 StabilizationPhase... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 987.3 MonitoringinfantswithSAM .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1037.4 Infantfeedingcounsellingandsupport ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 103
CHAPTER EIGHT 107emergency nUtrition response .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1078.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1078.1 StepsforEmergencyNutritionResponse ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1088.2 GeneralrequirementsforEmergencyNutritionReliefProgrammes ... ..... ..... ..... ..... ..... 1108.3 ExitStrategyforEmergencyNutritionResponse(ENR) ..... ..... ..... ..... ..... ..... ..... ..... ..... 111
CHAPTER NINE 113nUtrition inFormAtion, edUcAtion And commUnicAtion .. ..... ..... ..... ...1139.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1139.1 NutritionEducationProgramme .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1149.2 CommunicatingNutritionInformation . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1159.3 Proceduresforplanningandfacilitatinganutritioneducationsession .... ..... ..... ..... ..... 1159.4 Conductinganutritioneducationsession .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1169.5 KeyNutritionRecommendations ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 117
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA6 JANUARY 2016
CHAPTER 10 121monitoring, sUpervision, reporting And evAlUAtion, QUAlity improvement And sUpply chAin mAnAgement For imAm.... ..... ..... ..... ...12110.0 Introduction. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12110.1Keydefinitions .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12210.2MonitoringofIMAMservices.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12210.3 IMAMservicesupervision... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12910.4 Reporting ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 12910.5 Evaluation .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 13010.6Qualityimprovementinintegratedmanagementofacutemalnutrition.... ..... ..... ..... ..... 13010.7 Supplychainmanagementforimam .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 136
reFerences ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...138
ANNEXES 141AnneX 1 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...142Equipmentandsuppliesneededforanutritionward/unit .... ..... ..... ..... ..... ..... ..... ..... ..... ..... 142WardEquipment/Supplies. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 142
AnneX 2 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...144TRIAGEOFSICKCHILDREN. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 144
AnneX 3 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1453A:Weight-for-LengthReferenceCarda..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1453B:WEIGHT-FOR-HEIGHTREFERENCECARDa .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 1473D:BodyMassIndexreferenceCard .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 153
AnneX 4 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...154PROTOCOLFORTHEINPATIENTMANAGEMENTOFTHESEVERELYMALNOURISHED ..... ..... ..... 154
AnneX 5 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...160TargetWeightforRehydration. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 160
AnneX 6 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...162AntibioticsReferenceCard ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 162
AnneX 7 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...164RecipesforF-75andF-100 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 164
AnneX 8 ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...166F-75,F100andRUTFReferenceCards. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 166
AnneX 9: therApeUtic milk reFerence cArds For inFAnts less thAn 6 months with sAm .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...1719A:Therapeuticmilkreferencecardsforinfantslessthan6monthswithSAM(stabilizationphase)1719B:TherapeuticmilkreferenceCardforinfantslessthan6monthswithSAMwhoarenotbreastfed(transitionphase). .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 172
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 7
AnneX 10.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...17624-HOURFEEDINTAKECHART ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... . 176
AnneX 11.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...177DAILYWARDFEEDCHART .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 177
AnneX 12.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...178WEIGHTGAINTALLYSHEETFORWARD .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 178
AnneX 13 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...179MONITORINGCHECKLISTS . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 179
AnneX 14 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...182SampleDischargeCard ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 182
AnneX 15.... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...184SpecializedNutritiousFoodsSheet ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 184
AnneX 16 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...186CRITICALCAREPATHWAYCHART(-5pages).... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 186
AnneX 17: reFerrAl Forms . ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...19417A:CommunityReferralForm .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 19417B:HMIS032:ReferralNote. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 195
AnneX 18 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...196INTEGRATEDNUTRITIONRATIONCARD .... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 196
AnneX 19 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...197HealthandNutritionEducationRecordform .. ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 197
AnneX 20 ... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ...198DOCUMENTATIONJOURNALFORQIACTIVITIES... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... 198
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA8 JANUARY 2016
List of tabLes* Table1:Gradingofbilateralpittingoedema
Table2:SummaryofClassificationofAcuteMalnutrition
Table3:AdmissioncriteriatoSFP
Table4:SFPRationsandtheirNutritionValue
Table5:Advantagesanddisadvantagesofdryandwetration
Table6:RoutineMedicationsforPatientsinSFP
Table7:TypesofExitsfromSFP
Table8:DischargecriteriafromSFP
Table9:Decision-makingframeworkforopeningaSupplementaryFeedingProgramme1
Table10:GuidanceoncriteriaforclosingSFPs
Table11:RoutineDrugsandSupplementsinOTC
Table12:AppetitetestforRUTF
Table13:EnergyandNutrientCompositionofRUTF(Plumpy’nut)
Table14:TypesandCriteriaforExitfromOTC
Table15:Signsofdehydration
Table16:SummaryofAntibioticsforSeverelyMalnourishedChildren
Table17:RoutineMedicinesandSupplements
Table18:Typesofdischarges,conditionsandactionsfromITC
Table19:KeyNutritionRecommendations
Table20:Toolsusedinmonitoring,supervisionandreportingforIMAMprogram
Table21:Typicaltargetlevelsforcure,mortalityanddefaultingrates
Table22:CoverageneededtoeffectagivenreductioninGAM
Table23:SampleactionplanforimplementationofQIinIMAMServices
Table24:TypesofIMAMsupplies
1
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 9
List of figures*Figure1:CoordinationandCommunicationbetweenIMAMcomponents
Figure2:ExistingHealthStructureinUganda
Figure3:StepsinCommunityMobilisationandInvolvement
Figure4:MeasuringMUAC
Figure5:Measuringweightindifferentcircumstances
Figure6a:MeasuringLength
Figure7:ChildrenwithClinicalSignsofSevereAcuteMalnutrition
Figure8:SummaryoftheNutritionAssessmentandClassificationofAcuteMalnutrition
Figure10:LayoutoftheOTCarea
Figure11:WHOTenStepsfortheManagementofSAM(WHO2003)
Figure12:Keepingthepatientwarmlycovered,especiallyatnight.
Figure13:SupplementalSucklingTechnique
Figure14:DecisionTreeforImplementingSelectiveFeedingprogrammes
Figure15:ASchemeforPlanningNutritionEducationProgrammes
Figure16:TheReportingSystemoftheIMAMProgramme
Figure17:WorkPlaceImprovementthrough5-S
Figure18:ThePDSAcycle
Figure19:ProcessFlowofPatientsinOTC
List of boxesBoxA:Measurementsforacutemalnutrition
BoxB:KeyMessagesonSupplementaryFeedingProgramme
BoxC:RequirementsforsettingupSFP
BoxD:DefinitionofSAMwithoutmedicalcomplications
BoxE:KeyMessagesatFirstOTCVisit
BoxF:BasicequipmentandsuppliesforOTC
BoxG:PreparationofReSoMalfromStandardORS
BoxH:F100-Dilutedforinfants
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA10 JANUARY 2016
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 11
forewordMalnutrition is a significantpublichealthproblemwhich isoftenneglected.The six-part Lancetseriesof2013onmaternalandchildundernutrition,documentedtheup-to-dateevidencejustifyingtheurgentprioritizationofglobalandcountrywidenutritioninterventions.
Management of acute malnutrition drew attention in Uganda from 2003/2004 at the peak ofthe Lord’sResistanceArmy (LRA) insurgency inNorthernUganda.Over the years, improvementofnutritionalstatusofUgandanshasgainedpriorityattheMinistryofHealth(MOH);andtherehasbeendevelopmentofsuccessivestandards,policies,andguidelinesinthisregard,inlinewithevidence-based global recommendations. In response to the need to standardize treatmentguidelines, in 2006, Uganda, with support fromUNICEF and VALID INTERNATIONAL, developedthefirstversionofguidelinesontheIntegratedManagementofAcuteMalnutrition(IMAM)whichcombined existing guidelineswith community therapeutic care (CTC) and integrated aspects oftreatmentofmalnourishedHIV/AIDSchildrenandadults.TheIMAMapproachisacomprehensivestrategywhichcombinesandlinksinpatienttreatment(severewithcomplications)withoutpatientcare (severewithoutcomplications),managementofchildrenwithmoderateacutemalnutrition(wherepossible)andcomprehensivecommunitymobilizationandinvolvement.
InMarch 2010, theMOH launched the IntegratedManagement of AcuteMalnutrition (IMAM)guidelinesthatfurtherincorporatedtreatmentofmalnourishedadolescents,adults,pregnantandlactatingwomen.Theseguidelinesprovidedtheframeworkforensuringappropriatepreventiveinterventions, early identification and treatment of the acutely malnourished. Since thispublication,therehavebeenvariousdevelopmentsandlessonslearntthroughuseoftheguidelinesforexample:(a)Mid-UpperArmCircumferenceisbeingincreasinglyusedtoassesswasting,(b)inNovember2013,theWorldHealthOrganization(WHO)releasednewupdatesonthemanagementofsevereacutemalnutritiontocontributetoimprovedqualityofcarefornutritionandhealthoftheseverelymalnourished(c)ready-to-usetherapeuticfoods(RUTF)arebecomingmoreavailablethrough importation as well as local production and (d) admission criteria into supplementaryfeedingprogrammehasbeenrevisedforpregnantwomen.Asaresult,moreopportunitiesnowexistforearlyidentificationandreferraloftheacutelymalnourishedfortreatment.Similarly,thereareincreasingopportunitiesforearlydischargeoftheseverelymalnourishedfromthehealthfacilitytocontinuereceivingcareinthecommunity.Thisupdatetakesintoaccountthesedevelopments.ThisversionoftheIMAMguidelineswasrevisedandupdatedthroughaconsultativeprocessinvolvinginternationalandnationaltechnicalexperts.
Icalluponallstakeholdersinvolvedinthemanagementofmalnutritiontoapplytheserevisedandupdatedguidelinesandintegratetherecommendationsintotheirprogrammes.HoweverIwouldliketoappealtoallUgandanstobemindfuloftherequirementthatonlytrainedhealthworkersshoulddirectlyadministertheinstructionsintheseIMAMguidelines,astheyarehighlytechnical.OtherstakeholdersmayrefertotheguidelinesforanyotherpurposeotherthantodirectlyimplementIMAM..Whilesomelocaladaptationsmaybemade,theseshouldbedoneincollaborationandwiththeconsentofMoH.TheMoHiscommittedtoensuringappropriateimplementationoftheseguidelines.
Dr.AchengJaneRuthDirectorGeneralofHealthServices
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA12 JANUARY 2016
acknowLedgements
TheMinistryofHealthwouldliketoverysincerelythankthefollowingorganisations:TheUnitedNations Children’s Fund (UNICEF), the World Health Organisation (WHO), the World FoodProgramme(WFP),theUnitedStatesAgencyforInternationalDevelopment(USAID),FamilyHealthInternational(FHI360-FoodandNutritionTechnicalAssistance(FANTAIII)Project,ActionAgainstHunger(ACF),MwanamugimuNutritionUnitMulagoHospital,MildMayUganda,BaylorUgandaandtheInternationalBabyFoodActionNetwork(IBFAN-Uganda).Theseprovidedthetechnicalandfinancial supportwhichwassoessential for thedevelopmentof the IntegratedManagementofAcuteMalnutrition(IMAM)guidelines.
Sincere gratitude is extended to all those on the list of contributors for their input throughouttheentireconsultativeprocess..SpecialrecognitiongoestoallthemembersoftheMaternalandChildHealthCluster,SeniorManagementCommittee,HealthPolicyAdvisoryCommitteeandTopManagementCommitteeoftheMinistryofHealthfortheirtechnicalinputinrefiningtheguidelines.
Finally,theMinistryofHealthwishestothankallstakeholdersnotmentionedbyname,whoinonewayoranother,eitherindividuallyorcollectively,contributedtotheproductionofthisrevisedandupdatedIMAMguidelines.
Listofcontributors
locAl consUltAnts
MwanamugimuNutritionUnit,MulagoNationalReferralandTeachingHospital
Dr.ElizabethKiboneka,Dr.EzekielMupereandJollyKamugisha
who technicAl eXperts
WHORegionalExperts Dr.FerimaZerbo,Dr.HanahBekele
MinistryofHealth DrJacentAsiimwe,Dr.K.Ssesanga,AgnesChandiaBaku,SarahNgalombi,SamalieNamukoseBananuka,AlbertLule,JosephOdyek,AgnesAntoniaKiro,LynetteKinconco,PerezKiryaIzizinga,MargieNagawa,EmmanuelAhimbisibwe,
WorldHealthOrganization(WHO) PriscillaRavonimanantsoa,Dr.FlorenceMTuryashemererwa
UnitedNationsChildren’sFund(UNICEF)
NellyBirungi,WilsonKirabira
WorldFoodProgramme(WFP) SiitiHalati,MartinAhimbisibwe,MaryNamanda
MakerereUniversityCollegeofHealthSciences
Dr.JulietAjok,JudithAgaba
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 13
who technicAl eXperts
MulagoNationalReferralHospital Dr.VictorMusiime,Dr.LanyeroBetty,SusanAwori,JollyNkayarwa,ScoviaBakesigaki,HanifaNamusoke
MildmayUganda GloriaKirungi
ActionAgainstHunger(ACF) EricSsebunya,
ConcernWorldwide HildaKawuki,JoyceNamitala,JosephMbabazi,MaryNnabagulanyi
WorldVisionUganda JoabTusaasire
BaylorUganda PatrickRichardOkoed
FortPortalRegionalReferralHospital
Dr.EuphrasiaKatutu
MbararaRegionalReferralHospital Dr.FrancisOriokot,NoelKansiime
KabaleRegionalReferralHospital AmosHashakaNdugutse
JinjaRegionalReferralHospital MansurToko
MorotoRegionalReferralHospital SimonOndoga
HoimaRegionalReferralHospital AlbertMugabi
SorotiRegionalReferralHospital ClementinaNyaketcho
AruaRegionalReferralHospital PatrickOyela
MbaleRegionalReferralHospital SirajeKijogo
SPRING KatherineOtim
Igangahospital AdoniaMaganda
Kitgumhospital MiltonPidoOcagiwu
Mityanahospital Kenneth
Apachospital AndrewSilasEwalu
Lacorhospital Dr.RichardNyeko
Kisorohospital MosesMutabazi
Tororohospital BenOkia
MoyoDistricthospital MoteKomaEdema
(FANTA/FHI360) Dr.HanifaBachou,KarenApophiaTumwiine,AhmedLuwangula
USAID/PIN BrianRwabwogo,AugustineKigonya
MSH-STRIDES TuryatembaLivingstone,
EGPAF/RHITES-SW EstherNaluguza
AVSI-SCORE JoanitaNSsebayiga
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA14 JANUARY 2016
acronyms and abbreviations AFASS Acceptable,feasible,affordable,sustainableandsafeAIDS AcquiredImmuno-DeficiencySyndromeANC Antenatal CareART AntiRetroviralTherapyBMI BodyMassIndexCBO CommunityBasedOrganizationCCP CriticalCarePathwayCHEWS CommunityHealthExtensionWorkersCHW CommunityHealthWorkerCMV CombinedMineralsandVitaminsCSB CornSoyaBlendDHO DistrictHealthOfficerDHT DistrictHealthTeamDNFP DistrictNutritionFocalPersonDOTS DirectlyObservedTreatmentsENR EmergencyNutritionResponseEPI ExpandedImmunisationProgrammeEPR EmergencyPreparednessandResponseF-100 Formula100F-75 Formula75FBF FortifiedBlendedFoodsGAM GlobalAcuteMalnutritionGFD GeneralFoodDistributionGFD GeneralFoodDistributionGMP GrowthandMonitoringProgrammeHb HeamoglobinHC HealthCentreHIV HumanImmuno-deficiencyVirusHMIS HealthManagementInformationSystemHSSP HealthSectorStrategicPlanHSQI HealthSectorQualityImprovementFrameworkID IdentificationNumberIEC InformationEducationandCommunicationIM IntramuscularIMAM IntegratedManagementofAcuteMalnutritionIMCI IntegratedManagementofChildhoodIllnessesINR IntegratedNutritionRegisterIPs ImplementingPartnersITC InpatientTherapeuticCare
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ITC InpatientTherapeuticCareIV IntravenousIYCF InfantYoungChildFeedingIYCF-E InfantYoungChildFeedinginEmergenciesLNS LipidbasedNutrientSupplementMAM ModerateAcuteMalnutritionMCH MaternalandChildHealthMoH MinistryofHealthMUAC MidUpperArmCircumferenceNGO Non-GovernmentalOrganisationNGT Naso-gastrictubeNMS NationalMedicalStoresOPD OutpatientDepartmentOTC Out-PatientTherapeuticCarePCP PneumocystscariniipneumoniaPMTCT PreventionofMother-to-childTransmissionQI QualityImprovementRCT RoutineCounsellingandTestingRNI RecommendedNutrientIntakeReSoMal RehydrationSolutionfortheMalnourishedRUTF ReadytoUseTherapeuticFoodSAM SevereAcuteMalnutritionSF SupplementaryFeedingSFC SupplementaryFeedingCentreSFP SupplementaryFeedingProgrammeSST SupplementalSucklingTechniqueTB TuberculosisTHR: TakeHomeRationsTWG TechnicalWorkingGroupUDHS UgandaDemographicHealthSurveyUNHCR UnitedNationsCommissionforRefugeesUNICEF UnitedNationsChildren’s’FundUTI UrinaryTractInfectionVHT VillageHealthTeamW/L WeightforlengthWFH WeightforheightWFP WorldFoodProgrammeWHO WorldHealthOrganisationYCC YoungChildClinic
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gLossary of terms
term deFinition
Client Anyindividual,whetherchildoradultthatisunderanyformofmanagementforacutemalnutrition.Insomeinstancestheyarealsoreferredtoaspatients.
CommunityMobilisation
Communitymobilisationincludescommunityassessment,communitysensitizationandengagement,activecase-findingandreferral,andcasefollow-up.
Defaulted Clientisclassifiedasdefaulteronthethirdconsecutiveabsence(i.e.,threeweeksabsent)(forSupplementaryfeedingprogrammeistwoconsecutiveabsences)
Died PatientdieswhileinCare
DischargedCured Patientmeetsdischargecuredcriteria
Non-Cured Patientdoesnotreachdischargecriteriaafterfourmonths(16weeks)intreatment(medicalinvestigationpreviouslydone)
Oedema+/Grade1
++/Grade2
+++/Grade3
Thisisthereferencefortheclassificationofnutritionoedema.Thegradingof+/++/+++orGrade1,2,3classifiestheoedemarangingfrommoderatetosevere.
SachetsofRUTF ThequantitiesoftheReadytoUseTherapeuticFoodsareusuallymeasuredinsachets.Insomeotherinstances,ithasalsobeenmeasuredinpackets
Shock Adangerousconditionpresentingwithsevereweakness,lethargyorunconsciousness,coldextremitiesandafast,weakpulse
TheABCDconcept Usedforidentifyingseriousillnessorinjuryduringtriagei.e.airway,breathing,circulation/consciousnessanddehydration
Transferredtomoreintensivecare(i.e.fromOTCtoITC)
Patient’sconditionisdeteriorating(accordingtoactionprotocol)
Triage Thewordtriagemeanssorting.Triageisthesortingoutofpatientsintoprioritygroupsaccordingtotheirneedsandtheresourcesavailable
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CHAPTER ONEintroduction
1.0 OverviewofMalnutritioninUgandaMalnutritioncanbeeitherunder-nutritionorover-nutrition(obesity).Thisguidelinewillspecificallydealwithacutemalnutritionasaformofundernutrition.Undernutritionistheresultofdeficiencyofprotein,energy,mineralsaswellasvitaminsleadingtolossofbodyfatsandmuscletissues.ItisofamajorpublichealthconcerninUgandathataffectsbothchildrenandadults.Thestatisticsshowthat300,000children(5%nationally)areestimatedtobeacutelymalnourishedandnearly120,000(2%)ofthemhavesevereacutemalnutrition(UgandaDemographicHealthSurvey,2011).TheHIVpandemicinthecountryhasexacerbatedthesituationasmorethan15%ofacutelymalnourishedchildrenpresentingtoinpatientfacilitiesareHIV-positive.Malnutritionisadirectcauseof35-55%ofallchildhooddeaths(WHO,1999,SPHERE2004)andhencetheurgencytopreventandaddressthe problem. Severewasting in children under 5 years in particular is associatedwith a 9-foldincreasedoddsofmortalitycomparedtoahealthychild.
1.1 AcuteMalnutritionasaformofunder-nutritionUnder-nutrition
Under nutrition is categorised as either acute (recent) or chronic (long term). It is caused byinadequate intake or poor absorption of nutrients in the body. There are four forms of under-nutrition: acute malnutrition, stunting, underweight and micronutrient deficiencies. The fourformscanbecategorisedaseithermoderateorseveremalnutritionandcanappearisolatedorincombination,butmostoftenoverlapinoneclientorpopulation.
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Under-nutrition is identified through anthropometry (body measurements), clinical signs andbiochemicaltests.Thesemeasurementsarethencomparedtoareferencevaluecommonlyreferredtoasnutritionindices.
Nutritionindicatorsaretheclassificationofspecificmeasuresofnutritionindicesbasedoncut-offpoints.Theymeasuretheclinicaloccurrenceofunder-nutritionandareusedformakingajudgmentor assessment. There are four common nutrition anthropometric indicators : Mid Upper ArmCircumference(MUAC)whichisusedtoassesswasting,weight-for-height(WFH)whichisalsousedtoassesswasting,height-for-age(HFA)whichisusedtoassessstuntingandweight-for-age(WFA)whichisusedtoassessunderweight.
Acute Malnutrition
Acutemalnutritionisarapidonsetconditioncharacterisedbybilateralpittingoedemaorsuddenweightlosscausedbyadecreaseinfoodconsumptionand/orillness.
Note:Itisimportanttointerpretadultoedemawithcautionasitmaynotbenutritionaloedemabutduetosomeunderlyingmedicalcomplaints.
Therearetwoformsofacutemalnutrition:
• Severe acute malnutrition (SAM) which is characterised by the presence of bilateral pittingoedemaorseverewasting.ApatientwithSAMishighlyvulnerableandhasahighmortalityrisk.
• Moderate acute malnutrition (MAM) whichischaracterisedbymoderatewasting.
1.2 ComponentsofIntegratedManagementofAcuteMalnutrition(IMAM)IMAM is an approach to address acute malnutrition and focuses on the integration of themanagementofacutemalnutritionintotheon-goingroutinehealthservicesatalllevels.
InUganda IMAMhas four components:Community, SupplementaryFeedingProgrammes (SFP),Outpatient Therapeutic Care (OTC) and Inpatient Therapeutic Care (ITC) programmes. TheCommunityservicesinvolveearlyidentification,referral,andfollow-upoftheacutelymalnourishedatcommunitylevel.SFPmanagesandtreatsMAMinchildrenof6-59monthsandothervulnerablegroupsthatincludepregnantwomen,lactatingwomenwithinfantslessthan6months,thosewithspecialneedssuchastheelderly.OTCprovideshome-basedmanagementandrehabilitationofSAMpatientsaswellasMAMpatientswithHIV/TBwhohaveanappetiteandnomedicalcomplications.ITCisforthemanagementofSAMwithmedicalcomplications.
Goodcoordinationandcommunicationbetweencommunity,SFP,OTCandITCisessentialtoensurethatpatientsremaininthesystemduringthetreatmentprocessforacutemalnutrition(Figure1below).
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FigUre 1: coordinAtion And commUnicAtion between imAm components
To ITC if patient deteriorates
To OTC if client stabilises
COMMUNITY • Mobilisation• Screening and identification of malnourished (Active Case
finding)• Referral of malnourished• Nutrition and health education• Links with other support groups/organizations
Out Patient Therapeutic Care (OTC)
Inpatient Therapeutic Care (ITC)
To ITC if patient deteriorates (SAM with
complications)
Supplementary Feeding Programme (SFP)
To OTC if patient deteriorates (SAM with no complications)
To SFP if recovery
HIV TESTING
1.3 PrinciplesofIMAMThecoreoperatingprinciplesare:
• Maximum coverage and access: Thisaimstoachievethegreatestpossiblecoveragebymakingservicesaccessibletothehighestpossibleproportionofapopulationinneed.Itaimstoreachtheentireacutelymalnourishedpopulation.
• Timeliness: Thisaimstobegincase-findingandtreatmentbeforetheprevalenceofmalnutritionescalatesandadditionalmedicalcomplicationsoccur.
• Appropriate care: Provisionofsimple,effectiveoutpatientcareforclientswhocanbetreatedathomeandclinicalcareforthosewhoneedinpatienttreatment.
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• Care for as long as it is needed: Improvingaccesstotreatmentensuresthatclientscanstayintheprogrammeuntiltheyhaverecovered.
• Additionally,IMAMalsoneedstobeeffectiveandsustainable.Bybuildinglocalcapacityandintegratingtheprogrammewithinexistingstructuresandhealthservices,IMAMalsoaimstoensurethateffectivetreatmentremainsavailableforaslongasacutemalnutritionispresentwithinthepopulation.
1.4 PurposeoftheIMAMguidelinesTheIMAMguidelinesspecificallydealwiththeidentification,treatmentandmanagementofacutemalnutrition and are intended to be usedby health andnutrition care providersworking at allhealthcarelevelsinUganda.Theguidelinescanalsobeusedbytraininginstitutionstostandardisetreatmentofacutemalnutritionwithnewgraduates joiningthehealthforce.TheguidelineswillalsohelpNGOs involved innutritionrehabilitationduringemergencies toguideandstandardizetreatmentprotocolsestablishedbyMinistryofHealth.TheguidelinescomplementothernutritionmaterialsdevelopedbyMinistryofHealth.
TheIMAMguidelinesareaimedatcontributingtoimprovedstandardisedtreatment,monitoringandreporting.Theycanalsobeusedasamobilising tool foraddressingacutemalnutritionandstrengtheningcapacities.CompliancewiththeguidelinesshouldcontributetotheoverallreductionofchildmortalityinUganda.
Althoughtheguidelineswillfocusonchildrenunderfiveyears,someinformationspecifictoolderchildren,adolescentsandadults isalso included.There isnosufficientevidencebasedresearchonthetreatmentofadultacutemalnutritiontogointoelaboratedetail,butasevidencebecomesavailable,theguidelineswillbeupdated.
1.5 IntegratingIMAMintotheExistingHealthStructureofUgandaThedeliveryofhealthservices inUganda isbybothpublicandprivatehealth facilitieswith theGovernment of Uganda being the owner ofmost facilities. Public health services are deliveredthroughVHTs,HC IIs,HC IIIs,HC IVs,GeneralHospitals,RegionalReferralHospitalsandNationalReferralHospitals(Figure2).
Facilitiesup toHCIVhave inpatient,outpatientand theatre facilities.TheHC III isanoutpatientdepartment(OPD)facilitywithdeliveryandinpatientfacilitieswhileHCIIisadaycarefacility.AtthevillagelevelaretheVillageHealthTeams(VHT)thatarethelinkbetweenthecommunityandthehealthstructure.
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FigUre 2: eXisting heAlth strUctUre in UgAndA
Hospital(National/ regional/ General
Health Centre IV (Sub district)
Health Centre III (In- /out- patient facility, 24hr care)
Health Centre II (Day care /outpatient)
Health Centre I (Village Health Team)
Initially,management of acutemalnutrition has been hospital-basedwith treatment integratedwithin the paediatric ward or within a separate nutrition rehabilitation unit affiliated to thepaediatricward.Thishasbeendonewithminimal communitymobilisationand/or involvement.The IMAM approach aims at broadening the scope of currentmanagement and decentralisingmanagementofacutemalnutritiontolowerlevels(HCIIIandHCII levels)dependingoncapacitywithintheindividualfacility.ThiswillbecombinedwithlinkingwiththeVHTsandothercommunity-levelfiguresaswellaspreventativeprogrammes.
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CHAPTER TWO community invoLvement
2.0 IntroductionCommunityacutemalnutritionservicesareacriticalcomponentoftheIntegratedManagementofAcuteMalnutrition(IMAM).Theseservicesshouldbeintegratedintoon-goingcommunityservices.ThecountryisimplementingacomprehensiveVillageHealthTeam(VHT)strategywhichtheIMAMapproachbuildsupon.TheVHTstrategyrequiresthateveryvillagehasVHTmemberswhoworktogethertomobilisecommunitiesforbetterhealth.ThesuccessoftheIMAMdependsonstrongcommunitymobilizationandinvolvementtomaximiseaccessandcoverageofhealthservices.
Community mobilization is defined as a capacity building process through which individuals,groupsororganizationsplan,carryoutandevaluateactivitiesonaparticipatoryandsustainedbasisto improve their health andother needs, either on their own initiativeor stimulatedbyothers(GrabmanH.andSnetro,2004)
Community involvement isdefinedastheactiveparticipationofpeople livingtogether insomeformofsocialorganizationandcohesionintheplanning,operationandcontrolofprimaryhealthcare,usinglocal,nationalandotherresources.Incommunityinvolvement,individualsandfamiliesassume responsibility for their communities’ health and welfare, and develop the capacity tocontributetotheirowncommunities’development(WHO,2004).ThevarioussectorsincommunityinvolvementwillincludebutnotlimitedtoministriesofHealth(MoH),Agriculture,AnimalIndustryand Fisheries (MAAIF), Gender, Labour and Social Development (MoGLSD) and Education andSports(MoES).Thiswillinvolvethestafffromthevarioussectorswhoworkatcommunitylevelse.g.VillageHealthTeams,agricultureextensionworkers,communitydevelopmentworkersandothercommunityresourcepersons.
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ThemainaimsofcommunityservicesforIMAMinclude:
• EmpoweringthecommunitybyincreasingknowledgeonacutemalnutritionandIMAM
• Increasingcommunitymobilizationforaccessandserviceuptake(coverage)ofIMAM
• Strengtheningearlycase-findingandreferralofnewacutecases,andfollow-up
• Providinghealth,nutritioneducationandcounselling
2.1 StepsincommunityMobilisationandInvolvementThesummaryofthestepsincommunitymobilisationandinvolvementinIMAMarepresentedinFigure3below.
FigUre 3: steps in commUnity mobilisAtion And involvement
STEP 1: Community Assessment
Theassessmentiskeyindeterminingthefactorsthatarelikelytoimpactonbothservicedeliveryanddemandforservices.Incommunityassessment,thefollowingneedtobeidentified:
• The key community persons, leaders and other influential people and organisations to helpsensitisethecommunitiesonthecomponentsoftheIMAMprogramme;
• Existingstructuresandcommunitybasedorganisations/groups
• Socialandculturalcharacteristicsrelatedtonutrition.
• Formalandinformalchannelsofcommunicationthatareknowntobeeffective
• Attitudesandhealthseekingbehaviours
• Otherexistingnutritionandhealthinterventionsinthecommunity
Theassessmentisconductedbydistricthealthworkers(communityhealthnurse,VHTandmembersofthedistricthealthteam(DHT).
Ongoing Community sensitization and mobilization
Links with other Community Initiatives
Community assessment
Developing messages
Community sensitization
Community training Implementation
On-going monitoring and
supervision
Recording and Reporting
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STEP 2: Developing messages and materials
• Develop sensitisationmessages for handbills or pamphlets, local radio as well as television.Meetingswith the community and religious leaders provide essential information about theIMAMServiceaims,methodsandactors.(Table19canprovideguidanceonthemessages).
• Develop a sensitisation plan detailing who and how to sensitise, based on the informationgatheredduringcommunitycapacityassessment.Reviewmessagewithinfluentialpersonsinthecommunitytocheckifitisculturallyappropriatebeforedisseminatingit.
STEP 3: Community Sensitization
• Engagethecommunityandotherpartnerswithcommunity-basedprogrammestodiscusstheproblemofmalnutrition,causesandpossiblesolutions.
• IntroduceandnegotiateontheadoptionofIMAMasanapproachtothemanagementofacutemalnutritionintheircommunities.
• Agreeonwhatneedstobedone;therelevantgroups,organisationsandstructurestobeinvolvedinIMAM;anddiscussclearrolesaswellasresponsibilities.
• Once services for the management of SAM have started, continue the dialogue to addressconcerns,maintainchangesinbehaviourandsharesuccessstories.
STEP 4: Community Training
• TheDHTshavearesponsibilitytoensurethattheidentifiedcommunityvolunteersaretrainedon identification,referralandhowtodisseminatemessageseffectively.RefertotheavailabletrainingpackagessuchasVHTTrainingPackage.
STEP 5: ImplementationCase-Finding and Referral
• Activecase-findingisimportanttoensurethatclientswithSAMareidentifiedearlybeforethedevelopment of severemedical complications. Identified clients are referred to the nearesthealthfacilityforfurtherassessmentandappropriatemanagement.
Theidentifiedcommunityhealthproviderswill:
• Screen for acute malnutrition at various contact points (house to house visits, communitymeetings, health facilities/outreachprogrammes, and at other opportunities) using theMid-upperarmcircumference(MUAC)andpittingoedema,forallclientgroups.
• Identifyandrefermalnourishedclientsappropriately.
Follow-up of Patients with Acute Malnutrition Patientswithacutemalnutritionontreatmentrequirefollow-upastheyareatanincreasedriskofdiseaseanddeath.Theyshouldbemonitoredtoensuresustainedimprovementintheircondition.
Followupshouldensureeffectivelinkagebetweenthecommunityandhealthfacilities.Itshouldentailthefollowing:
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• Conducting home visits of malnourished clients for follow up as determined by the healthprovider
• Followinguponabsentordefaultingpatients
• Givingfeedbacktohealthproviders
• Linkingclients/patientstolivelihood/safetynetprogrammesavailableinthecommunity
STEP 6: On-going Community Sensitisation and Supervision
• This mainly involves constant dialogue, in which the communities periodically voice theirviews and suggest alternative coursesof action. This entails regularmeetings (monthly and/orquarterly)withkeycommunityrepresentatives,healthstafffromthenearesthealthfacility,beneficiariesandotherpartnerstodiscussdifferentaspectsoftheprogrammesuchas:
o Reviewingtheselectionandmotivationofvolunteers;
o Thecommunity’sperspectiveoftheprogrammewhichmayincludeidentifyingnewbarrierstoaccess;and
o Jointsolutionstoproblemslimitingtheimpactoftheprogramme.Thispromotescommunityownershipofprogrammedevelopmentandimplementation.
STEP 8: Recording and Reporting
• One of the key responsibilities of the VHTmembers is tomaintain records of screened andreferredcommunitymembers;thehealtheducationsessionsconducted;aswellastheanalysisandsubmissiontohealthfacilities.
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Contact points at health facility level:
• Immunisationcentres
• YoungChildclinics(YCC)
• HIV/AIDS/TB,cancer,
• MotherBabyCarePoint/AntenatalCare(ANC)andpostnatalclinics.
• Outpatientdepartments
• Inpatientclinicsorwards
• Othercareandsupportclinics
CHAPTER THREE nutrition assessment and
cLassification of acute maLnutrition
3.0 IntroductionForearlydetectionandmanagementofacutemalnutrition,nutritionassessmentshouldbedoneatallcontactpointsandspecialattentiontocommunitieswithhighriskofmalnutritionincludingpregnantandlactatingmothers,children,HIV/AIDS,TB,cancer,andotherchronicconditions.
3.1 Wheretheassessment/screeningshouldbedoneAcutemalnutritioncanbeidentifiedthroughnutritionalscreeningand/orassessmentatdifferentcontactpoints.
Contact points at community level:• Day-to-dayorhouse-to-house
• Duringmasscampaigndays
• IntegratedChildhealthdays
• Integratedoutreaches
• Schoolsandcommunityprogrammesandothers.
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TheMidUpperarmCircumference(MUAC) measurement andWeight-for-Height(WFH) indexareusedtoassesswasting,aclinicalmanifestationofacutemalnutrition,reflectingtheclient’scurrentnutritionalstatus.MUACinvolvesmeasuringthecircumferenceoftheclient’sleftmid-upperarm.MUACisabetterindicatorofmortalityriskassociatedwithacutemalnutritionthanWFHz-score(WorldHealthOrganisation[WHO]standards).MUACassessmentisusedforchildrenolderthan6monthsofage,pregnantandlactatingwomen(6monthspostpartum)andadultswhocannotstand.
ThewFh indexshowshowachild’sweightcomparestotheweightofachildofthesameheightandsexintheWHOstandards.AWFHstandarddeviationbelow-2z-score
ofthemedian(WFH<-2z-score)oftheWHOstandardsindicateswasting.
TheBody Mass Indexisusedasameasureofacutemalnutritionforadults(18yearsandabove)whoarenotpregnantorlactating(6monthspostpartum).Forpregnantandlactatingwomen(andotheradultswhocannotstand)MUACisused.
Bilateral pitting oedemaisaclinicalmanifestationofacutemalnutritioncausedbyanabnormalinfiltrationandexcessaccumulationofserousfluidinconnectivetissueorinaserouscavity.Bilateralpittingoedema(alsocalledkwashiorkor)isverifiedwhenthumbpressureappliedontopofbothfeetforthreesecondsleavesapit(indentation)inthefootafterthethumbislifted.
Measurements for acute malnutrition
boX A
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3.2 NutritionAssessmentNutritional assessment is a comprehensive evaluation to determine the nutrition status of anindividual.Thiscanbedonethroughtakinganthropometryaswellastakingmedicalanddietaryhistory;performingclinicalexamination,and laboratorytests. Itshouldbedonebyaskilledandknowledgeableworkerinnutrition.
Anthropometry
This refers to thephysicalmeasurementofbodyparts in comparison to reference standards. Itincludesbutnotlimitedtothefollowingmeasurements:
• Mid-Upper-ArmCircumference(MUAC)incm;
• Body WeightinKgandroundingofftothenearest0.1kg(100g);
• Length (forchildrenbelow2yearsorlessthan87.0cm)or height (forchildrenabove2years, or 87.0 cm or more, adolescentsandadults)in cmroundingofftothenearest0.1cm;
Steps in anthropometryConduct Triage(seeannex2)tofasttrackseriouslyillpatients.
Triageisthesortingoutofpatientsintoprioritygroupsaccordingtotheirneedsandtheresourcesavailable.
Determine ageDeterminethepatient’sagefromrecordssuchastheChildHealthCard/MotherChildPassportorrecallbythemother/caregiver.
Measure MUAC • Ruleoutbilateralpittingoedema
• MeasuretheMidUpperArmCircumferenceonthelessactivearm(commonlyleftarmoftheclient).Tolocatethecorrectpointformeasurement,flextheclient’selbowto900.
• Locatethetipoftheshoulder(acromion)andelbow(olecranon)ontheleftflexedarmasshowninFigure5.
• Determinethemid-pointbetweenthetipoftheshoulderandtheelbow
• PlacetheMUACtapearoundthemiddleoftheleftupperarm(thearmshouldbehangingdownthesideofthebodyandrelaxed).
• ReadthemeasurementfromthewindowoftheMUACtapewithouttighteningorlooseningit.
• RecordtheMUACtothenearest0.1cmandthecolourcode(Green,Yellow,Red).
• Repeatthemeasurementtoensureaccuracy
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FigUre 4: meAsUring mUAc
Measure weight
• MakesuretheweighingscaleiscalibratedtoZerobeforeeachmeasurementistaken.
• Clientsshouldbeweighedwithminimumofclothingandnojewellery.
• Theweightreadingshouldbedoneassoonastheindicatoronthescalehasstabilised.
• Weightisrecordedtothenearest0.1kg(100g).
Note: Weighing scales should be standardised after every 100 measurements using a known weight.
FigUre 5: meAsUring weight in diFFerent circUmstAnces
Figure 5c: weighing a child who cannot stand Figure 5a: weighing a child up
to 25kg
Figure 5b: Weighing a child who can stand
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Measure Length/Height
• Childrenwhoareshorterthan87.0cm(orlessthan2years)aremeasuredwhilelyingdown;tallerchildren(equaltoormorethan87.0cmorolderthan2years)aremeasuredwhilestanding.
• Makesurethechildisbarefootandhasnoheadgear
• Makesureshoulderblades,buttocksandheelstouchthesurfaceofthelength/heightboard;kneesshouldbefullystraightandarmsstretchedonthesides;andneckshouldbestraightwitheyeslookingstraightaheadwiththeheadpiece/footpieceplacedfirmlyinposition.
• Themeasurementisreadtothenearest0.1cm.
Note: If a child is less than 2 years old will not lie down for a measurement of length, measure the standing height and add 0.7 cm to convert it into length. If the child aged 2 years and older cannot stand measure the recumbent length and subtract 0.7 cm to convert it to height
FigUre 6A: meAsUring length
FigUre 6b: meAsUring height
How to take length of children < 87cm
How to take height of children > 87cm standing
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Take Medical and dietary history
• Obtainpatientinformationincludingage,sexandpossiblerecentalterationinbodyweight
• Checkthepatient’s/clienthealthrecordandaskthecaregiveraboutanymajorhealthissueswhichcanhavenutritionalimplications
• Askaboutfeedingpractices.
Perform Clinical Examination
Thisentailsboththegeneralaswellasthesystemicevaluationofthepatient,fromheadtotoe,withemphasisonsignsofvisibleseverewasting,bilateralpittingoedema(Figure7),andmedicalcomplications(hypothermia,hypoglycaemia,cornealulcerations,verysevereanaemia,dermatosis,heartfailure,dehydration/shock,severeinfections,shockandIMCIdangersigns).
FigUre 7: children with clinicAl signs oF severe AcUte mAlnUtrition
Bilateral pitting oedema
Oedemaisswellingfromexcessfluidinthetissuesandcanbeseeninthefeet,lowerlegsandarms.Inseverecasesitisgeneralized.Oedemacausedbyacutemalnutritionoftenpresentswithspecialcharacteristics:
• Itisbilateralpitting(leavesadepressiononpressureappliedforatleast3-5seconds)
• Doesnotchangewithtimeofthedayorposture
Note: If the swelling is only in one foot, it may just be a sore or infected foot
Oedemaiscommonlygradedasshowninthetable1below:
b: child with bilateral pitting oedemaa: child with visible signs of severe wasting
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tAble 1: grAding oF bilAterAl pitting oedemA
observAtion grAde
Nooedema (0)
Bilateralpittingoedemainbothfeet(belowtheankles) +/(Grade1)mild
Bilateralpittingoedemainbothfeetandlegs,(belowtheknees)handsorlowerarms
++/(Grade2)moderate
Bilateralpittingoedemaobservedonbothfeet,legs,arms,face +++/(Grade3)severe
Note: It is important to interpret oedema with caution as it may be a sign of underlying medical condition (e.g. nephritic syndrome, severe anaemia, high blood pressure, other renal or heart conditions) or physiological changes such as in pregnancy. A clinician should take detailed history, physical examination and where possible biochemical tests
Dermatosis
Dermatosisoftheskiniscommonamongchildrenwithoedema.Dermatosiscanbecategorizedas:
• +Mild:discolorationorafewroughpatchesofskin
• ++moderate:multiplepatchesonarmsand/orlegs
• +++severe:flakingskin,rawskin,fissures(openingsintheskin)
Eye signs
Childrenwithseveremalnutritionmayhavesignsofeyeinfectionand/orvitaminAdeficiency.
• Bitot’s spots –superficialfoamywhitespotsontheconjunctiva(whitepartoftheeye).TheseareassociatedwithvitaminAdeficiency.
• Pus and inflammation (redness)aresignsofeyeinfection.
• Corneal clouding is seenasanopaqueappearanceof thecornea (the transparent layer thatcoversthepupilandiris).ItisasignofvitaminAdeficiency.
• Corneal ulceration isabreakinthesurfaceofthecornea.ItisasignofseverevitaminAdeficiency.
3.3 ClassificationofacutemalnutritionAcutemalnutritioniscategorizedasmoderateorsevere.Itcanbeclassifiedusingcutoffs,z-scoresand/orbilateralpittingoedema(Table2below)
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tAble 2: sUmmAry oF clAssiFicAtion oF AcUte mAlnUtrition
Age cAtegory
nUtritionAl indicAtor
moderAte AcUte MALNUTRITION (MAM)
severe AcUte MALNUTRITION (SAM)
Infantslessthansixmonths
WeightforLength(WFL)
Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)
Lessthan-3z-score(<-3SD)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema
Childrenfrom6to59months
WeightforLength/Height(WFL/H)
Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)
Lessthan-3z-score(<-3SD)
MUACcutoff Greaterorequalto11.5cmandlessthan12.5cm(≥11.5cm&<12.5cm)
Lessthan11.5cm(<11.5cm)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema
*Childrenandadolescentsfrom5yearsto19years
BMIforage Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)
Lessthan-3z-score(<-3SD)
MUACcutoff 5tolessthan10yearsGreaterorequalto13.5cmandlessthan14.5cm(≥13.5cm&<14.5cm)
Lessthan13.5cm(<13.5cm)
10tolessthan15yearsGreaterorequalto16.0cmandlessthan18.5cm(≥16.0cm&<18.5cm)
Lessthan16.0cm(<16.0cm)
15tolessthan18yearsGreaterorequalto18.5cmandlessthan21.0cm(≥18.5cm&<21.0cm)
Lessthan18.5cm(<18.5cm)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema
*Adults BMI Greaterorequalto16andlessthan17kg/m2(≥16and<17kg/m2)
Lessthan16kg/m2 (<16kg/m2)
MUACcutoff Greaterorequalto19.0cmandlessthan22.0cm(≥19.0cm&<22.0cm)
Lessthan19.0cm(<19.0cm)
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 39
Age cAtegory
nUtritionAl indicAtor
moderAte AcUte MALNUTRITION (MAM)
severe AcUte MALNUTRITION (SAM)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutmedicalcauses)
*Pregnantwomenandlactatingmotherswithinfantlessthan6months
MUACcutoff Greaterorequalto19.0cmandlessthan22.0cm(≥19.0cm&<23.0cm)
Lessthan19.0cm(<19.0cm)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutphysiological/medicalcauses)
*Elderly60yearsandabove
MUACcutoff Greaterorequalto16.0cmandlessthanorequal18.5cm(≥16.0cm&≤18.5cm)
Lessthan16.0cm(<16.0cm)
Bilateralpittingoedema
Nobilateralpittingoedema Presenceofbilateralpit-tingoedema(ruleoutphysiological/medicalcauses)
*Sphere 2011
SAM can be uncomplicated or complicated. Uncomplicated SAM is for children 6months and above, adolescents and adults who have no medical complications.AppetitetestisessentialandshouldbeperformedforSAMpatientswithoutmedicalcomplications because anorexia or poor appetite is considered to reflect severedisturbanceofmetabolism.ThetestwilldifferentiatecomplicatedfromuncomplicatedSAMforpatientshavingSAMwithoutmedicalcomplications(refertochapterfive-OTCfordetails).
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA40 JANUARY 2016
FigUre 8: sUmmAry oF the nUtrition Assessment And clAssiFicAtion oF AcUte mAlnUtrition Algorithm
nutrition assessment
§ Check for bilateral pitting oedema
§ Measure MUAC,
§ Measure weight and length/height and for children interpret the growth curve.
§ Determine the WFH for children less than 5 years
§ Determine the BMI for age for children 5 to19 years
§ Determine the BMI for adults
§ Assess for medical complications
Moderate acute malnutrition (MaM)
No bilateral pitting oedema
WFL/H/BMI- for- age ≥ –3 and < –2 z-score
Adults: BMI ≥16 & <17
Or
MUAC
6 to 59 months: ≥ 11.5–< 12.5 cm
5 to <10 years: ≥ 13.5–< 14.5 cm
10 to < 15 years: ≥ 16.0–< 18.5 cm
15 to <18 years: ≥ 18.5 & < 21.0 cm
Adults 18years and above: ≥19 - < 22.0 cm
Pregnant/Lactating women: ≥19 - < 23.0 cm
Elderly 60 years and above: ≥ 16.0cm - ≤ 18.5cm
Severe acute malnutrition (SaM)
Bilateral pitting oedema (any grade)
Or
WFL/H/BMI for age < –3 z-scores (see annex 3)
Adults: BM I <16
Or
MUAC
6 to59 months: < 11.5 cm
5 to <10years: < 13.5 cm
10 to <15 years: < 16.0 cm
15to <18 years: < 18.5 cm
Adults 18years and above: <19.0 cm
Pregnant/Lactating women: <19.0 cm
Elderly 60 years and above: < 16.0cm
SAM with medical complications
OR bilateral oedema +++ OR infant less than 6 months (manage in ITC).
SAM with no medical complication
Passes appetite test on RUTF, (manage in OTC)
For all MAM manage in SFP
aSSESSMEnT CLaSSIFICaTIOnCLaSSIFICaTIOn anD
aCTIOn PLan
Encourage and counsel on good nutrition
no acute Malnutrition
Weight gain parallel to or greater than the median growth curve
WFL/H ≥ –2 z-scores
OR MUAC
6-59 months: ≥ 12.5 cm
5 to <10 years: ≥ 14.5 cm
10 to <15 years: ≥ 18.5 cm
15 to <18 years: ≥21.0 cm
Adults 18 years and above: > 22.0 cm
Pregnant/Lactating: women: ≥ 23.0 cm
Follow up every 1- 2
weeks.
Follow up every 1-2
weeks.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 41
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA42 JANUARY 2016
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 43
CHAPTER FOUR suPPLementary feeding
Programme for management of moderate acute maLnutrition
4.0 IntroductionSupplementary Feeding (SF) is the provision of nutritious food in addition to the regularmealstoclientswithoratriskof moderateacutemalnutrition(MAM) inspecifiedgroups(particularlyyoungchildren,pregnantwomen,breastfeedingmothersandtheelderly)andforaspecifiedperiodoftime. Supplementary FeedingProgram (SFP) involves theprovisionof nutritious food aswellasotherservices(routinemedication,nutritionandhealtheducation,HIVcounsellingandtestingamongothers).SFPpreventsdeteriorationofpatientswithMAMtoSAM,providesacontinuumofcaretopatientsdischargedfromInpatientTherapeuticCare(ITC)andOutpatientTherapeuticCare(OTC).SFPisparticularlyimportantinemergencysituations.
Therearetwomechanismsthroughwhichfoodmaybeprovided:
GeneralFoodDistribution(GFD)orSelectiveFeedingProgrammes(SFPs)
• TheGeneralfoodrationsinpractice,rarelyprovidesufficientfoodtoallowforcatch-upweightgainforthosealreadymalnourished
• SFPsarethereforea“safetynet”forthosewhosefamiliescannotcopeandarenotsustainedbythegeneralration
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TherearetwotypesofSFP:blanketandtargetedsupplementaryfeeding.
blanket sFpaimsatprovidingsupplementaryfoodrationtoallmembersofaspecifiedatriskgroupforadefinedperiodregardlessoftheirnutritionalstatus.Blanketsupplementaryfeedingisprovidedwhentheprevalenceofacutemalnutritionishigh(GAMrate>15%withthepresenceofaggravatingfactors)andgeneralfooddistributionisinadequate.Itaimsatpreventingfurtherdeteriorationofthegroups’nutritionalstatusandreducesMAM.
Targeted SFP provides nutritional support to individuals of MAM. It generally targets childrenunderfiveyears,malnourishedpregnantandbreastfeedingmothers,andothernutritionallyatriskindividuals.ItaimsattreatmentofMAM.
SFPmaybeimplementedthrougha largenumberofdecentralizedsites.ThesearelocatedatornearthesitesforOTC,andshouldbewithinaday’swalk(roundtrip)forthebeneficiary.ThishelpsfacilitatereferralsbetweenSFPandOTC.SFPshouldhavestronghealth/nutritioncounsellingandeducationactivitiesaswellaslinkagestolivelihoodprogrammes(refertoChapterNine)
Supplementaryfoodcanbedistributedaswetrationsason-sitefeedingordryrationsastakehome.
AdmissionCriteriaintoSFP(seeTable3)
PatientswhomeetthefollowingcriteriashouldbeadmittedtoSFP(Table3)
tAble 3: Admission criteriA to sFp
Age cAtegory nUtritionAl indicAtor Admission criteriA
Childrenfrom6to59months
WeightforLength/Height(WFL/H)
Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)
MUACcutoff Greaterorequalto11.5cmandlessthan12.5cm(≥11.5cm&<12.5cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Childrenandadolescentsfrom5yearsto19years
BMIforage Greaterorequalto-3z-scoreandlessthan-2z-score(≥-3SD&<-2SD)
MUACcutoff 5 to less than 10 yearsGreaterorequalto13.5cmandlessthan14.5cm(≥13.5cm&<14.5cm)
10 to less than 15 yearsGreaterorequalto16.0cmandlessthan18.5cm(≥16.0cm&<18.5cm)
15 to less than 18 years Greaterorequalto18.5cmandlessthan21.0cm(≥18.5cm&<21.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Adults BMI Greaterorequalto16andlessthan17kg/m2(≥16and<17kg/m2)
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 45
Age cAtegory nUtritionAl indicAtor Admission criteriA
MUACcutoff Greaterorequalto19.0cmandlessthan22.0cm(≥19.0cm&<22.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Pregnantwomenandlactatingmotherswithinfantlessthan6months
MUACcutoff Greaterorequalto19.0cmandlessthan23.0cm(≥19.0cm&<23.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Elderly60yearsandabove
MUACcutoff Greaterorequalto16.0cmandlessthanorequal18.5cm(≥16.0cm&≤18.5cm)
Bilateralpittingoedema Nobilateralpittingoedema
Admission Process in SFP
ThefollowingstepsareimportantduringtheadmissionforSupplementaryfeedingservices.
FigUre 9: steps And Flow oF Activities At An sF site
EXIT
rCT
ENTRy
aWaITInG arEa
TriageHealth and nutrition
education
BanTHrOPOMETrIC
arEa
CCLInICaL
aSSESSMEnT
DrEGISTraTIOn
POInT
E DruG DISPEnSInG
arEa
FFOOD DISTrIBuTIOn arEa
Food distributionHealth and Nutrition Education
raTIOn PrEParaTIOn arEa
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA46 JANUARY 2016
STEP 1: Triage ( see annex 2) and Nutrition/Health Education
• Conduct triage to fast-track seriously illpatients(seeAnnex1fordetails )
• Identify referred patients from thecommunity,ITC,orSFP.
• Give sugar water solution (1 roundedteaspoon of glucose/sugar in 50 ml water=3 tablespoonsof sugarwater)ororal10%dextrose (Refer to ITC on how it can bereconstituted) to any patients with SAMsuspectedtobeatriskofhypoglycaemiaandreferimmediatelytoITC
• Conduct health and nutrition education tocaregivers/orpatientsnotseriouslyill.
STEP 2: AnthropometrySTEP 3: Clinical assessmentNote: Steps 2 and 3 will follow the same procedure as described in chapter three.
Assessallpatients(newandfollow-up)attendingOTC. Inaddition,theclinicianshould:
• Review the previous treatment for patientsreferred/transferred from other clinics toavoid overdose of routine medicines (seesectionontreatmentprotocol)
• Ensurethattheycontinuewiththetreatmentstartedonearlier
• Patients on treatment for HIV/AIDS, TBshouldbecounselledtocontinuewiththeirmedication.
• Those diagnosed after admission toSFP should be referred to appropriateprogramme/health facility for treatment,careandsupport.
step4: Explain to the patient that he/she ismoderately acutely malnourished. Explainhow the SFP intervention functions andwhenthepatientshouldreturntothehealthcentre.ExplainwhythepatientisbeingadmittedintheSFPandwhenhe/shewillexittheprogramme.
Preparation of ReSoMal from standard ORS:• Water-2litres
• WHO-ORSone-1litrepacket
• Sugar-50g
• 40mlMineralmixsolution*orCombinedmineralsandVitamins (CMV) (20mls-1redscoopmixedin18mlsofboied,colledsafewater)
*Themineralmixsolutionmaybepreparedbythehospitalpharmacy.
Alternatively, a commercial product, calledCombined Mineral Mix (CMV), maybeused.
boX b
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 47
step 5: Registerpatient informationintheIntegratedNutritionRegister(INR)refertoAnnex......(IntegratedNutritionRegister).
step 6:Fillouttheintegratednutritionrationcard.(Annex18)
step 7:Dispenseroutinemedicationsasshownintable6
step 8:Conducthealthandnutritioneducationanddispensefoodration,includingdemonstrationoffoodsupplementpreparationifrequiredandgivereturndate.
Step 9: Linkpatienttoanyexistinglivelihoodprogrammeswithinthecommunity
step 10:Compile,summariseandsubmitreports
Supplementary Foods and Ration SizeSupplementaryfoodsmustbeenergydense,highinproteinandrichinmiconutrients,culturallyappropriate,easilydigestibleandpalatable.
Readytousesupplementaryfoodsusuallyprovide500kcalperpersonperdayonassumptionthattheydonotshareandareinsmallquantities.
Thesupplementarydryrationshouldprovidefrom1,000-1,200kcalperpersonperdayand35–45gramsofproteininordertoaccountforsharingathome.Itshouldbedesignedtoprovide10-13%ofthetotalenergyfromproteinand30-40%totalenergyfromfat.Wetrationshouldprovide500-700Kcaland15-25gramsofprotein.2
Theserationsmaybegivenonaweeklytomonthlybasisdependingonthesupplementaryfoodtype,programdesignandcontext.
Therearespecializednutritiousfoodsthatcanbeusedforthedifferenttargetgroups.Theseinclude:
• Fortifiedblendedfoods(Cornsoyblend(CSB),supercerealplusandsupercereal).
• Lipidbasednutrientsupplement(LNS)suchassupplementaryplumpy
Lipid Based Nutrient Supplement (LNS)
• Targetgroup:Children6-59months
• Keyingredientsinclude:Peanuts,sugar,whey,vegetableoil,milk,soyprotein,cocoa,vitaminsandminerals
• Nutrientprofile(92g)
o 500kcal,
o 13gprotein(10%),
o 31gfat(55%).
o Containsessentialfattyacids,
o Meets recommended nutrient intake (RNI) and protein digestibility corrected amino acidscore(PDCAAS)
2 WHO.Guideline:Updatesonthemanagementofsevereacutemalnutritionininfantsandchildren.Geneva:WorldHealthOrganization;2013.2UNHCR,guidelinesforselectivefeeding:UnitedNationsHighCommissionforRefugees
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JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 49
Fortified Blended Foods Super Cereal Plus
• Targetgroup:Children6-59months
• Keyingredientsinclude:Corn/wheat/rice,soya,milkpowder,sugar,oil,vitaminsandminerals
• Nutrientprofile(200g-includesprovisionforsharing)
o 787kcal,
o 33gprotein(17%),
o 20gfat(23%).
o Containsessentialfattyacids,
o Meets recommended nutrient intake (RNI) and protein digestibility corrected amino acidscore(PDCAAS)
Corn Soy Blend CSB/Super Cereal
• Targetgroup:PregnantandLactatingWomen,MalnourishedindividualsonART/DOTS
• Keyingredientsinclude:Corn/wheat/ricesoya,vitaminsandminerals
• Nutrientprofile(200-250g-includesprovisionforsharing)
o 752-939kcal,
o 31-38gprotein(16%),
o 16-20gfat(19%).
o Containsessentialfattyacids,
o Meets recommended nutrient intake (RNI) and protein digestibility corrected amino acidscore(PDCAAS)
tAble 4: sFp rAtions And their nUtrition vAlUe
TAkE-HOME RATIONS ON-SITE RATIONSExampleTHR1
ExampleTHR2
ExampleTHR3
ExampleOn-Site1
ExampleOn-Site2
ExampleOn-Site3
FBF(g) 250 200 125 100Soy-basedRUSF(g) 92*FortifiedBiscuits(g) 125FortifiedVegetableOil(g) 25 20 10 10Sugar(g) 20 15 10 10nUtritionAl vAlUesEnergy(Kcal) 1300 1000 500 573 630 530Protein(g) 45 36 13 18 23 18Fat(g) 40 32 33 21 17.5 16
THR: Take Home Rations Source: IMAM WFP-UNHCR-SFP guidelines, 2009
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Bothdryrations(takehome)andwetrations(on-sitefeeding)haveadvantagesanddisadvantagesasillustratedintable5below.
tAble 5: AdvAntAges And disAdvAntAges oF dry And wet rAtion
type oF rAtion
AdvAntAges disAdvAntAges
Dryration • Possibilityformotherstoparticipateinmealpreparation
• Nutritionandhealtheducationpossible
• Abletocheckchildrenandensuretheyeattheirmeal(Sharingtherationandmisuseoffoodislimited)
• Trainingpersonnelinfoodpreparationandhygieneisdone
• Bringingstaffandbeneficiariestogetherpossible
• Noguaranteethatthebeneficiarywilleatthewholeration
• Lackofmonitoringofuseoftherationinhomes
• Difficulttoholdhealtheducationsessionsandtohavecollectivedemonstrations
• Largeamountoffoodrequired
Wetration • Possibilityformotherstoparticipateinmealpreparation
• Nutritionandhealtheducationpossible
• Abletocheckchildrenandensuretheyeattheirmeal(Sharingtherationandmisuseoffoodislimited)
• Trainingpersonnelinfoodpreparationandhygieneisdone
• Bringingstaffandbeneficiariestogetherpossible
• DisruptionoffamilytasksduetodailypresenceatSFC
• Increasedriskoftransmissiblediseases
• Largestaffrequirement
• Largeconstructionneeds
• PossibilitythatfoodtakenattheSFCwillbeasubstituteforthatinthehome
Treatment protocols in SFP
Theseinclude:
• SupplementationwithvitaminAonadmission*(onlyiftheyhavecomedirectlytoSFPoriftheyhavenotreceivedanyVitaminAsupplementationinthelast30days).
• Treatmentofallchildrenforworminfestation(Deworming)
• Measlesvaccinationforallchildrenbetweenninemonthsandfifteenyearsofage
• Supplementation of iron and folic acid on admission. These should be administered amongpatientswithsignsofanaemiaandinpregnantwomen.(Refer to Table 6)
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tAble 6: roUtine medicAtions For pAtients in sFp
medicAtion when Age prescription dose
VitaminA* Onadmissionifnotreceivedintheprecedingmonth
6monthsto1year<6monthsnotbreastfed
100000IU
50000IU
Singledoseonadmission
>1yearofage 200000IU
Albendazole
OR
Onadmissionifnotreceivedinthepreceding6months
<1year Donotgive
1-2years>2years
200mg400mg
Singledoseonadmission
Mebendazole**(Givenonlyifalbendazoleisnotavailable)
Onadmission <1year Donotgive
1-2year>2years
250mg500mg
Singledoseonadmission
Iron:Giveonlywithsignsofanaemiaordiagnosedwithanaemia
OneachSFPvisit Children<10kg 30mg ½tabdaily
Children≥10kg 60mg 1tabdaily
FolicAcid Onadmission Children<1yearChildren>1year
2.5mg5mg
Singledosedaily
Measles****vaccination
OnadmissionifnorecordofreceivingPreviously
≥9monthsand<15years
Vaccine Once if not receivedthevaccinationyet
CotrimoxazoleHIV-positiveandexposedpatients(Antibioticcover for PCP prophylaxis)
Dailydosetocontinue
Dosedependantonbodyweight
DifferentstrengthsofCotrimoxazole(RefertoTable11
Oncedailybutcontinueindefinitelyasprophylaxis.
*Do not give if patient received within the previous 6 months. However it can be provided if the patient has eye signs of Vit A deficiency, has/had measles in the last 3 months3
** Dose can be given again after 3 months if signs of re-infection appear.
***Pregnant and lactating women should attend the Antenatal Care / Post-Natal Care for Iron/folic Acid supplementation
****Follow National immunization guidelines for measles vaccination
3
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Follow-Up of a Patient in SFP
ThefollowingshouldbedoneateachvisitoftheSFP
• Reviewtheregularityofattendanceanddiscusswithcaregiverthereasonsforanyabsence
• Anthropometry:Takeweight,height/lengthandMUACmeasurementstoassessprogress.StaticweightorweightlossmayrequirereferraltoOTCifadmissioncriteriaaremet.
• Doamedicalassessmentandreferfortreatmentifrequired.
• Conductgrouphealthandnutritioneducation.
• Assessthesupplyofthesupplementaryfood
• Assessthereadinessfordischargeaccordingtodischargecriteria
• Linkthepatienttofoodsecurityandlivelihoodprograms
Exit Criteria from SFP
ApatientcanexitfromSFPeitherasadischargeortransfer
Dischargesinclude:cured,defaulters,non-respondentsanddeaths.
tAble 7: types oF eXits From sFp
type oF eXits description
TransfertoOTC/ITC Staticweight for height orMUAC orweight loss for two consecutivevisits)and/ormedicalcomplications(i.e.notrespondingtotreatment)
Nonresponse For 3months* and have not reached the target weight for height orMUACwithoutaggravatingconditionslikemalaria,diarrhoea,etc
Defaulter Patientsmissingtwoconsecutivevisits
Dead Patientsdiedwhileontheprogramme
Cured AttainedWFHorBMI forAgeZ score>-2SD,BMI foradultsabove19years>18.5Kgm-2ornormalMUACcutofffortherespectiveagecategory.RefertoTable8forthecutoffsforthevariousagegroups.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 53
tAble 8: dischArge criteriA From sFp
Age cAtegory nUtritionAl indicAtor eXit criteriA
Childrenfrom6to59months
WeightforLength/Height(WFL/H)
Greaterorequalto-2z-score(≥-2SD)
MUACcutoff Greaterorequal12.5cm(≥12.5cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Childrenandadolescentsfrom5yearsto19years
BMIforage Greaterorequalto-2z-score(≥-2SD)
MUACcutoff 5tolessthan10yearsGreaterorequalto14.5cm(≥14.5cm)
10tolessthan15yearsGreaterorequalto18.5cm(≥18.5cm)
15tolessthan18yearsGreaterorequalto21.0cm(≥21.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Adults BMI Greaterorequalto17kg/m2(≥17kg/m2)
MUACcutoff Greaterorequalto22.0cm(≥22.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Pregnantwomenandlactatingmotherswithinfantlessthan6months
MUACcutoff Greaterorequalto23.0cm(≥23.0cm)
Bilateralpittingoedema Nobilateralpittingoedema
*Elderly60yearsandabove
MUACcutoff Greaterorequalto18.5cm(≥18.5cm)
Bilateralpittingoedema Nobilateralpittingoedema
*SPHERE2011
4.1 OpeningandClosingaSupplementaryFeedingProgramme
Opening a Supplementary Feeding Programme
AdecisionaboutwhethertoopenSFPsshouldtakeintoconsideration;malnutritionrates,contextualfactors,publichealthpriorities,availablehuman,materialandfinancialresourcesandtheobjectivesoftheimplementerasdetailedinTable9.Thedecision-makingframeworkneedstobeusedrelativetolocalcircumstances.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA54 JANUARY 2016
TABLE 9: DECISION-MAkINg FRAMEWORk FOR OPENINg A SUPPLEMENTARy FEEDINg progrAmme4
Finding Action reQUired
Malnutritionrate(GAM)≥15%or 10–14%plusaggravatingfactors
Serious situation:
• Generalrations(unlesssituationislimitedtovulnerablegroups)• Blanketsupplementaryfeedingforallmembersofvulnerable
groups,especiallychildren,pregnantandlactatingwomen• Therapeuticfeedingprogrammeforseverelymalnourished
individuals
Malnutritionrate(GAM)10–14%or 5–9%plusaggravatingfactors
Risky situation (alert):
• Nogeneralrations,but• TargetedSupplementaryfeedingforindividualsidentifiedas
malnourishedinvulnerablegroups• Therapeuticfeedingprogrammeforseverelymalnourished
individuals
Foodavailabilityathouseholdlevel<2100kcalperpersonperday
Unsatisfactory situation:
• Improvegeneralrationsuntillocalfoodavailabilityandaccesscanbemadeadequate
Malnutritionrate(GAM)under10%withnoaggravatingfactors
Acceptable situation:
• Noneedforpopulationinterventions• Attentiontomalnourishedindividualsthroughregular
communityservices
Aggravating factors can include:
• Worseningofthenutritionalsituation
• Foodavailabilityathouseholdlevellessthanthemeanenergyrequirementof2100kcal/person/day
• Thegeneralfooddistribution(GFD)isbelowmeanenergy,proteinandfatrequirements
• Crudemortalityratemorethan1per10000perday
• Epidemicofmeaslesorwhoopingcough
• Highprevalenceofrespiratoryordiarrhoealdiseases.
4.2 RequirementsandProcessforSettingUpaSupplementaryFeedingSiteTheSFPcanbeimplementedatasitewithinahealthfacilityorcommunity,providedthefollowingrequirementsareinplace:
• Trainedserviceproviders(refertoBoxC)
• Functionalanthropometricequipment
• Stockcontrolsystems
• MonitoringandReporting(M&R)tools
4 WHO(2000).TheManagementofNutritioninMajorEmergencies,Geneva:WHO
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• Information,EducationandCommunicationmaterialsandjobaidsforhealth/nutrition
• Continuoussupplyofsupplementaryfood
• Safeandsecureplaceforstoringenoughsupplementaryfoodtolastatleasttwomonths
• Routinemedications
When to Close a Supplementary Feeding Programme
Theclosure/exit strategy shouldbeplanned fromthebeginningof theprogramme.Steps takenandthefinaldecisionshouldalwaysbemadeinconsultationwithallstakeholders.Populationlevelassessmentofnutritionstatusshouldbepartofthedecisiontocloseaprogramme.
CriteriaforclosingblanketandtargetedSFPsaresummarizedinTable10
tAble10: gUidAnce on criteriA For closing sFps
blAnket sFp tArgeted sFps
• GeneralFoodDistribution(GFD)isadequateandismeetingplannedminimumnutritionalrequirements.TheGFDshouldalsohaveaspecificfoodthatmeetstheminimumnutritionalrequirementsforyoungchildren.
• Prevalenceofacutemalnutritionis<15%withoutaggravatingfactors.
• Prevalenceofacutemalnutritionis<10%withaggravatingfactors.
• Diseasecontrolmeasuresareeffective.
• GFDisadequate(meetingplannednutritionalrequirements).
• Prevalenceofacutemalnutritionis<10%withoutaggravatingfactors.
• Controlmeasuresforinfectiousdiseasesareeffective.
• Deteriorationinnutritionalsituationisnotanticipated,i.e.seasonaldeterioration.
Thedurationof ablanket SFPdependson the scale and severityof thedisaster, aswell as theeffectivenessoftheinitialresponse5.Attheendofthisperiodifthesituationisstillpoor,eitherblanketfeedingcouldbecontinuedortargetedfeedingcouldreplacetheprogrammetoensurethatthemostvulnerablearetreated.
Targeted SFP canbeclosedwhentheprogrammehaslessthan30beneficiariesandtheseshouldcompletetreatmentwhilethenewcasesshouldbereferredtootherservicessuchashealthcentresorhospitalsand/orlivelihoodprogrammes.Inunstableandinsecuresituationstheprogrammemaybemaintainedasa‘safetynet’.
Whenfeasibleandappropriate,agradualprocessofhandoverandintegrationintolocalprimaryhealth services, community health programmes like safe motherhood, HIV/ AIDS, PD Hearth,immunization,integratedmanagementofchildhoodillnesses(IMCI)shouldbeundertaken.
5 Initialplanningtimeframesgenerallyanticipateadurationof3monthsforablanketSFP.
NOTE• In a non emergency situation where there is no SFP, there should be routine nutrition and health
education, routine practical food demonstrations, routine medications, HIV counselling and testing and follow ups to prevent deterioration of MAM to SAM.
• Link to food security and livelihood programmes
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ThefollowingaretherequirementsthatshouldbeputintoconsiderationwhensettingupaSFP.(i) key Staff • In-chargeofthecentre• RecordsAssistant• Nurse/PublicHealthNurse• Nutritionist• DomesticAssistant• StoreKeeper• SocialWorker
• Supportstaff(Securityguardsandcleaners)(ii) Location
• Presenceofawatersource:Thewatersourceshouldbenearbyforhandwashing,cleaningequipmentandthewatershouldbesafefordrinking.
• Closetoahealthfacility:Thewalkingdistanceshouldbe2hoursorlessonfoot;
• Capacityofthesite:Thenumberofbeneficiariesshouldnotbetoolarge
(iii) Structure• Asuitableexistingstructure,preferablyata
healthfacilityor,existingstructuressuchasahouse,school,church,underatreeetc.Ifnoneoftheseisavailable,constructasimplefencedstructurebigenoughtocontainroomforregistration,andtakinganthropometric
measurements,1shelterforwaitingwherehealtheducationsessionscouldalsobeheldandadistributionroom
• Toiletorlatrineswithawatersourcenearbyforhandwashing
(iv) Equipment and basic supplies
Basic equipment:Weighingscalesforchildrenandadults,Heightboard,MUACtapes(childandadult),Calculator,furniture,sourceofheat,cookingequipment,mixingequipmentsuchasbowls,spoonsandladles.
Basic supplies/items: IntegratedNutritionRationcard,Referralforms,Dailyscreeningtools,IntegratedNutritionRegister(INR),stockcards,RegisterforGrowthPromotionMonitoring(atcommunityandhealthfacilitylevels),ListofOutpatientandinpatienttreatmentsites,EssentialmedicinesasrequiredintheroutinemedicalprotocolforSFP,Thermometer,Timewatch,Scissors,Foodrations,Hygieneandsanitationsupplies,Information,EducationandCommunicationmaterialsforhealth/nutritioneducation,dozingcharts,rationdistributionchartsandjobaids(WeightforHeightz-scoretables,BMIforagez-scoretables)
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(v). Storage facilities• Asolidstructurewithconcreteand
cementedfloor,wellventilatedandprotectedfromdampness,rodentsandpestsandsecurefromtheft
• Thestoragecapacityhastobesuitableforthequantitytobestoredi.e.1tonneoffoodstufftoabout2m³ofspace
• Thefacilitiesshouldbeeasilyaccessibletotrucksatalltimes
• Fooditemsshouldbestackedonpallets.
(vi). Determining quantity and frequency of delivery of suppliesThiswilldependon:
• Typeofsupplementaryrationtobegiven
• Numberofbeneficiaries
• Distancebetweenthecentralwarehouseandthesupplementaryfeedingcentre
• Availabilityofvehicle(s),fuelanddriver(s)
• Typeofvehicle(truck,pick-up);and
• Weatherandterrain
(vii). Security measures and procedures in place for transporting logistics and supplies.
1. Loadingthevehicleatthecentralwarehouse
• Thequantitiesnecessaryforeachcentreshouldbeestablishedinadvance,basedonthestockremaininginthecentreandtheestimatedneedsoftheperiod.
• Thestorekeepershouldrecordthequantityrequestedfor,signit,andsoshouldthedriverwhenthevehicleisloaded.Thisshouldalsoberecordedonthestockcardsforthecentralwarehouse
2. Destinationtothecentre
• Atrusteddriverandasaferouteshouldbeusedforthistaskinordertoavoidtheft
3. Deliverytothecentre
• Thefoodsdelivered(quantities,stateofthesacks,etc.)shouldbenotedinadeliverynoteandsignedbythedriverandthesupervisorofthecentre
• Thedeliverynoteshouldthenbecheckedbythesupervisoryteam,thencomparedwiththatofthewarehouse
• Thedeliverymustbedoneinthepresenceofthesupervisorofthecentre.
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CHAPTER FIVE outPatient theraPeutic care
for the management of acute maLnutrition with no medicaL
comPLications
5.0 IntroductionOutpatienttherapeuticcare(OTC)isaimedatprovidinghome-basedtreatmentandrehabilitationforSevereAcuteMalnutrition(SAM)patientswhohaveanappetiteandnomedicalcomplications.OTCalsoaimsattimelydetectionofacutemalnutrition,referral,andearlytreatmentbeforeonsetofmedicalcomplications.Follow-upoftheenrolledpatientsisalsoacrucialpartofmanagement.
OTCcanfunctioneitherasastaticormobileservice.StaticOTCservicesshouldbeconductedinasmanyhealthfacilitiesaspossible(withsufficientcapacityinplace)andshouldbeintegratedintoroutineservicedelivery.Similarly,mobileOTCservicesshouldbeintegratedintoroutineoutreachservicese.g.,inemergencysituationsandotherwise.Thisensuresgoodaccessandcoveragesothatasmanyacutelymalnourishedpatientsaspossiblecanaccesstreatmentwithinaday’swalkfromandbacktotheirhomes.
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AfullyfunctionalOTCshouldhavethefollowinginplace:
• ServiceproviderstrainedinIMAM
• Up-to-dateIMAMguidelines
• Functional anthropometric equipment(weighing scales, height boards, MUACtapes),monitoringandreportingtools.
• Appropriate Information, Education andCommunication materials for examplecounselling tools, and IMAM Job Aids forhealth/nutritioneducation.
• AdequatesupplyofRUTF
• Routinemedications
• ServicestoscreenforHIVandTB.
RequirementsforOTCarelistedinBoxF.
5.1 AdmissionCriteriaforOTCAll patients who meet the following criteriashouldbeadmittedandtreatedinOTC(seeBoxDandTable2)
• SAMwith no medicalcomplications,clinicallywellandalert,andwithappetite(abilitytoeattheReadytoUseTherapeuticFood[RUTF])
• Discharges for ITC irrespective of theiranthropometry
Note: For the success of the IMAM services, the home conditions or environment should be conducive6 and caregiver willing to treat at home.
6 MayincludeGoodWater,SanitationandHygiene,(WASH)practices,childcaringpractices,andfoodsecurity
Definition of SAM without medical complicationsThepatienthasappetiteforRUTF,clinicallywellandalert.ANDForChildrenBilateralpittingoedema(+/Grade1or++/Grade2)ORWFL/HorBMIforage<–3z-scoresORMUAC6to59months:<11.5cm5to<10years:<13.5cm10to<15years:<16.0cm15to<18years:<18.5cmForadultsBilateralpittingoedema(+or++)ORBMI<16ORMUAC<19.0cmPregnant and LactatingWomen with anInfantlessthansixmonthsMUAC<19.0cm
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5.2 AdmissionprocessandactivitiesinOTCThelayoutoftheOTCareashouldbewellplannedtoensureasteadyflowofpatientsaswellasorganisedprovisionofcomprehensivehealthandnutritionservices(Figure 10).
FigUre 10: lAyoUt oF the otc AreA
Note: This layout is for a stand alone OTC. However, these activities can be integrated into existing outpatient clinics e.g., OPD, YCC, MCH, TB clinics, HIV/ART clinics, , etc.
STEP 1: Triage (Refer to annex 2)
• Conducttriagetofast-trackseriouslyillpatients
• Identifyreferredclients/patientsfromthecommunity,ITC,orSFP.
• Give50mlsof10%glucoseorsugarsolution (1 teaspoonofglucoseorsugar in50mlof safewater)toanypatientswithSAM,suspectedtobeatriskofhypoglycaemia
• Conducthealthandnutritioneducationtocaregiversof/orpatientsnotseriouslyill.
Steps 2 and 3 will followthesameprocedureasdescribedinchapter three. Assessallpatients(newandfollow-up)attendingOTC. Inaddition,theclinicianshould:
• Review the previous treatment for patients referred/transferred from other clinics to avoidoverdoseofroutinemedicines(Table11)
• Ensurethattheycontinuewiththetreatmentstartedearlier.
PatientsontreatmentforHIV/AIDS,TBshouldbecounselledtocontinuewiththemedication.ThosediagnosedafteradmissiontoOTCshouldbereferredtoappropriateprogramme/healthfacilityfortreatment,careandsupport.
Dispensing Medicine & RUTF
Qualified persons Registered &
Counseled on HIV Testing
RUTF test amount served to client Fails if does not
complete/Passes if completes amount
Clinical Assessment/ Immunization update
Anthropometric measurements
TRIAGE Nutrition & Health
GENERIC FLOW OF ACTIVITIES IN OTC
2) Anthropometry Area
3) Clinical Assessment
1) Waiting Area
5) Registration and counsellingin OTC4) Appetite Test 6) Dispensing
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tAble 11: roUtine drUgs And sUpplements in otc
condition to be mAnAged DRUg/SUPPLEMENT WHEN/FREqUENCy
Hypoglycaemia 10%glucose/sugarsolution Once,atthetriage
Bacterialinfections Amoxicillin Twicedailyfor5-7days(accordingtobodyweight)
Firstdosetobestartedonadmissionundersupervisionofthehealthworker.
Explainhowtocompletetreatmentathome.
Measles(checkChildHealthcard:Ifnotalreadyvaccinated)
Vaccinateif≥9monthsupto5years
Onadmissionsingledose
Malaria(doBloodSmearorRDT) Anti-malarials Treataccordingtonationalprotocolsiffoundtobehavemalariaparasites.
VitaminAdeficiency(CheckforsignsofvitaminAdeficiencyastheconditionofeyescandeteriorateveryrapidly.
Ifcornealulcerationispresent,refertoITC
• DonotgiveVitaminAtopregnantwomen
• DonotgivevitaminAroutinelytolactatingmothersexceptwherethereisclinicaldeficiency(seechapter9)
• DonotgivevitaminAroutinelytoanypatientonRUTF
VitaminAcapsule
0-6months-50,000IU
6-12months-100,000IU
>12months-200,000IU
Shouldbegivenonlyonce at dischargefromOTCandundersupervisionofthehealthprovider.
Anaemia(checkforsignsofanaemiaanddorelevantinvestigations)
IronandFolicAcid-5mg Treataccordingtocause.
Helminthicinfection(worminfestation)
Mebendazole:
1-2years:250mg
>2years:500mg
ORAlbendazole:
1-2years:200mg
>2years:400mg
Atsecondvisit
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STEP 4: Perform the appetite test with RUTF
Ensurethatmother/caregiverandchildwashhandswithcleanwaterandsoap.Assesspatient’sappetitebygivingasmallamountofRUTF(Table12).MalnourishedchildrenmayrefusetotakeRUTF because they are in an unfamiliar/strange environment. If so, the mother/caregiver andhealthworkershouldmovethechildtoacomfortablesettingandslowlyencouragethechildtoeattheRUTF.Provideenoughsafedrinkingwaterforthepatient.PatientswhopasstheappetitetestshouldbeconsideredforadmissiontoOTC.
Patientswhofailtheappetitetestshouldbesentbacktotheclinicianforreassessment.
tAble 12: Appetite test For rUtF
WEIgHT (kg) sAchets oF rUtF
<4 <1/4
4.0 – 6.9 >1/4
7.0 – 9.9 ½
10.0 – 14.9 ½-¾
15.0 – 29.9 ¾-1
≥30.0 >1
STEP 5: Registration and Counselling in OTC
• Recordthepatient intheIntegratedNutritionRegister(INR)asperpatientcategory(e.g.newadmissions,relapses,)
• ExplainthereasonsandpurposeforadmissiontotheOTCandexpectedtreatment,careandsupport.
• CalculatetheamountofRUTFtobegiventothepatient(RefertodosingchartforRUTFinAnnex:8)andrecordontheintegratednutritionrationcard.
• Counselcaregivers/patientsonkeymessages(RefertoBoxE)
• Linkcaregivers/patientstootherprimaryhealthcareservicesorinitiatives(e.g.,YCCorgrowthmonitoring programme, HIV/TB, VHT, livelihood programmes, etc.) as may be needed orrequired.
• Counsel caregivers/patients to return for scheduled follow-upvisits toenablemonitoringofprogress. Depending on the OTC site’s schedule and the ability of the patient to return orcaregivertobringinthechild,weeklyorbi-weeklyfollow-upsessionsshouldbescheduled.
• Askthecaregiver/orpatienttoreturnforeachOTCfollow-upsession,andtheimportanceofcompliancewiththisisexplained.
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key Messages at First Visit 1. RUTFisbothafoodandmedicineforseverely
malnourishedpatientsonly.Itshouldnotbeshared
2. Give small regular meals of RUTF andencouragethepatienttoeatoften(ifpossibleeightmealsaday)
3. NevermixtheRUTFwithotherfoods.Mostcereals and beans contain anti-nutrientsand inhibitors of absorption thatmake thespecial nutrients in theRUTF that the childneedstorecoverunavailableforthechild.IfotherfoodsaregiventheyshouldbegivenataseparatetimefromtheRUTF
4. For children who are still breastfeeding,always breastfeed before offering RUTF.Continuetobreastfeedregularly
5. AlwaysofferthepatientplentyofsafewatertodrinkwhiletakingRUTF.
6. Ensurethepatient’shandsarewashedwithcleanwaterandsoapbeforeeating.
7. Keep food clean and covered, includingsachets of RUTF which should be rolled upfrom the opened end and kept in a cleancoveredcontainer
8. Ifa patienthas diarrhoea,continueto feedwith RUTF. Offer frequent meals in smallquantitiesifthepatient’sappetiteisreduced
9. Malnourished patients get cold quickly.Therefore, always keep them covered andwarm
10. If the patient develops a reaction to RUTF,discontinue use and take to the nearesthealthfacilityfortreatment.
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Step 6: Dispense medication and RUTF
DispensingofRUTFandOTCmedicationsshouldbeintegratedwithinthefacilitydispensingsystem.
PatientsadmittedtotheOTCshouldreceivetheprescribedRUTFaswellasroutineandappropriatemedication(Table11)
RUTF in Management of Severe Acute Malnutrition in OTC RUTF is an energy and nutrient-dense pre-packed paste designed for the treatment of acutemalnutrition.Therationgiventoapatientisbasedonhis/herweightandtheintakerequirementofbetween175and200kcal/kg/day.RUTFisdose-relatedandshouldbegivenonprescription.
Composition of RUTF
• Hasacaloricvalueof500kilocalories(kcal)per92gofproduct
• Contains25%peanutbutter,26%milkpowder,20%oil,27%sugar,2%combinedmineralsandvitamins(CMV).
Benefits of using lipid based RUTF
• Itiseasytocalculatethequantityrequiredforeachbeneficiarybasedonweight
• Itdoesnotrequirepreparationorcooking
• Patientcanjustopensachetandeatdirectly
• Doesnotneedtobedilutedwithwater.Thiseliminatestheriskofcontamination.
• Canbeusedathomewithsupervisionfromthehealthfacility
• Reduces on the number of staff necessary or needed for preparation and distribution oftherapeuticfood
• ItreducestheneedforITCadmission
• RUTFhasalongshelflife
• Itdoesnotrequirerefrigeration
Nutrient Composition of RUTF (plumpy’ nut)The energy and Nutrient Composition of Guidelines for Integrated Management of AcuteMalnutritioninUganda
Plumpy’nutisshowninTable13.
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TABLE13: ENERgy AND NUTRIENT COMPOSITION OF RUTF (PLUMPy’ NUT)
nUtrient per 92g sAchet nUtrient per sAchet 92g
Energy 500kcal VitaminA 840mcg
Proteins 12.5g VitaminD 15mcg
Lipids 32.86g VitaminE 18.4mg
Calcium 276mg VitaminC 49mg
Phosphorus 276mg VitaminB1 0.55mg
Potassium 1022mg VitaminB2 1.66mg
Magnesium 84.6mg VitaminB6 0.55mg
Zinc 12.9mg VitaminB12 1.7mcg
Copper 1.6mg VitaminK 19.3mcg
Iron 10.6mg Biotin 60mcg
Iodine 92mcg Folicacid 193mcg
Selenium 27.6mcg Pantothenicacid 2.85mg
Sodium <267mg Niacin 4.88mg
How to Administer RUTF• Washhandswithcleanrunningwaterandsoap
• TheRUTFshouldbegiventothepatientinsmallamountsandfrequently(e.g.½sachet*8timesperday)providedthatthedailyamountisaccordingtoprescription.
• AlwayshavesafedrinkingwaternearbywheneverthepatientiseatingRUTF.
• MakesurethatthepatientconsumesandfinishestherecommendedRUTF.RUTFshouldnotbegivenatthesamesittingwiththefamilypot.
• Anutritiousmealmadefromlocallyavailablefoodscangraduallybeintroducedasthepatient’shealthimproves.
• ChildrenshouldbesupervisedwhiletheyconsumetheirRUTFandmeals.
Allergic Reactions to RUTF:Althoughitisunlikely,thereisaminimalriskofapatienthavinganallergicreactiontothepeanutbutterinRUTF.ItisimportanttoaskforhistoryofallergytotheRUTFingredients.
Theallergymaycausereactionsintheformof:• Skinchanges:hives,Rashes
• Bodyswelling,
• Shortnessofbreath,
• Anaphylacticshock.
Ifthepatientdevelopsanyofthesesymptoms,discontinueadministeringRUTF.Thepatientshouldbetreatedforallergicreactionatthenearesthealthfacilityimmediatelyandpharmaco–vigilanceformfilledappropriately.
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Exit Process and Discharge CriteriaThepatientcanexitascured,non-respondent,dead,transferredanddefaulted.Table14showsthecategoriesandcriteriaforexitfromOTC.
tAble 14: types And criteriA For eXit From otc
cAtegory oF dischArge
dischArge criteriA Action
Cured* • WFL/Hor≥-2z-scores(6-59months)
• BMI-for-age≥-2z-scores(5-19years)
• BMI>18kg/m2(adults>18years)
• AND• Nobilateralpittingoedema
for2weeks• ClinicallywellandalertORMUAC:• ≥12.5cm(6monthsto
<5years)• ≥14.5cm(5to<10years)• ≥18.5cm(10to<15years)• ≥21.0cm(15to<18years)• >22.0cm(pregnantand
lactatingwomenwithinfantlessthan6months)
• ≥22.0cm(Adults)AND• Nobilateralpittingoedema
for2weeks• Clinicallywellandalert
• RecordinINRas“Cured”.• Linkcaregivers/patientstoother
primaryhealthcareservicesorinitiativesatFacility/orcommunity:o YCCorGrowthMonitoring&
Promotion(GMP)programmeo SFPorotherLivelihood
programmeswhereavailableo HIV/AIDS/TBcareandtreatment
services
Non-Respondent • Hasnotreacheddischargecriteriaafterthreemonths(fourmonthsfortheHIV/TBpatients)
• RefertoITCforre-evaluationIfHIV/TBstatusisknown:• Assessonacase-by-casebasisand
takeactionafterdiscussionwiththepatient’sHIV/TBtreatmentprovider
Defaulted • Absent(notreportedorfollowed-upinthecommunity)for2consecutivevisits
• Makeafollow-uphomevisittoassesssituationtosupportthefamilyinmonitoringthepatientprogress
• Onreturn,thepatientmayre-enterOTCifhemeetstheadmissioncriteria
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cAtegory oF dischArge
dischArge criteriA Action
• Followthecriteriaforregisteringthepatientasare-admissionusingthenumberpreviouslygiven
TransferredtoITC • ConditionhasdeterioratedandrequiresITC
• Notrespondingtotreatment
• Fillareferralslipwithinformation(includingmedicines)andthereasonfortransfer
• RecordinINRas“transferredtoITC”
Transfertoothermedicalservices
• Ifpatient’sconditiondeterioratesneedingattentionforothermedicalservices
• Fillareferralslipwithinformationincludingmedicinesandthereasonfortransfer
• RecordinINRas“transferredtoothermedicalservices”
TransfertootherOTC
• PatienttransferredtoothernearbyOTCsorasrequestedbycaregiver
• UseareferralformandstatereasonsfortransfertoanotherOTC
• RecordinINRas“transferredtootherOTC”
Died • Diedwhileonprogramme • RecordinINRas“died”
Note: *If the patient meets the above criteria and has spent a minimum of four weeks in the programme (a minimum of three visits to OTC including the initial visit) and a maximum of 90 days
5.3 DischargeProcedures• Thankthecaregiver/orpatientontheroleshehasplayedonensuringrecoveryofthepatient
• Whentheclienthasattainedtheappropriateexitcriteria,dischargeon last ration(at least1weekssupply)andlinktolivelihoodprogramandcomplementarynutritionservices(Table14)wherethereisnoSFPortransfertoSFPifavailable.
• RecordthedischargeoutcomeintheINRandtheintegratednutritionrationcard.
• Advisethecaregiver/orpatientongoodnutritionandcaringpractices.
• Advisethecaregiver/orpatientto immediatelygotothenearesthealth facility ifpatienthasinabilitytoeatorhasanyofthefollowingsignsandsymptoms:
o Noappetiteo Vomitingo Lethargicorunconsciouso Convulsionso Bilateralpittingoedemao Losingweighto Highfevero Diarrhoeaorfrequentwaterystoolsorstoolswithblood
o Difficultorfastbreathing
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5.4 ProcessandRequirementsforSetting-upanOTCProcess for Setting-up an OTC
• Identify theneed for setting-up anOTC (for example, highGAMand SAM rates, aggravatingfactors)throughconductinganeedsassessment
• Identifyotherstakeholdersincludingpartners
• Mobilizeresourcesincludingfinancial,human(knowledgeableandskilled),space,equipments,supplies,andtools
• Mobilize,sensitizeandinvolvethecommunity
• SelectionofOTCsite
• MaketheOTCfunctional
• CreatinglinkageswithinIMAMnetwork
• Monitoring,reporting,supervisionandevaluationoftheprogramusingexistingstructures.
Requirements for setting-up an OTCLocation
• OTCservicesshouldbeintegratedwithintheexistingHealthFacilityinfrastructure
• MobileOTCshouldbeintegratedwithinotheroutreachprogrammes.
• Thesiteshouldhavethefollowing:
o Ashadeandadequatespacetoserveasawaitingareaforthebeneficiariestoseat(Triage,Heathandnutritioneducation)
o Cleanwaterandsoapforhandwashing
o Safedrinkingwaterforconductingappetitetest
Human resource Theseinclude:
• AnIn-charge,nutritionist,dispenser,recordsassistant,threenurses,onehealtheducator,onehealthassistant,oneporter,securityguard,storekeeper,andmedicalsocialworkerdependingonthelevelofthehealthfacility.
• Thesepersonnel shouldhavebeen trainedon integratedmanagementof acutemalnutritionpackage.Someofthesestaffmaybealreadyemployedatthehealthfacilitiesandifso,thereisnoneedforrecruitingmore.However,whereallpositionscannotbefilledthenthereshouldbetaskshifting.
Equipment and supplies
• EquipmentandsuppliesforOTCaredescribedinBoxF.
• Theequipmentshouldbefunctionaltoensureaccuracyofthemeasurements
• Some of the equipment should be routinely calibrated and standardized according to themanufacturer’sinstructions.
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• Suppliesshouldbeorderedthroughroutinesupplychainmanagementsystem
• Goodsupplychainmanagementpracticessuchastimelyorderingandaccurateforecastingofsuppliesshouldbeobservedtopreventstock-outsandoverstockingthatmayleadtolossessuchasexpiryofsupplies,damagesamongothers
Storage facilityThestorageperiodfornutritioncommoditiesisusuallylessthanthreemonthsandnotmorethan12months
Thebasicfacilityrequirementsshouldinclude:
• Adequatestoragespacewithspaciouswalk-ways
• Adequatelightingandventilation
• Protectionfrominsectsandrodents
• Clean,dryandrainproofstorageroom
• Securedstoragearea,withlockandkeyandaccesstoonlyauthorizedpersons
• First-expiryfirst-out(FEFO)andfirst-infirst-out(FIFO)principleobserved
• Freefromdirectsun-heat
• Medicinesandsuppliesstoredonpalletsawayfromfloorsandwalls
Data collection tools and Job aidsThetoolsinclude:
• INR,integratednutritionrationcards,tallysheets,HMISreportingforms(Monthlyandquarterly)
Jobaidsmayinclude:
• Counsellingcards,RUTFdosingandappetitetestchart,admissionanddischargecriteriachart,routinemedication charts,WFL/Hand BMI for- age-z-score reference charts, BMI referencecharts
guidelines and IEC MaterialsOTCshouldhavethemostupdatedversionofthefollowingguidelinesforpurposesofreference:
• IntegratedManagementofAcuteMalnutrition(IMAM)
• InfantandYoungChildFeeding(IYCF)
• IntegratedManagementofChildhoodIllnesses(IMCI)
• Micronutrientsupplementation
• Maternalnutritionand
• GrowthMonitoringandPromotion(GMP)
Similarly,IECmaterialsshouldbeharmonizedwiththeguidelines.
StaffshouldbecontinuouslyupdatedontheuseoftheseguidelinesandIECmaterials.
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Basic equipment and supplies for OTCBasic equipment• Salter/hangingscaleandweighingpants• Electronicstandingscale• MUACtapes(childandadult)• Heightboard• Calculator• Thermometer• Clock• Scissors
Basic supplies• IntegratedNutritionRegister• IntegratedNutritionRationcards,• Tallysheets• Reportforms/books,• Communityreferralslip• HMIS032healthfacilityreferralnote• RoutinemedicationsforOTC• RUTF• IMAMguidelines• Safewater• Sugarorglucose• Weightforlength/heightz-scorecharts• BMIcharts/wheels• BMIforagez-scorecharts• JobAids(RUTFAppetitetest,Dosingcharts,
MUACandBMIcut-offs,listofinpatientandoutpatienttreatmentsites)
• IECmaterials• Folderfiles• RUTF• Cleanwaterandsoapforhandwashing• Jugandcups• Jerrycansforstorageofdrinkingwater• Wastedisposalbins• Benches/chairsandtables• RCTkitforHIVtesting• RDTstripsformalaria• Foodandcookingdemonstrationmaterials
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CHAPTER SIXinPatient theraPeutic care for management of acute maLnutrition with medicaL
comPLications
6.0 IntroductionIn-patient Therapeutic Care (ITC) is for management of Severe Acute Malnutrition (SAM) withmedicalcomplications.Itcanbeprovidedinaspecialisedunitinahealthfacilityorinachildren’swardatahealthfacilitywith24-hourcare.ThepurposeofITCistoconcurrentlyprovidemedicalandnutritionaltherapy,inadditiontootherformsofcare(psychosocial,stimulation,playtherapyandinvolvingthemother/caregiverincare).(refertoannerx4onProtocolforITC)ITCconsistsoftwophases;stabilisation(phase1)andtransitionandrehabilitation(phase2).
6.1 AdmissionCriteriaAllpatientsunderthecircumstancesbelowshouldbeadmittedandtreatedinITC.
• PatientswithSAMwithanyofthefollowingmedicalcomplications:
o Hypoglycaemia
o Hypothermia(<35°Caxillaryand35.50Crectal)
o Infections
o Severedehydration
o Shock
o Verysevereanaemia
o Cardiacfailure
o SevereDermatosis
o Cornealulceration
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• PatientswithSAMandanyofthefollowingIMCIdangersigns:
o Anorexia,noappetite
o Intractablevomiting
o Convulsions
o Lethargy,notalert
o Unconsciousness
o Inabilitytodrinkorbreastfeed
o Highfever(>39°Caxillaryand38.5°Crectal)
6.2 AdmissionProcess
STEP 1: Triage (Refer to Annex 2)
• Conducttriageandfast-trackseriouslyillpatientsforassessmentandcare
• Identifyreferredpatientsfromthecommunity,OTC,otherITC,orSFPandothercontactpoints
• Givesugarwatersolution(1roundedteaspoonofglucose/sugarin50mlwater(3tablespoonsofwater)ororal10%dextrosetoanypatientswithSAM,suspectedtobeatriskofhypoglycaemia
• ExplaintheadmissionprocesstothemotherorcaretakerofpatientswithcomplicatedSAMandcomfortthem
• Advisethemotherorcaregivertohandlethepatientgently
STEP 2: Re assess to confirm referred cases
• DetermineageofthepatientbasingonPatientHealthCard/MotherChildPassportorrecallofthecaregiver.
• Checkforthepresenceofbilateralpittingoedema
• MeasureMUACforchildren6monthsandabove,adultsincludingpregnantwomenandpatientswhocannotstand
• Takeweightofthechild
• Takelengthmeasurementforchildrenlessthan2years(<87.0cm)orheightmeasurementforchildrenolderthan2years(>87.0cm),adolescentsandadults.
• Classifythenutritionstatus(seeFigure8).
STEP 3: Clinical Assessment
• Assessthepatient’smedicalconditionthroughhistorytakingandphysicalexaminationtoidentifyanymedicalcomplicationsthatmayrequireinpatientcare.Thisentails:
o Takingrelevantmedicalhistory(currentandpastillnesses,drugs,medicationsetc).
o Taking dietary history/feeding practices in terms of variety, amount and frequency,preparation,hygienepractices,active/passivefeeding
o Conductingaphysicalexamination(bothgeneralandsystemic).
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 75
o Conducting basic relevant investigations (Hb, blood sample for malaria, stool analysis,urinalysis,chestx-ray(absenceoftheseinvestigationsshouldnotdelayadmission).
o HIV testing should be done in all patients according to Provider Initiated Testing andcounselling
o Recordingallthefindings
Management Process
On admission the patient should be managed in the stabilisation phase and transferred torehabilitation/OTCwhenthemedicalcomplicationshaveimproved.
The general Principles for Routine Care (The 10 steps)
Step1:Treat/preventhypoglycaemia
Step2:Treat/preventhypothermia
Step3:Treat/preventdehydration
Step4:Correctelectrolyteimbalance
Step5:Treat/preventinfections
Step6:Correctmicronutrientdeficiencies
Step7:Startcautiousfeeding
Step8:Achievecatchupgrowth
Step9:Providesensorystimulationandemotionalsupport
Step10:Preparefordischarge/transfertoOTC
Figure11showsthephasesandtimeframeformanagementofSAMpatientsinITC.
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FIgURE 11: WHO TEN STEPS FOR THE MANAgEMENT OF SAM (WHO 2003)
10 Steps Stabilization Phase Days1-2
Transition Days3-7
Rehabilitation Phase/otc Week2-6
1. Treat/PreventHypoglycaemia
2. Treat/PreventHypothermia
3. Treat/PreventDehydration
4. CorrectElectrolytes
5. Treat/PreventInfections
6. CorrectMicronutrients
7. StartCautiousfeeding
8. Achievecatchupgrowth
9. Providesensorystimulationandemotionalsupport
10. Preparefordischarge/transfertoOTC**
*Ironisgivenafter2daysonF100,ifpatientistakingRUTF,ironshouldnotbegiven
**Prepare to transfer to OTC during transition if OTC services are available or discharge afterrehabilitationphase
6.2 StabilisationPhase/Phase1Managingmedical complications is critical during the first 48 hours of admission in ITC. If notpreventedortreatedappropriatelyandpromptlythiscanleadtoahighdeathrate.Thecommonmedical complications are hypoglycaemia, hypothermia, infections, severe dehydration, shock,cardiacfailure,severedermatosisandverysevereanaemia.
Iffeasible,childreninthestabilisationphaseshouldbephysicallyseparatedfromthechildreninthetransitionandrehabilitationphasesandfromchildrenwithotherdiseases.Adultscanbemanagedontheparentwards(e.g.TB,cancerwardsetc)
Treatment and Prevention of hypoglycaemia
Hypoglycaemia is blood glucose less than 3mmol/l or 54mg/dl. Perform a blood glucose test(Dextrostix,Glucostixorlabtest)onadmissionbeforegivingglucoseorfeedingifpossible.
Causes of hypoglycaemia
Inadequate intake of food:malnourishedchildrenmayarriveatthehospitalhypoglycaemiciftheyhavebeenvomiting,toosicktoeatoriftheyhavehadalongjourneywithoutfood,waitingtoolongforadmissionoriftheyarenotbeingfedregularly.
Signs of hypoglycaemia:
• Lethargy,limpness,lossofconsciousnessorconvulsions
• Semiconsciouswiththeeyespartlyopened
• Drowsiness(theonlysignbeforedeath)
• Hypothermia(axillarytemp<35°C,rectal<35.5°C)
+/-Iron*NoIron
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 77
Treatment of hypoglycaemia
Ifbloodglucoseisloworhypoglycaemiaissuspected,takeimmediateaction;
• Ifpatientisconscious:
o Give50mlof10%glucoseorsugarsolution(1roundedteaspoonofglucose/sugarin50mlsafewater=(3tablespoonsofsafewater),orallyorbynasogastrictube(NGT)
o ThenfeedF75every30minutesfortwohoursgivingone-quarterofthetwo-hourfeedeachtime(RefertoAnnex8fortheamounttogive).Providethetwo-hourlyfeedsdayandnight.
o Alwaysgivefeedsthroughoutthenight
• Ifpatientislethargic,unconscious,orconvulsing,:
o Give intravenous(IV)sterile10%glucose(5ml/kg), followedby50mlof10%glucoseorsucrosebyNGT,thengiveF75asabove(two-hourfeeds,dayandnight).Ifonly50%glucosesolution isavailable,diluteonepart to fourparts sterileboiledwateroronepartof50%glucoseto9partsof5%glucosetomakea10%solution
o Takeanotherbloodsampleafter2hoursandcheckthepatient’sbloodglucoseagain.
o Ifbloodglucoseis3mmol/lorhigher,changeto2hourlyfeedsofF75.
o Ifbloodglucoseisstillbelow3mmol/l,ensureantibioticshavebeengivenandcontinuetogiveF75everyhalfhour.
o Continuetomonitorthelevelofconsciousnessandbloodglucoselevel.
Prevention of hypoglycaemia
Ifapatient’sglucoseisnotlowandpatienthasnoclinicalsigns;
• FeedchildrenstraightawaywithF75andthenevery2-3hoursdayandnight.
• Encouragemothers/caregiverstowatchforanydeterioration,helpfeedandkeeppatientwarm
Treatment and prevention of hypothermia
Hypothermiaislowbodytemperatureofbelow35°C(axillary).Severelymalnourishedchildrenareatgreaterriskofhypothermiathanotherchildrenandneedtobekeptwarm.Thehypothermicpatienthasnothadenoughcaloriestowarmthebody.Ifthepatientishypothermicheisprobablyalsohypoglycaemic.Bothhypothermiaandhypoglycaemiaaresignsthatthepatienthasaserioussystemicinfection.Allhypothermicchildrenshouldbetreatedforhypoglycaemiaandforinfectionaswell.
Treatment of hypothermia
• Keepwarm:useindirectheat(nottooclosetothebody).
• Have themotherhold the childbyputting the childon themother’s /caregiver’sbare chest(Kangarootechnique/skintoskincontact).
• Keepthepatientcoveredincludinghishead.
• FeedF752hourly
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• Monitorandrecordthetemperatureevery30minutesduringthefirsthour,theneveryhouruntilimprovementisregistered.
• Keeptheroomwarmespeciallyatnight
Note: Do not use hot water bottles due to the danger of burning fragile skin.
Prevention of hypothermia
• Keepwarmbyclothing,covertheheadandlegsaswell),coveringwithawarm/survivalblanket,andorputtingthechildonthemother’s/caregiver’sbarechest (Kangarootechnique/skin toskin)andcoveringbothofthem.
• Thecareproviderorcaregivershouldwarmtheirhandsbeforetouchingthepatient
• Avoidexposureduringexaminationandbathing
• Keep the patient dry. e.g. promptly change patient’s clothes and bedding and child’s wetnappies,anddrythepatientthoroughlyafterbathingandavoidprolongedmedicalexaminationandweighing
• Maintainroomtemperatureat25°Cto36.5°Candavoiddraughtsaswellaskeeppatientsawayfromwindowsanddoors
Monitoring for hypothermia
• Takebodytemperatureevery2hours.Stopre-warmingwhenitrises>36.5°C(taketemperaturehalfhourlyifheaterisused).
• Ensuringthepatientiscoveredatalltimes,especiallyatnight
• Checkbloodglucoseleveli.e.checkforhypoglycaemiawheneverhypothermiaisfound
Note: If a low-reading thermometer is unavailable and the patient’s temperature is too low to register on an ordinary thermometer, the healthcare provider should assume the patient has hypothermia.
FigUre 12: keeping the pAtient wArmly covered, especiAlly At night.
Treatment/ Prevention of Dehydration
Dehydrationoccurswhenapatientusesorlosesmorefluidthanwhatistakeninsuchthatthebodydoesnothaveenoughwaterandotherfluidstocarryonitsnormalfunctions.Itiscausedmostlybydiarrhoea,vomiting,excessivesweatingandinabilitytodrink.
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Preparation of f ReSoMal from standard ORS:• Water-2litres
• WHO-ORSone-1litrepacket
• Sugar-50g
• 40mlMineralmixsolution*orCombinedmineralsandVitamins (CMV) (20mls-1redscoopmixedin18mlsofboied,colledsafewater)
*Themineralmixsolutionmaybepreparedbythehospitalpharmacy.
Alternatively, a commercial product, calledCombined Mineral Mix (CMV), maybeused.
Signs of dehydration
It is often difficult to determine dehydrationstatus inapatientwithSAMastheusualsignsof dehydration such as lethargy, sunken eyes/anterior fontanel,may be present and yet thepatient may not be dehydrated. Dehydrationtends to be over diagnosed and its severityover-estimated in children with SAM. This isbecause it is difficult to estimate accuratelythe dehydration status of children with SAMusingclinicalsignsalone.Therefore,healthcareprovidersshouldaskthemotherorcaregiverifthepatienthashadrecentandfrequentwatery diarrhoea or vomitingratherthansmallmucoidstools commonly found in severemalnutritionbut which do not cause dehydration. If so,assumedehydrationandgiveReSoMal.
ReSoMal is Rehydration Solution forMalnutrition.ItisamodificationofthestandardOralRehydrationSolution(ORS)recommendedbyWHO.ReSoMal contains less sodium,moresugar, andmorepotassium than standardORSand is intended for severely malnourishedpatientswithdiarrhoea,exceptifprofuseliquiddiarrhoea (e.g. cholera). It should be givenby mouth or by nasogastric tube. ReSoMal isavailable commercially in some places, but itmay also be prepared from standardORS andsomeadditionalingredients(SeeBoxG)
Note: Do not give standard ORS to severely malnourished children, except in case of profuse liquid diarrhoea.
It is useful to look for the usual signs ofrehydration (Refer to Table 15) as they canbeusedtodetectimprovementduringrehydration.
boX F
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tAble 15: signs oF dehydrAtion
lethArgic Alethargicpatientisnotawakeandalertwhenheshouldbe.Heisdrowsyanddoesnotshowinterestinwhatishappeningaroundhim.
restless, irritAble Thepatientisrestlessandirritableallthetime,orwheneverheistouchedorhandled.
Absence oF teArs Observewhetherthepatienthastearswhenhecries.
sUnken eyes Theeyesofaseverelymalnourishedpatientmayalwaysappearsunken,regardlessofthepatient’shydrationstatus.Askthemotherifthepatient’seyesappearunusual.Photographs6,30,and31(inthePhotographs booklet)showsunkeneyes.
dry moUth And tongUe
Feelthepatient’stongueandtheinsideofthemouthwithaclean,dryfingertodetermineiftheyaredry.
thirsty SeeifthepatientreachesoutforthecupwhenyouofferReSoMal.Whenitistakenaway,seeifthepatientwantsmore.
skin pinch goes bAck slowly
Usingyourthumbandfirstfinger,pinchtheskinonthepatient’sabdomenhalfwaybetweentheumbilicusandthesideoftheabdomen.Placeyourhandsothatthefoldofskinwillbeinalineupanddownthepatient’sbody,notacrossthebody.Firmlypickupallthelayersofskinandtissueunderthem.Pinchtheskinforonesecondandthenrelease.Iftheskinstaysfoldedforabrieftimeafteryoureleaseit,theskinpinchgoesbackslowly.(Note: The skin pinch may always go back slowly in a wasted patient.)
Note: • A non-oedematous patient can present with some signs of dehydration that would normally
be found in dehydrated non-malnourished patient, e.g. sunken eyes, slow skin pinch, etc. It is important to take history and determine if there has been recent fluid loss (recent diarrhoea or vomiting)
• A non-oedematous patient with very visible veins is not dehydrated
• In very rare circumstances an oedematous patient with recent frequent watery diarrhoea or vomiting may become dehydrated- be extremely careful when diagnosing this.
• A patient with loose mucoid non watery diarrhoea is NOT likely to be dehydrated and does NOT need rehydration therapy
• Although patients with oedema have a high body fluid volume they may be dehydrated as a result of further loss of fluid from the intravascular space.
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Treatment of dehydration
Inboththeoedematousandnon-oedematousSAM,themarginofsafetybetweendehydrationandover-hydrationisveryNARROW.Hence,careandcautionmustbetakeninmakingadecisiononhowtoavoidover-hydrationandcardiacfailure.
Adecisionmustbetakenon:
• Howtorehydrate(route,choiceofsolution,amount,rateofrehydration)
• Whattomonitorduringrehydration
Fluidmanagement should be done cautiously. It is important to determine the patient’s targetweight(seeannex5)beforegivingReSoMalasfollows:
Ifknown,usetheweightofthepatientbeforeepisodeofdiarrhoeaastargetweight
Ifnotknown,takethepatient’sweightbeforegivingReSoMal.Calculatetheminimumat2%andmaximumat5%ofthatweight.Addthefigureobtainedtotheweightofthepatientandusethatastargetweight
• Ifthechildisbreastfeeding,encouragethecaregivertocontinue.
• GiveReSoMalslowly,sincetoomuchfluidtooquicklycancauseheartfailure.ThebestwayofgivingReSoMalisbycup.NGTcanbeusedforgivingReSoMalatthesamerateifapatientistooweaktotakeorally.NGTshouldbeusedinweakerorexhaustedpatients,thosewhovomit,havefastbreathingorpainfulmouthsores.IVfluidsshouldnotbeusedtotreatdehydrationexceptinshock.Theoralrouteispreferredas,thepatient’sthirstyhelpstoregulatetheamountgiven.
• ItisessentialtostopgivingReSoMalwhenthepatientreachesthetargetweight.Forchildren,startwithReSoMal5ml/kgevery30minutesfortwohours,orallyorbyNGT,thenReSoMal5-10ml/kg/hourforthenextfour-to-10hours,alternatingwithF75everyhour.
a) Monitoring patients on ReSoMal
• Monitor all patients taking ReSoMal for signs of hydration (improvement), over-hydration(complication)andshock(worsening),every30minutesforthefirsttwohours;thenhourlyuntilhe/sheimproves.
• Closelymonitor for signsofover-hydration.Thesignsofexcessfluid (over-hydration) includeincreasingrespiratoryandpulserates,increasingoedemaandpuffyeyelids.Ifthesesignsoccur,stop fluids immediately and reassess after one hour. Monitor the progress of rehydration:Observethepatientevery30minutesfortwohours,thenhourlyforthenextthree-to-10hours,recording:
o Pulserate(slowingrate)
o Respiratoryrate(slowingrate)
o Feelingofthirst(lessthirstifrehydrationworking)
o Passingurineandurinefrequency
o Stool/vomitfrequency
o Lesslethargicandmorealert
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• Signsofimprovinghydrationstatus
o Lesslethargic
o Lessthirsty
o Skinpinchnotasslow
o Slowingofrapidrespirationandpulserates
o Passingurine
Note: Although these changes indicate that rehydration is proceeding, many severely malnourished children will not show these changes even when fully rehydrated.
Ifapatienthasthreeormoreoftheabovesignsofimprovinghydrationstatus,stopgivingReSoMalroutinelyinalternatehours,insteadofferReSoMalaftereachloosestoolasdescribedbelow:
• Forchildrenlessthan2years,give30-50mlaftereachloosestool,children2yearsandolder,give100mlaftereachloosestool.
Atthesametimeasthepatientgainsonweightduringrehydration,theremustbeanimprovementinclinicalsignsandsignsofdehydrationshoulddisappear.Ifthatisnotthecase,thendiagnosisofdehydrationwasfalseandReSoMalmustbestopped
Prevention of dehydration
Apatientwithcontinuingwaterydiarrhoeashouldbe fedwithF75.TheapproximatevolumeofstoollossesshouldbereplacedwithReSoMal.Asaguide,give30-50mlofReSoMalifapatientisagedlessthan2yearsor100mlsifaged2yearsorolderaftereachwaterystool.
Note: It is common for patients with SAM to pass many small unformed stools. These should not be confused with watery stools and do not require fluid replacement.)
Case with profuse liquid diarrhoea
In case of profuse liquid diarrhoea (e.g. cholera), ReSoMal should not be given and should bereplacedbyWHOlowosmolarityORSwithoutchangingtheamountandfrequency.
Management of shock
Shock is a dangerous condition presentingwith severeweakness, lethargy or unconsciousness,coldextremitiesandafast,weakpulse.Itiscausedbydiarrhoeawithseveredehydration,severehaemorrhage, burns, cardiac failureor septicaemia. There is a decrease intissueperfusion andoxygendeliveryduetosevereinfectionandsepsis.
ApatientwithSAMisconsideredtohaveshockifhe/sheislethargicorunconsciousandhascoldhandsaswellaseither:
• Slowcapillaryrefill(>3seconds);
• Weakorfastpulse;or
• Absenceofsignsofheartfailure(refertoSectionbelowoncardiacfailure)
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Septic shock
Insepticshock,superficialveins,suchastheexternaljugularandscalpveinsaredilatedratherthanconstricted.Asshockworsensthepatientdevelopskidney,liver,intestinalorcardiacfailure.Whenapatientreachesthisstage,survivalisunlikely.
Shockfromdehydrationandsepsisarelikelytoco-existinpatientswithSAM.Theyaredifficulttodifferentiateonclinicalsignsalone.Childrenwithdehydrationwill respondto IVfluids,whereasthosewithsepticshockandnodehydrationwillnotrespond.
Ifthepatientmeetsthecriteriaofshockdescribedabove,applythefollowing:
• Giveoxygen.
• Givesterile10%glucose5ml/kgbyIV
• Keepwarm
• GiveoneoftheIVfluidsasdescribedbelow(15ml/kgover1hour).
o Half-strengthDarrow’ssolutionwith5%glucose(dextrose)
o Ringer’slactatesolutionwith5%glucose*
o 0.45%(half-normal)salinewith5%glucose*
Note: *If either of these is used, add sterile potassium chloride (20mmol/l)
• If respiratoryandpulse ratesareslowerafteronehour, thepatient is improving.Repeat thesameamountoffluidforonehourandcontinuetocheckrespiratoryandpulserateeverytenminutes.
• If respiratoryandpulse rates increase, stop the IV. Thenassume that thepatienthas septicshock.MaintaintheIVlinewithfluidat4ml/kg/hrwhilewaitingforblood.
• Givebloodtransfusion.Beforegivingblood,stoptheIVfluidsandanyoralfeeds.Giveadiuretic(Frusemide1mg/kg).Givewholefreshbloodat10ml/kgslowlyoverthreehours.Incaseofsignsofheartfailure,givepackedcellsinsteadofwholebloodasthesehaveasmallervolume.
• Givebroadspectrumantibiotics(seedetailsinsectionofantibiotics)
• Reducephysicaldisturbance;NEVERtransferpatientasstressleadstodramaticdeterioration)
Manage very severe anaemia
Anaemiaisalowconcentrationofhaemoglobinintheblood.Verysevereanaemiaisahaemoglobinconcentrationof<4g/dl(orpackedcellvolume<12%).Verysevereanaemiacancauseheartfailureandmustbetreatedwithabloodtransfusion.Asmalnutritionisusuallynottheonlycauseofverysevereanaemia,itisimportanttoinvestigateotherpossiblecausessuchasmalariaandintestinalparasites(forexample,hookworm).
If it isnotpossible to testhaemoglobin, relyonclinical judgment.Forexample, judgebasedonpalenessofgums,palms,lipsandinnereyelids.
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Transfusing a patient with severe acute malnutrition with very severe anaemia (Hb <4.0 g/dl)
1. Lookforsignsofcongestiveheartfailuresuchasfastbreathing,respiratorydistress,rapidpulse,engorgementofthejugularvein,coldhandsandfeet,cyanosisofthefingertipsandunderthetongue.
2. Getbloodready. If therearenosignsofcongestiveheart failure,give10ml/kgwhole freshblood.Iftherearesignsofcongestiveheartfailure,givepackedcells(5–7ml/kg)insteadofwholeblood.
3. Transfuseslowlyover3hours
4. StopalloralintakeandIVfluidsduringthetransfusion.
5. Give a diuretic tomake room for the blood. Frusemide (1mg/kg, given by IV) is themostappropriatechoice.
cardiac Failure
Cardiacfailureistheinabilityofthehearttopumpsufficientlytomaintainbloodflowtomeettheneedsofthebody.Thecommoncauseofcardiacfailureleadingtosuddendeathishypervolemiaduetoover-hydration,over-feeding,bloodtransfusionandhighsodiumdiet.Severemalnutrition,severeanaemia,andseverepneumoniaareamongothercauses.
Itisthereforeimportanttowatchoutforsignsofcardiacfailureduringstabilisationandtransition.Theseinclude:
• Clinicalsignsofdeteriorationwithincreasingweightgain
• Increasingorreappearanceofoedema
• Suddendifficultyinbreathing
• Fastbreathingis50breaths/minin2–12monthsold,40breaths/minifabove1year
• Acuteincreaseinrespiratoryrateby≥5breath/min,especiallyduringrehydration
• Increasingpulseratesof25beats/minalongwithconfirmedincreaserespiratoryrate
• Prominentsuperficialandneckveins
• Coldhandsandfeet
• Cyanosis(bluediscolourationoffingers,toesandunderthetongue)
• Tendernessdevelopingovertheliver
• Acutefallinhaemoglobinconcentration
• Severepalmpallor.
Note: Heart failure and Pneumonia are clinically similar and can be difficult to differentiate.
Ifthepatientgainsweightbeforetheonsetofrespiratorydistress,diagnoseheartfailure
b) Treating Congestive Cardiac Failure
• Positiontheindividualtoanuprightsittingposition
• Giveoxygen
• Stopallfluidsandfeedsuntilcardiacfunctionimproves
• Administerdiuretic(Frusemide1mg/Kg).Thisistoreducefluidandleavewayforblood,and
• Digoxinandcardiotonicsnotoftenadvisedduetothestateofhypokalaemia.
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c) Monitoring a patient in cardiac failure
Closemonitoringofapatientincardiacfailureisessentialduringtreatment.ImportantparametersshouldbetakenfrequentlyandrecordedintheCriticalCarePathwayForm(Annex16)
Theseinclude:• Pulseratesevery30minutes
• Respiratoryratesevery30minutes
• Anassessmentoftheengorgementoftheneckvein
• Anassessmentoftheliversizeandtenderness
• Oxygenflowing
d) Preventing congestive cardiac failure in severe malnutrition
• Feedcautiously,onlygivetheprescribedamountoffeeds
• Avoidbloodtransfusionandonlytransfuseifpatientisveryseverelyanaemic(Hb<4g/dl)asdescribedabove.
• Rehydratecautiously
o GiveIVfluidsonlyincaseofshock
o Changetooralrehydrationassoonaspatientregainsconsciousness(SeedescriptionforIVfluidsabove)
o Giveappropriatesolution(ReSoMal)thatcontainslowsodiumcontentandhighpotassium,andgiveappropriateamounts
Manage Acute Abdomen (paralytic ileus) Septicshockcancomplicateothersystemsincludingthegut,causinggastricdilatationthatpresentwithsuddenabdominaldistension,absentbowelsoundsandintestinalsplash.Paralyticileuscanoccurasaresultofautonomicdisruption,concomitantischaemiaorasaresultofacomplicationofhypokalaemia,abdominaltraumaorsepsis.
Management of acute abdomen associated with shock
• Keepthepatientonnilbymouth
• Giveoxygen
• GiveIVfluids
• PassNGTifindangerofaspiration
• Aspiratecontentsofstomachandrinsewithisotonicclearfluid(5%dextroseor10%sucrose-50mlintostomachandgentlyaspirateallbackagain.Repeatuntilthefluidisclear.
• Introducesugarwater(10%sucrose)intothestomachat5ml/kg.Leaveitinforonehour.
• Aspirateandmeasurethevolume.Ifitislessthantheamountpreviouslyintroduced,returntothestomach.
• GiveBroadSpectrumAntibiotics(Intramuscular(IM)orIV)
• Stopalldrugsthatmaybecausingtoxicity(e.g.metronidazole)
• GivesingledoseofMagnesiumsulphate(2mlof50%solution).
• GivefluconazoleororalNystatintocleargastricandoesophagealcandidiasis
• Keeppatientwarm.
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NOTE: If patient is unconscious, give IV glucose and monitor carefully for 3 hours without any other treatment
Signs of improvement includeachangein intestinalfunction,decreaseinabdominaldistension,visible peristalsis, return of bowel sounds and decreasing volume of gastric aspirate. If patientimproves,startgivingsmallvolume(halftheamount)ofF75byNGT.
If no improvement is recorded after 3 hours, putup IV infusionwithfluid containing adequatepotassium.
YoucanaddSterilePotassium(20mmol/L)toIVsolutionsthathavenopotassium.
give AntibioticsGiveallseverelymalnourishedchildrenantibiotics forpresumed infection.Givethe firstdoseofantibioticswhileotherinitialtreatmentsaregoingon,assoonaspossible.
Antibiotic recommendationswould bebasedon the local patternsof resistance. The importantprincipleisthatallseverelymalnourishedchildrenshouldbegivenappropriateantibiotics.
Select antibiotics and prescribe regimenSelectionofantibioticsdependsonthepresenceorabsenceofcomplicationsaspreviouslydescribed(seesummarytablebelowfordetailsandannex6(antibioticreferencecard))
tAble 16: sUmmAry oF Antibiotics For severely mAlnoUrished children
iF: give:
NOCOMPLICATIONS Amoxicillin oral:25mg/kgevery12hoursfor5daysoruntilreferralforoutpatientcare.
WITHCOMPLICATIONS
(shock,hypoglycaemia,hypothermia,dermatosiswithrawskin/fissures,respiratoryorurinarytractinfections,orlethargic/sicklyappearanceetc)
gentamicin1IVorIM(5mg/kg),oncedailyfor7days,plus:
Ampicillin IVorIM(50mg/kg),every6hoursfor2days
Followedby:Amoxicillin Oral: 25 mg/kg,every12hoursfor5days
If resistance to amoxicillin and ampicillin, and presence of medical complications:
Seedetailsofdrugusebelowthedrugkit(supportmaterial):
Inthecaseofsepsisorsepticshock:IMcefotaxime (Forchildren/infantsbeyondonemonth:50mg/kgevery8to12hours)+oralciprofloxacin (5to15mg/kg2timesperday).
Ifsuspectedstaphylococcalinfections:Add:cloxacillin (12.5to50mg/kg/dosefourtimesaday,dependingontheseverityoftheinfection).
If a specific infection requires an additional antibiotic, ALSO give:
Specific antibiotic aredirectedonthedrugkit(seesupportmaterials).Refertothenotesofthedrugkitforsevereacutemalnutritionwithmedicalcomplications.
1Ifthepatientisnotpassingurine,gentamicinmayaccumulateinthebodyandcausedeafness.Donotgivetheseconddoseuntilthepatientispassingurine.2Ifamoxicillinisnotavailable,giveampicillin,50mg/kgorallyevery6hoursfor5days.
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Manage Corneal Ulceration
Cornealulcerationisabreakinthesurfaceofthecornea(eye’ssurface).Theeyemaybeextremelyredorbleeding,orthepatientmaykeeptheeyeshut.Cornealulcerationisverydangerous.Ifthereisanopeninginthecornea,thelensoftheeyecanextrude(pushout)andcauseblindness.
Check for corneal ulceration.
Touchtheeyesextremelygentlyandaslittleaspossible.Iftheeyesareclosed,waituntilthepatientopenshiseyestocheckthem.
Ifthepatienthascornealulceration,givevitaminAandinstillonedropofatropine(1%)eyedropsimmediately.
TreatalsowithhighdoseofvitaminA(seesectionbelow)ifthepatienthas:
• VisibleclinicalsignsofvitaminAdeficiency(bitot’sspots,cornealclouding,xerosis)
• Signsofeyeinfection(pusinflammation)or
• Measlesnoworinthepastthreemonths
Foreyeinfectiongivegentamicin(0.3%)eyedrops
Manage Dermatosis
Dermatosis refers to any skin disease or condition especially one that is not characterized byinflammation.Dermatosisisgradedasmild(+),moderate(++)andsevere(+++)
Ifthepatienthasonlymildormoderatedermatosis,useregularsoapforbathing.
If the patient has severe (+++) dermatosis, bathe for 10 to 15 min/day in 0.01% potassiumpermanganatesolution.Sponge thesolutionontoaffectedareaswhile thepatient is sitting inabasin.
Ifthepatienthasseveredermatosisbutistoosicktobebathed,dab0.01%potassiumpermanganatesolutionorgentianviolet.
Applybarriercreamtorawareasusingointmentssuchaszincandcastoroilointmentorpetroleumjellyandparaffingauzedressing.Fordiaperareascolonisedwithcandida,usenystatinointmentorcreamafterbathing.Candidiasisisalsotreatedwithoralnystatinorotherrecommendedantifungal.
Micronutrient Supplements
Vitamin A supplementation
Patients with severe acute malnutrition should receive 5000 IU daily recommended intakethroughoutthetreatmentperiod.Thisshouldbeprovidedeitherasanintegralpartoftherapeuticfoodsoraspartofamulti-micronutrientformulation.
ChildrenwithsevereacutemalnutritiondonotrequireahighdoseofvitaminAasasupplementif they are receiving F-75, F-100 or ready-to-use therapeutic food that complies with WHOspecificationsorvitaminAispartofotherdailysupplementsunlesstheyhaveconditionsdescribedalreadyabove(seesectionontreatmentofcornealulcerations).
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ChildrenwithsevereacutemalnutritionshouldbegivenahighdoseofvitaminA(50000IU,100000IUor200000IU,dependingonage)onadmission,onlyiftheyaregiventherapeuticfoodsthatarenotfortifiedasrecommendedinWHOspecificationsandvitaminAisnotpartofotherdailysupplements.
Folic Acid supplement
FolicacidisavitaminoftheBcomplexthatisimportantfortreatingandpreventinganaemiaandrepairingthedamagedgut.Eachchild,exceptinfantslessthan6months,shouldbegivenalargedose(5mg)onDay1andasmallerdose(1mg)onsubsequentdays,unlessthepatientisreceivingF-75andF-100orifthefeedscontainCMV(CombinedMineralVitaminMix).
Multivitamin supplement
IfCMVisusedinpreparingfeeds,thenthefeedswillincludeappropriatevitamins,otherwisegivemultivitamindropsdaily(notincludingiron).
Other Specific Cases
HIV/AIDS
ChildrenwithHIV/AIDSandsevereacutemalnutrition:
• Whoqualifyforlifelongantiretroviraltherapyshouldbestartedonantiretroviraldrugtreatmentas soon as possible after stabilization ofmetabolic complications and sepsis. This would beindicated by return of appetite and resolution of severe oedema.HIV-infected childrenwithsevereacutemalnutritionshouldbegiventhesameantiretroviraldrugtreatmentregimens,inthesamedoses,aschildrenwithHIVwhodonothavesevereacutemalnutrition.
• Whoarestartedonantiretroviraldrugtreatmentshouldbemonitoredclosely (inpatientandoutpatient)inthefirst6–8weeksfollowinginitiationofantiretroviraltherapy,toidentifyearlymetaboliccomplicationsandopportunisticinfections
• ShouldbemanagedwiththesametherapeuticfeedingapproachesaschildrenwithsevereacutemalnutritionwhoarenotHIVinfected
• ShouldreceiveahighdoseofvitaminAonadmission(50000IUto200000IUdependingonage)andzincformanagementofdiarrhoea,asindicatedforotherchildrenwithsevereacutemalnutrition, unless they are already receiving F-75, F-100or ready-to-use therapeutic food,whichcontainadequatevitaminAandzinciftheyarefortifiedfollowingtheWHOspecifications.
• Inwhompersistentdiarrhoeadoesnotresolvewithstandardmanagementshouldbeinvestigatedto exclude carbohydrate intolerance and other infective causes,whichmay require differentmanagement,suchasmodificationoffluidandfeed intake,orantibiotics.Foranyothercaretreatment,refertothenationalHIV/AIDStreatmentguidelines.
malaria
Ifthepatient’stestispositive,treataccordingtothenationalprotocol.
Monitor other danger signs
Watchcarefullyanypatientwithaninfectionsuchaspneumoniaorsepsis,earinfection,orurinarytractinfection(UTI)foroccurrenceofthesignsbelow:
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• Anorexia(LossofAppetite)
• Changeinmentalstate(forexample,becomesLethargic)
• Jaundice(yellowishskinoreyes)
• Cyanosis(tongue/lipsturningbluefromlackofoxygen)
• Difficultbreathing
• Difficultyfeedingorwaking(drowsy)
• Abdominaldistension
• Newoedema
• Largeweightchanges
• Increasedvomiting
• Petechiae(bruising)
• Alertaclinicianifanyofthesedangersignsappear.(Seeannex8forsummaryofdangersigns)
Feeding in Phase I: Stabilization
Feedingisobviouslyacriticalpartofmanagingsevereacutemalnutrition;however,feedingmustbestartedassoonaspossiblewithF75(seerecipesofpreparingF75inAnnex7)cautiouslyandinfrequentsmallamounts.Iffeedingbeginstooaggressively,oriffeedscontaintoomuchproteinorsodium,thepatient’ssystemsmaybeoverwhelmed,andthepatientmaydie.
Determinefrequencyandamountoffeeds
On the first day, feed the patient a small amount of F-75 every 2 hours (12 feeds in 24 hours,includingthroughthenight).Nightfeedsareextremelyimportanttopreventhypoglycemia.
The front of the F75 reference card ( see annex8) of is for severely malnourished children with no oedema, or with mild or moderate oedema.
The reverse side is only for children admitted with severe (+++) oedema.)
Therecommendedamountforachildwithnooedema/oedemagrade+and++is130ml/kg/dayofF75.Ifoedemais+++,therecommendedamountis100ml/kg/day(seeAnnex8fortheamountoffeedtogiveaccordingtothepatient’sweight).
After the first day, increase the volume per feed gradually so that the patient’s system is notoverwhelmed.Givelessfrequentfeeds(every3hoursorevery4hours).
Eachpatient’sfeedingplanshouldberecordedona24-HourFeedIntakeChart(Annex10)
Older children, adolescents and adults should receive the same F75 milk formula as children.Encourageadolescentsandadultstotakethisformulamilkalone.
Feeding methods
Twofeedingmethodsarerecommended:oralorbyNGT.
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Oral Feeding
Duetomuscleweaknessandslowswallowing,theriskofaspirationpneumoniaishighespeciallyformalnourishedchildren.Therefore,greatcaremustbetakenwhilefeeding.PreferablyuseacupandasaucerwhenfeedingchildrenwithSAM.
Caution:
• Never leave the child to feed alone (ensure supervised feeding)
• The patient should never be force-fed; should never have his/her nose pinched, and should never be laid on the back to have the milk poured into his/her mouth.
• Encourage breastfeeding on demand between formula feeds. Ensure that the patient still gets the required feeds of F-75 even if breastfeeding
Feeding by Naso-gastric Tube (NgT)
Itmaybenecessarytouseanasogastrictube(NGT)ifthepatientisveryweak,hasmouthulcersthatpreventdrinking,orifthepatientcannottakeenoughF-75bymouth.Theminimumacceptableamountforthepatienttotakeis80%oftheamountoffered.Ateachfeed,offertheF-75orallyfirst.UseanNGtubeifthepatientdoesnottake80%ofthefeed(i.e.,leavesmorethan20%)for2or3consecutivefeeds.NGfeedingshouldbedonebyexperiencedstaff.DonotplungeF-75throughtheNGtube;letitdripin,orusegentlepressure.
Ifthepatientdevelopsaharddistendedabdomenwithverylittlebowelsound,give2mlofa50%solutionofmagnesiumsulphateIM.
Feeding children who have vomiting
Ifthepatientvomitsduringorafterafeed,estimatetheamountvomitedandofferthatamountoffeedagain.Ifthepatientkeepsvomiting,offerhalftheamountoffeedtwiceasoften.Forexample,ifthechildissupposedtotake40mlofF-75every2hours,offerhalfthatamount(20ml)everyhouruntilvomitingstops.
Providecontinuedcareatnightbecausemanydeathsinseverelymalnourishedchildrenoccuratnight.
Important things not to do and why
Donot givediuretics to treatoedema. Theoedema is partlydue topotassiumandmagnesiumdeficienciesthatmaytakeabout2weekstocorrect.Theoedemawillgoawaywithproperfeedingincludingamineralmix containingpotassiumandmagnesium.Givingadiureticwillworsen thechild’selectrolyteimbalanceandmaycausedeath.
• Do not give iron during the initial feeding phase. Addirononlyafterthechild has been on F-100 for 2 days (usually during week2).Asdescribedearlier,givingironearlyintreatmentcanhavetoxiceffectsandinterferewiththebody’sabilitytoresistinfection.
• Do not give high protein formula (over1.5gproteinperkgbodyweightdaily).Toomuchproteinin the first days of treatmentmaybe dangerous because the severelymalnourished child isunabletodealwiththeextrametabolicstressinvolved.Toomuchproteincouldoverloadtheliver,heart,andkidneysandmaycausedeath.
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• Do not give IV fluids routinely. IVfluidscaneasilycausefluidoverloadandheartfailure inaseverelymalnourishedchild.
BesurethatpersonnelintheemergencytreatmentareaofthehospitalknowtheseimportantthingsNOTtodo,aswellaswhattodo.
Transition
ThisphaseisdesignedtopreparepatientsforPhaseIIorOTC(rehabilitation/catchupgrowth).
How to Recognize Readiness for Transition:
Lookforthefollowingsignsofreadiness:
• Returnofappetite(easilyfinishes3-4hourlyfeedsofF75
• Reducedoedemaorminimaloedema
In settings where RUTF is provided as a therapeutic food in rehabilitation phase:
OncechildrenarereadytomoveintotherehabilitationphaseperformacceptancetestforRUTF(table12)andtheyshouldtransitionfromF-75toready-to-usetherapeuticfoodover2–3days,astolerated.Therecommendedenergyintakeduringthisperiodis100–135kcal/kg/day.
give RUTF slowly and gradually
TwoapproachesfortransitioningchildrenfromF-75toready-tousetherapeuticfoodaresuggested:
• Startfeedingbygivingready-to-usetherapeuticfoodasprescribedforthetransitionphase(seeannex8).Letthechilddrinksafewaterfreely.Ifthechilddoesnottaketheprescribedamountofready-to-usetherapeuticfood,thentopupthefeedwithF-75.Increasetheamountofready-to-usetherapeuticfoodover2–3daysuntilthechildtakesthefullrequirementofready-to-usetherapeuticfood,or
• Givethechildtheprescribedamountofready-to-usetherapeuticfoodforthetransitionphase.Letthechilddrinksafewaterfreely.Ifthechilddoesnottakeatleasthalftheprescribedamountofready-to-usetherapeuticfoodinthefirst12hr,thenstopgivingtheready-to-usetherapeuticfoodandgiveF-75again.Retrythesameapproachafteranother1-2daysuntilthechildtakestheappropriateamountofready-to-usetherapeuticfoodtomeetenergyneeds.
Childrenwithsevereacutemalnutritionwhopresentwitheitheracuteorpersistentdiarrhoea,canbegivenready-to-usetherapeuticfoodinthesamewayaschildrenwithoutdiarrhoea.Ifachildisbreastfeeding,encouragethemothertocontinue.
If the RUTF is not available or if the child does not accept it, give F100:
Thetransitionisspreadoverthreedays,duringwhichtheF-100isadministeredaccordingtothefollowing:
First48hours(2days):GiveF-100every3-4hoursinthesameamountsofF-75thatwerebeinggiven.Donotincreasethevolumefor2days.ThenonDay3:Add10mlateachmealuntilthechildfinisheshismeal.Ifthechilddoesnotfinishameal,offerthesameamountforthenextmeal;ifhe/shefinishesthen,furtherincreasethenextmealby10ml.Continueuntilthechildleavesabit
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ofmostofhismeals(usually,whenthevolumereachedaround30ml/kgpermeal).Ifthechildisbeingbreastfed,encouragemotherstobreastfeedbetweenF-100rations.
In inpatient settings where F-100 is provided as the therapeutic feed in the rehabilitation phase:
ChildrenwhohavebeenadmittedwithcomplicatedsevereacutemalnutritionandareachievingrapidweightgainonF-100shouldbechangedtoready-to-usetherapeuticfoodandobservedtoensurethattheyacceptthedietbeforebeingtransferredtoanoutpatientprogramme
F100 should never be given to take home.
Providing medical treatment in the transition phase
Continuetheroutinemedicaltreatment(Table16)andrecordontheCriticalCarePathway(CCP).GiveanyspecificmedicaltreatmentprescribedandrecordontheCCP.
Monitor the patient carefully during transition
Inthetransitionphase,individualmonitoringofpatientsisdoneevery4hours.Checkthepatient’srespiratoryandpulserateandcallaclinicianforhelpifanydangersignsoccur.
Criteria for Transfer from Transition back to Stabilization phase
Allpatientswhodevelopsignsofmedicalcomplicationsshouldbereturnedtostabilizationphase.Thesignsinclude;• Lossofappetiteandnottaking80%ofthemeasuredfeeds
• Increasing/developmentofoedema
• Medicalconditionsnotimprovingorjustdeteriorating
• Anysignsoffluidoverload
• Significantre-feedingdiarrhoeasothatthereisweightloss
Criteria for Transfer from Transition to OTC or Phase II
• Goodappetite(ifthepatientpassestheacceptancetestandtakesmorethan80percentofthedailyrationofRUTF)
• Reducedoedemato++/Grade2or+/Grade1ornooedema
• Medicalcomplicationshavebeenresolved
• Clinicallywellandalert
6.4 RehabilitationPhase/Phase2ApatientprogressingtotherehabilitationphaseonRUTFcanbedischargedfromITCtoOTCifavailable.
RefertoOTCwhenthepatientistakingtheentireamountofRUTFproposedduringtransition(atleast150kcal/kg/day).
Beforeleaving,themother/caretakershouldreceivearationofRUTFcoveringtheneedsofthechildforonetotwoweeksandshouldbeinformedofthereferralsiteclosesttowherehelives.
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If no programme for outpatient management of severe acute malnutrition is available:
Duringrehabilitation,thepatientisexpectedtogainweightrapidly,andtheamountofF-100givenshouldbeincreasedasthechildgains.Ifnopossiblereferralforoutpatientcare,feedfreelywithF-100duringrehabilitation,toanupperlimitof220Kcal/kg/day(seeannex8foramounts)
Medications in Rehabilitation phase/Phase 2Thepatientshouldcontinuetoreceiveanyprescribeddrugsandcompletethecourse.
RoutinemedicinesandsupplementsshowninTable17shouldfollowthescheduleasprescribed.
tAble 17: roUtine medicines And sUpplements
medicAtion WHAT TO gIVE / USE FreQUency
Ironsupplement FerrousSulphate300mgs/day(3mgelementalFe/kg/day)
2divideddoses
do not give iron iF the child receives rUtF
Note:Evenifthepatientisanaemic,heshouldnotbegivenironuntilheisrecoveringandhasbeenonF-100fortwodays(i.e.aftertwodaysoftransition).Ifgivenearlier,ironcanhavetoxiceffectsandreduceresistancetoinfection.
De-worm7 Mebendazole>1year:500mg
Albendazole≥1year:200mgs
Albendazole>2years:400mgs
Measlesimmunisation8
9months(upto5years)ifnorecordthatithasbeengivenbefore
Singledoseafter2daysonF-100orRUTF
Singledoseassoonasthechildisstable
Monitoring During Phase II Individualmonitoringof the recoveringchild in rehabilitationphase isdonedaily.The followingparametersshouldbemonitoreddailyandrecordedontheCCP:
• Bodytemperature,pulseandrespirationrate
• Weight,whichshouldbeplottedontheweightchartoftheCCP(RefertoAnnex16).
• Oedema
7 ReportoftheWHOInformalConsultationontheuseofPraziquantelduringPregnancy/LactationandAlbendazole/MobendazoleinChildrenunder24months
8 ManagementofsevereMalnutrition:Amanualforphysiciansandotherhealthworkers,WHO1998
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• Vomitingordiarrhoea
• Refusaltofeed
• Clinicalexamination.
• Length/heightorMUACatdischarge
6.5 CriteriatomovefromPhaseIIbacktotheStabilisationPhase(Phase1)If a patient develops any signs of a medical complication, he should be referred back to thestabilisationphase.
Failure to Respond during Rehabilitation phase
Somepatientsmayfailtogainweightduringrehabilitation.Suchpatientsshouldbere-evaluatedinvestigatedandtreatedappropriately
Criteria for discharging children 6 – 59 months from treatment
Childrenwithsevereacutemalnutritionshouldonlybedischargedfromtreatmentwhentheir:
• Weight-for-height/lengthis≥–2Z-scoreandtheyhavehadnooedemaforatleast2weeks,or
• Mid-upper-armcircumferenceis≥12.5cmandtheyhavehadnooedemaforatleast2weeks.
Criteria for discharging patients 5 years and above
• RefertoTable2forMUACandBMIcut-offsand
• Theyhavehadnooedemaforatleast2weeks.
Theanthropometricindicatorthatisusedtoconfirmsevereacutemalnutritionshouldalsobeusedtoassesswhetherapatienthasreachednutritionalrecovery,i.e.ifmid-upper-armcircumferenceisusedtoidentifythatapatienthassevereacutemalnutrition,thenmid-upperarmcircumferenceshouldbeusedtoassessandconfirmnutritionalrecovery.Similarly,ifweight-for-length/heightisusedtoidentifythatapatienthassevereacutemalnutrition,thenweight-for-length/heightshouldbeusedtoassessandconfirmnutritionalrecovery.
Childrenadmittedwithonlybilateralpittingoedemashouldbedischargedfromtreatmentbasedonwhicheveranthropometricindicator,mid-upperarmcircumferenceorweight-for-length/heightisroutinelyusedinprogrammes.
Percentage weight gain should not be used as a discharge criterion
give general discharge instructions
Inadditiontofeedinginstructions,mothers/caregiverwillbetaught:
• Howtocontinueanyneededmedicationsathome
• Signstobringthechildbackforimmediatecare(Refertodangersigns)
• Whenandwheretogoforplannedfollow-up:-at1week,2weeks,1month,3months,and6months;-thentwiceeveryyearuntilwhenthechildis3yearsold.
• Whereandwhenachildshouldbetakenforgrowthmonitoringandpromotiononmonthlybasisupto2years
• Whentoreturnfornextimmunization.
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• WhentogotothehealthcentreforvitaminAanddeworming(every6months);
• Howtocontinuestimulatingthechildathomewithplayactivities.
IfapatienthastobetransferredtoOTC,thefollowingactionsshouldbetaken:
• Completeareferralsliptooutpatientcare,includingasummarysectiononmedicalinterventionandtreatmentgiventothepatient.
• Informthemother/caregiverwhereandonwhichdaytogoforoutpatientcare
• Givemothers/caretakerskeymessagesonRUTFandbasichygiene.
• Themother/caregivershouldalsobegiveninstructionsformedicationsathome
• Informthemother/caregivertoreturnthechildonappearanceofanydangersigns.
Ifearlydischarge (before reaching -2SD) isunavoidable,and there isnoprogrammeforOTC, itiscriticaltomakespecialarrangementsforfollow-up(homeandspecialcarevisitsbysocialandhealthcare)(SeedischargecardinAnnex14)
Ensureadequatearrangementsforlinkingthecaregiverandpatientwithappropriatecommunityinitiativesandforfollow-uphavebeenmadesuchassupplementaryfeeding,foodsecurity,socialprotection,safetynets,etc.
tAble 18: types oF dischArges, conditions And Actions From itc
cAtegory oF dischArge
dischArge criteriA Action
Cured • Acutemedicalconditionshavebeenresolved
• Thepatientiseatingwell(caneatfamilyfoods)
• Nobilateralpittingoedemafortwoweeks
• Clinicallywellandalert• WFL/H≥-2z-scores(infants,
childrenandadolescents)• MUAC≥12.5cm(children6to59
months)
• TransfertoSFPifaccessible/availableforfollowuponceeverymonthforthreemonths
• Referforfollow-upatclosesthealthfacilityandcommunity
• Linktotheavailablelivelihoodprogrammes
• ForHIV-positiveclients,ensureongoingtreatmentthroughanHIVtreatmentprogramme
TransfertoOTC • Noworryingmedicalcondition• Passedappetitetest• InTransitionPhaseandtakingRUTF• Oedemaifpresenthasreducedto
+/Grade1or++/Grade2
• TransfertonearestfunctionalOTCifavailable
Died • Diedwhileonprogramme • Completefileandcardappropriately
Defaulted • Absentfortwoconsecutivedays • Mayre-entertheITCifpatientmeetstheadmissioncriteria
• Re-admitwiththeoldregistrationnumberandinvolvetheVillageHealthTeamforfollow-upduringhomevisits,ifavailable.
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CHAPTER SEVEN inPatient management of infants
Less than six months with sam
7.0 IntroductionSevereacutemalnutritionin infantswhoarelessthan6monthsofageisdefinedas;weightforlength<-3Z-scoreorpresenceofbilateralpittingoedema.
Infantslessthan6monthsoldwithSevereAcuteMalnutrition(SAM)shouldalwaysbetreatedinaninpatientunituntildischarge.TheobjectivesofITCareto:
• improveorre-establish,effectiveexclusivebreastfeedingbythemother
• providetemporaryorlonger-termappropriatetherapeuticfeedingfortheinfants;and
• Providenutrition,psychological,andifneededmedicalcareforthecaregivers.
Infantslessthan6monthsmaybecomemalnourishediftheyhaveneverbeenbreastfedorbeenonlypartiallybreastfed.Therearealsoothercausesofmalnutritioninthisagegroupwhichmayberelatedtoeitherthemotherorthechild.
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7.1 AdmissionCriteria• Weight-for-lengthlessthan-3Z-scores
• Anypittingoedema
• Recentweightlossorfailuretogainweight
• Ineffectivefeeding(attachment,positioningandsuckling)directlyobservedfor15-20minutes,ideallyinasupervisedseparatearea
• Anymedicalorsocialissueneedingmoredetailedassessmentorintensivesupport(e.g.disability,depressionofcaregiver,orotheradversesocialcircumstance)
• Anyseriousclinicalconditionormedicalcomplicationasoutlinedforinfants6monthsofageorolderwithsevereacutemalnutrition
• Anyinfantswhohavebeenidentifiedtohavepoorweightgainandwhohavenotrespondedto nutrition counselling and support (IMCI) should be admitted for further investigation andtreatment
• AnyinfantwithageneraldangersignasdefinedbyIMCIshouldbeadmittedforurgenttreatmentandcare
Severelymalnourishedyounginfantsneed:
1. Diagnosisofmedicalcomplicationsandtreatmentifanyarefound.
2. Warmthtotreatandpreventhypothermia.
3. Initialre-feeding(formetabolicstabilization)whichmayrequiremilkfeedsinadditiontobreastmilk,orwhereaninfantisnotbreastfedinsteadofbreastmilk.
4. Feedingforcatch-upgrowth(nutritionrehabilitation).
5. Continuousmonitoringofweightandfeedintake.
6. Follow-uptoreducetheriskofbecomingmalnourishedagain.
Note: Low birth weight infants are not usually severely wasted or oedematous and so are unlikely to meet the criteria for SAM. Therefore, they should be managed according to the WHO guidelines specifically for “Low birth weight babies”.
7.2 StabilizationPhase
Medical management and micronutrient supplementation
Infantswhoarelessthan6monthsofagewithsevereacutemalnutritionshouldreceivethesamegeneralmedicalcareasinfantswithsevereacutemalnutritionwhoare6monthsofageorolder:
• Infantswith severe acutemalnutritionwho are admitted for inpatient care should be givenparenteral antibiotics to treat possible sepsis and appropriate treatment for other medicalcomplicationssuchastuberculosis,HIV,surgicalconditionsordisability;
• Infantswithsevereacutemalnutritionwhoarenotadmittedshouldreceiveacourseofbroad-spectrumoralantibiotics,suchasamoxicillin,inanappropriatelyweightadjusteddose
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Feeding during stabilization
• TheFeedingapproachforinfantswhoarelessthan6monthsofagewithSAMshouldbeprioritizeestablishing,orre-establishing,effectiveexclusivebreastfeedingbythemotherunlessunderdifficultcircumstances (orphaned,abandoned,medical reasons). Ifan infant isnotbreastfed,supportshouldbegiventothemothertorelactate.
• InfantslessthansixwithSAMshouldalsobeprovidedasupplementaryfeed:
o Supplementarysucklingapproachesshould,wherefeasible,beprioritized.
o Forinfantswithsevereacutemalnutritionbutnooedema,expressedbreastmilkshouldbegiven,and,wherethisisnotpossible,commercial(generic)infantformulaorF-75ordilutedF-100(seeBoxG)maybegiven,eitheraloneorasthesupplementaryfeedtogetherwithbreastmilk.
o Forinfantswithsevereacutemalnutritionbutnooedema,expressedbreastmilkshouldbegiven,and,wherethisisnotpossible,commercial(generic)infantformulaorF-75ordilutedF-100maybegiven,eitheraloneorassupplementaryfeedtogetherwithbreastmilk.
• Forinfantswithsevereacutemalnutritionandoedema,infantformulaorF-75shouldbegivenasasupplementtobreastmilk.
• Supportthemothertobreastfeedevery2to3hoursforatleast20minutes.
• InfantslessthansixwithSAMshouldnotbegivenundilutedF-100atanytime(owingtothehighrenalsoluteloadandriskofhypernatraemicdehydration).
• Ifthereisnorealisticprospectofbeingbreastfed,theinfantsshouldbegivenappropriateandadequatereplacementfeedssuchascommercial(generic)infantformula,withrelevantsupporttoenablesafepreparationanduse,includingathomewhendischarged.
• Inadditionassessmentofthephysicalandmentalhealthstatusofmothersorcaregiversshouldbepromotedandrelevanttreatmentorsupportprovided
Feeding an infant less than six months of age with SAM with prospect to breastfeed
The main objective is to restore effective exclusive breastfeeding. During the initial phase oftreatment,breastfeedingmustbecomplementedwith infantformulaorcommercialtherapeuticmilk,whilestimulatingtheproductionofbreastmilk.
If the infant is able to suckle:
Theinfantshouldbebreastfedasoftenaspossible.Encouragethemothertobreastfeedtheinfantatanytime,assoonastheinfantwants,betweenshotsofmilksupplement.
o Halfanhourtoanhourafterfeeding,givetherapeuticmilkusingasupplementalsucklingtechnique(SST)(seesectionbelow).
o Thetherapeuticmilkshouldbegiven2to3hourly(seeannex9foramounts).
• Donotincreasetheamountoftherapeuticmilkiftheinfantisregularlygainingweight.
Iftheinfantlosesweightorhasastaticweightonthreeconsecutivedays,buttakesallfeedsandcontinuestobehungry,add5mlmoreateachfeed.
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Feeding Procedure:
• During breastfeeding, ensure goodpositioning and good attachment of theinfanttoensureefficientsuckling.
• Use the SST to stimulate breast milkproduction. If this is not possible, give themilk supplement with a cup and a sauceror nasogastric tube (using gravity but notpumping).
Note: Only feed with an NGT when the infant is not taking sufficient milk by mouth
The supplemental suckling technique
The SST is recommended to re-establishbreastfeedingaswellastoprovidemaintenanceamounts of therapeutic feeds for severelymalnourished infants. This method involvesthe infant suckling the breast while taking asupplement(therapeuticfeed).Thetherapeuticfeed supplement is given in a cup through athin tube along the nipple. The mother holdsa cup containing F75. The tip of a nasogastrictube (size No. 8) is placed in the cup and theother end of the tube is placed on the nippleof thebreast (Figure13).The infant shouldbepositionedtobreastfeed.Thecupisplaced5-10cmbelowthenippletofacilitatebreastfeeding.Whenthebabysucklesmorestrongly, thecupcanbeloweredto30cm.
FigUre 13: sUpplementAl sUckling techniQUe
F100-Diluted for infantsInfants below 6months of age should notreceiveF100fullstrengthastheconsistencyis unsuitable, F75 and F100 diluted havesimilar concentration to breast milk witharound 75 calories per 100ml. PreparedF100 should be further diluted by adding30%safewater
IfF100isnotreadilyavailable,infantscanbefedwiththesamequantitiesofcommercialinfant formula diluted according to theinstructionsonthetin.Ifthereisarangeofmilkformulastochoosefrom,useaformuladesignedforprematureinfants.
Notethatinfantformulaisnotdesignedtopromoterapidcatch-upgrowth.
Unmodified powdered whole milk should notbeused.
boX c
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IftheinfantisNOTabletosuckleorissucklingweakly:
• Ifthemotheriswilling,encouragehertostartexpressingherbreastmilk.
• Showherhowtohandexpressallthatshecanatleast8-12timesaday.Thiswillstimulateherbreaststomakemoremilk.
• Measuretheexpressedbreastmilkand feed it to thebabybycupandsaucerornasogastrictube,inthesamewayasthesupplementarymilk.
• Givetheexpressedbreastmilkinadditiontothefullamountofsupplementarymilk.
• Whentheinfantstartstosuckle,givesomeorallofthesupplementaryfeedsbysupplementarysucklingtechniqueifpossible.
• Ifthemotherisreluctanttoexpresshermilkbutherbabyistooweaktosuckleeffectively,useSSTwiththecupheldashighasthebaby’smouth.Astheinfantgainsstrength,lowerthecup.
Feeding during Transition:
Whentheinfantbeginstogainweight(atleast20gperday)for2to3days:
• Graduallydecreasetheamountofmilksupplement(therapeuticfeed)byonethird,sothattheinfantgetsmorebreastmilkandmaintainthisamountfor2to3days
• Iftheinfantcontinuestogainweightsatisfactorily(20gperday),furtherreducetheamountofmilksupplement,inthesameproportions,untilnotgivinganymore.
• Ifweightgain isnotsatisfactorywithreducingthevolumeofmilksupplement, increasethevolumetothepreviouslevelfor2daysandtryagain.
Feeding during Rehabilitation:
Duringthisphase,theinfantshouldnotreceiveanymoremilksupplementandshouldbegainingweightwithexclusivelybreastfeeding.
Observe feeding in order to ensure that the infant is feedingwell, and as often and as long aspossible.
Preparethemothertoexclusivelybreastfeedtheinfantuntiltheageof6monthsbeforestartingtodiversifyfoodat6months.
Note: If the mother is HIV positive, refer her for specialized care on HIV and infant feeding.
Discharge criteria:
Any in-patient stay inanutritionwardorhospital shouldbeas short aspossible toavoid crossinfectionanddefaulting.
Infantswhoarelessthan6monthsofagecanbedischargedwhen;
Theyarebreastfeedingeffectivelyorfeedingwellwithreplacementfeeds
• Breastfedinfantscanbedischargedwhentheyhavegainedaminimumof20gramsperdayonbreastfeedingalonefor5days,regardlessofthetotalbodyweightorweight-for-length
• Haveweightforlength≥-2Z-score
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Feeding infants less than six months with SAM with no prospect to breastfeed
Feeding during Stabilization
Incaseswherethemotherdiedorunderdifficultcircumstancesasalreadydescribedabove,theinfantshouldtobefedonappropriateandadequatereplacementfeedssuchascommercialinfantformula,orF75ordilutedF100:
• Dilutetheinfantformulaasdirectedonthepackage
• Calculatetheappropriatevolumeaccordingtotheweightoftheinfantonadmission(seeAnnex9foramountstogive).
• Give the volume for 24 hours inmeals organized every 2 hourswith a cup and a saucer ornasogastrictube
• Continuetogivethefullvolumeofmilkuntilthebabyshowsthefollowingsignsofrecovery:
o Lossofalloedema
o Improvedappetite
Feeding during Transition
Thisphaseshouldcontinuefor4-5days.
Whentheinfantshowsthesignsofrecoverymentionedabove:
• Increasethevolumeby30%(seeAnnex9fordetails)
• Monitortheinfant’sweight.Weigheverydayanduseappropriatescales.
Feeding during Rehabilitation
Duringrehabilitation,infantsshouldbefedusingacupandasaucer;themotherorcaregiverwillhavetobesensitizedtousethesamemethodtofeedtheinfantathomeafterdischarge.
• After4-5days,increasethevolumeofmilkrationsforanother30%(seeAnnex9)
• Iftheinfantisstillhungryafterfinishingthefeed,givehimmore.Increasethefeedsby5mlperfeed
Itisessentialtoshowtheinfant’scaregiverhowtodilutecommercialinfantformula(cleanwater,properdilution),howmuchtogive,howoftenandhowtocleantheutensilsduringtherehabilitationphase.
Supervisepreparationoffeedsandfeedingwhiletheinfantisonthenutritionunit/ward.
Discharge criteria:
Foraninfantwhoisnotbreastfed,theplanningandpreparationfordischargeisespeciallyimportantsincethefuturefeedingsecurityoftheinfantismoreuncertainthanifhewasbreastfed.
Dischargecanbedonewhen:
• Stafffindsthatthepersoncaringfortheinfantisconfidenttoprepareandgivethebreastmilksubstitutecorrectly
• Theinfanthasgainedatleast20gperdayfor5days
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Micronutrient supplementation
Theinfantshouldreceivethefollowingmicronutrientssupplements:
vitamin A:
• Giveadoseof50,000IUtoeveryinfantatthetimeofdischargefromthenutritionunit/ward.
Iron:
• Ironsupplementshouldbegivenwhentheinfantstartstogainonweight.• Giveiron3mg/kg/dayintotwodivideddoses(crushthetabletanddiluteitinthemilk).
Folic acid• Give2.5mg(onetablet)asasingledoseonadmissionifachildisbeingfedonF75ordiluted
F100.
• Ifachildisbeingfedoninfantformulagive2.5mgoffolicacidonthefirstdayandasmallerdose(1mg)onsubsequentdays.
• Thechildshouldbesenthomewithatleastaweek’ssupplyoffolicacidondischarge
• Whenachildreturnsforfollowup,morecanbegiven.
7.3 MonitoringinfantswithSAMInfantslessthan6monthswithSAMarefragileandrequireclosemonitoring.Theseinfantsneedtobereviewedbyanurseordoctorornutritionistdaily:
ThefollowingparametersshouldbemonitoreddailyandrecordedontheCCP:
• Recordandreviewthetotalintakeofsupplementarymilkfeedsand/ornumberofbreastfeedsper24hours.
• Assessandrecordoedema(+/Grade1,++/Grade2,+++/Grade3)
• Monitorweight gain, urinary output, activity level and other signs that breastmilk is beingproduced.Minimumacceptableweightgainduringcatch-upgrowthinyounginfants(weighinglessthan4kgsonadmission)is20geveryday
Note: other important information such as: vomiting, refusal to be fed, placement of a nasogastric tube.
7.4 Infantfeedingcounsellingandsupport• Mothersshouldbecounselledandsupportedtocontinuebreastfeedingortore-lactateifthey
hadstopped.
• Infants should be supplementedwith therapeuticmilk administered through the SST. This isnecessaryasatemporarymeasureuntilbreastfeedingorre-lactationisfullyestablished.
• HIV-positivemothersofinfantswithSAM,shouldbesupportedtocontinuebreastfeedingasperthecurrentnationalHIVpolicyguidelinesonInfantandyoungchildfeeding.
• A mother choosing to re-lactate will need more support than a mother who is alreadybreastfeeding.
• Motherandbabyshouldsleeptogethertoencouragebreastfeedingespeciallyovernight.
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Nutrition support for the breastfeeding mother
• Allmotherswhoarebreastfeeding/re-lactatingshouldbecounselledand supportedon theirownfeedingandnutrition.Wherepossible,theyshouldreceiveextrameals.
• AllbreastfeedingmothersshouldreceiveIronandfolicacidsupplements(60mgofironperdayand400mgoffolicacid)tocomplete6monthsupplementation.
Infants less than 6 months of age with SAM and who don’t require inpatient care, or whose caregivers declined admission for assessment and treatment.
• CounsellingandsupportforoptimalIYCFshouldbeprovided,basedongeneralrecommendationforfeedinginfantsandyoungchildren,includingforlowbirthweightinfants
• Weightgainoftheinfantshouldbemonitoredweeklytoobservechanges;ifinfantdoesn’tgainweight,orlossesweightwhilethemotherorthecaregiverisreceivingsupportforbreastfeeding,thenhe/sheshouldbereferredtoinpatientcare
• Assessmentofthephysicalandmentalhealthstatusofmothersorcaregiversshouldbepromotedandrelevanttreatmentorsupportprovided
Follow-up
Continuityofcareafterdischargeisimportantfortheseinfants,tosupervisethequalityofrecoveryandeducatethecaregivers.Itisalsoimportanttosupporttheintroductionofcomplementaryfoodsattheappropriateageof6months.
• Monitor infant’s progress closely, support safe replacement feeding and growth monitoringthroughclosehealthfacilityormaternalandchildhealthprogramme
• HIVexposed/positive infantsshouldbereferredandfollowedup inPaediatricHIVclinic/anti-retroviraltherapyclinic
• Supportbreastfeeding/replacementfeedingthroughclosehealthfacilityormaternalandchildhealthprogramme.
• It is also important to support appropriate introduction of complementary food at age of 6months
Discharge from all Care
Infantswhoare lessthan6monthsofageandhavebeenadmittedto ITCcanbetransferredtooutpatientcarewhen:
• Allclinicalconditionsormedicalcomplications,includingoedema,areresolved,
• Theinfanthasgoodappetite,isclinicallywellandalertandweightgainoneitherexclusivebreastfeedingorreplacementfeedingissatisfactorye.g.abovethemedianoftheWHOgrowthvelocitystandardsormorethan5gms/kg/dayforat-least3successivedays
• Theinfanthasbeencheckedforimmunizationsandotherroutineinterventions,andthemothersorcaregiversarelinkedwithneededcommunitybasedfollow-upandsupport.
• Infantswhoarelessthan6monthsofagecanbedischargedfromallcarewhentheyarebreastfeedingeffectivelyorfeedingwellwithreplacementfeeds,andhaveadequateweightgainandhaveaweightforlength≥-2Zscore
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CHAPTER EIGHTemergency nutrition resPonse
8.0 IntroductionEmergenciesmaybeeitherman-madedisaster, suchas anexacerbationof anon-going conflictwithpopulationdisplacement,orduetoenvironmentalissuessuchasaseriousdroughtorsevereflooding/landslides.Thelocalinfrastructuremaynothavethecapacitytorespondduetolimitedresourcesparticularlyfinancial,human,logisticsand/orstructurallimitations.Geographicalisolationmay furtheraffectability to respond.When situations suchas thisoccurespecially if there is asubstantialproportionofthepopulationaffected,thisoftenresultsinfoodshortagesandimpairsthenutritionalstatusofaffectedcommunities,inparticularinfants,childrenandadolescents,butalsoadults,especiallypregnantandlactatingwomenandelderlypersons.Thereisaneedtorapidlyrespondtopreventincreasedand/orexcessivemorbidityandmortality.
Nutritional EmergencyNutritionalemergencyoccurswhenthereisanabnormallyhighrateofacutemalnutritionresultingfromacrisisevent.
• Globalacutemalnutritionrate>10%or
• Crudemortalityrate>1death/10,000personsperdayor
• Under-fivemortalityrates>2deaths/10,000underfivesperday(SPHERE,2004)
Emergency Nutrition Response: An intervention that primarily aims to prevent individualswithmildandmoderatemalnutritionfrombecomingseverelymalnourishedandtotreatall formsofacutemalnutritionduringnutritionalemergencies.
Therearethreemainnutritionreliefresponses:o Generalfooddistributionsforalltheaffectedhouseholds*
o SupplementaryFeedingProgramme(SFP)formoderatelymalnourished individualsandat-riskgroups(blanketortargeted)*
o Therapeuticfeedingprogramme(TFP)forseverelymalnourishedindividuals*
• FormoreinformationontheserefertorelevantsectionsofthisIMAMguideline.
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Emergencynutritioninterventionsrequiresubstantialresourcestobeset-upandmonitored.Non-governmentalorganisations(NGOs)oftensupporttheMinistryofHealth(MoH)withcollaborativeimplementation.
8.1 StepsforEmergencyNutritionResponse
Step 1: Coordination and information sharing
Coordinationofalltheemergencyactivitiesatalllevelsandamongallimplementingpartnersiskeytoensureeffectiveness.Thispreventsduplicationofprogrammesandalsoidentifiesgapsthathavenotbeenmetineachsector.
Step 2: Conduct Rapid Nutrition Assessment
• Jointlyplanandconductaninitialassessmenttounderstandthesituationandidentifytheextentofthethreattopeople’slives,theircopingstrategiesandaccesstoservicessuchashealth,safedrinkingwater/sanitationandbasicdietusingnationalstandardisedtoolsorguidelines..
• Conductamulti-sectoralassessment,tounderstandthedifferentfactorsaffectingmalnutritioni.e. the immediate, underlying and basic causes. This will ensure a holistic approach to themanagementofacutemalnutrition.
• Review existing interventionswhere an existing humanitarian response is in place but thereisdeteriorationinthesituation,andidentifyneedsrequiredtoincreasecapacitytomeetthedemandsofadeterioratingsituation.
• Carryouton-goingnutritionsurveysperiodicallyduringtheprogrammetomonitoreffectivenessofresponse
Step 3. Selecting appropriate emergency nutrition responses
• Whentheemergencyassessmentreportsindicatethatthenutritionneedsareunmet,and/orthereareincreasing/highlevelsofacutemalnutrition,appropriateresponsesareidentified.Adecisionchart(Figure13)canbeusedforguidanceonthetypeofresponserequired.
• The under five age-group, pregnant and lactating women are usually the primary target inemergencynutritioninterventions.OtheridentifiedvulnerablegroupssuchastheelderlyandchronicallyillespeciallyPeopleLivingwithHIV/AIDS(PLWHA)andTBpatientsshouldbetargeted.
• Thenutritionstatusofunder5agegroupisusuallytakenastheproxyindicatorofthenutritionstatusofthecommunitytoinformnutritionplanninginemergencysituations.
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FigUre 14: decision tree For the implementAtion oF selective Feeding progrAmmes
Step 4. Planning an emergency nutrition response
Theseresponsesshouldinclude:• Establishing an emergency response team (refer to section 8.2) with defined roles and
responsibilities.
• Selectingnutritionprogrammesites.Programmesitesareidentifieddependingonthepopulationsizeaffected,theplannedgeographicalcoverageandaccessibility.Thesizeoftheprogrammewilldependonthepopulationneedsandthecapacityoftheimplementingpartner.Theareacanbedefinedbyusingadministrativeboundaries.
• Integrating screening and referral for acutemalnutritionat all health facility and community
aggravating Factors
General food ratio below the mean energy requirements
Crude mortality rate > 1 per 10,000 per day
Epidemic of measles or whooping cough
High prevelance of respiratory or diarrhoeal diseases
Malnutrition rate
Proportion of child population (6 months to
5 years) who are
• below 80% weight for height or
• below -2 Z-score weight for height
MALNUTRITION RATE10-14%
OR
OR
MALNUTRITION RATE<5% in presence of
AGGRAVATING FACTORS
MALNUTRITION RATE>=15%
MALNUTRITION RATE10-14% in presence of AGGRAVATING FACTORS
MALNUTRITION RATE5-9% in presence of
AGGRAVATING FACTORS
MALNUTRITION RATE<10% WITH NO
AGGRAVATING FACTORS
SERIOUSBLANKET supplementary
feeding programme
THERAPEUTIC feeding Programme
ALERTTargeted supplementary
feeding programme
THERAPEUTIC feeding programme
ACCEPTABLENo need for population level
interventions(individual attention formalnourished trhough
regular community services)
ALWAYS IMPROVE GENERAL RATION
GENERALRATION<2,100
Kcals/person/day
OR
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contactpoints.Ensuremedical-nutritional follow-upofpatientswithMAMandSAMwithoutmedical complications andmanagementof thosehaving SAMwithmedical complications asin-patients.
• Maximizingpositiveimpactandlimitingharm(beawareofcompetitionforscarceresources/increasedresources,misuseormisappropriationofsupplies).
• Providingequitablehumanitarianservices..
8.2 GeneralrequirementsforEmergencyNutritionReliefProgrammesPersonnel• When implementing emergency nutrition interventions the appropriate staff and staffing
levelsarevital.Thereisaneedformanagers/administration,logisticssupport, technicalstaff(clinicians,nutritionists,nurses,recordsperson,etc)andsupportstaff.
• Wherepossiblepriotizerecruitmentofqualifiedlocalstaffastheyunderstandthecontext,speakthelocallanguageandunderstandthecultureofthepopulation.
• Allthestaffmustbetrainedandorientatedpriortocommencingthereliefprogrammes.Theyshouldhaveclearjobdescriptionswithclearrolesandresponsibilities.
Thefollowingaresomestaffneededonsite:• Programmemanager
• Supervisors,
• Technicalstaffe.g.doctors,nutritionists,nurses,pharmacistsetc.
• Administratorssuchasregistryclerks
• Store-keepersandfooddistributionsupervisors
• Supportstaff(Securityguards,cleaners)etc
• Villagehealthteams(VHTs)orCommunityhealthextensionworkers(CHEWs).
Supply Provision Inanyemergencyresponse, it is importanttohaveagoodlogisticssystemtoensurethereisnobreakinthesystem.Theseprogrammesneedtoruncontinuouslyandnotbeaffectedbylackofcommodities.Bufferstocksshouldbeinplaceespeciallywhereinsecurityisanissue.
Programme Linkages for Prevention and Management of Acute Malnutrition in EmergenciesPreventing and addressing under nutrition requiresmulti-sectoral action and other programmelinkagesforpreventionandmanagementofacutemalnutritioninemergencies.Theseinterventionsincludeinfantandyoungchildfeedinginemergencies(IYCF-E),health,water,sanitationandhygieneandfoodsecurity.
i) Acute malnutrition
• ThemanagementofMAMshouldbelinkedwiththemanagementofSAMwhereverpossible.• Linkagesatthehealthfacilityandcommunitylevelsareessentialinemergenciestotakecareof
theincreasednumbersofacutelymalnourishedchildren.
• Referralmechanismsbetweenpreventionandmanagementofacutemalnutritionactivitiesarealsoveryimportantandshouldbeestablishedaspartofthenutritionresponse.
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ii) Infant and young Child Feeding in emergencies (IyCF-E)
• It is importanttoaddressIYCF-Easpartofthepreventionofacutemalnutrition,particularlyto emphasizeexclusive and continuedbreastfeeding andoptimal complementary feeding inchildren6-23monthsofage.
• It isalso importantto includebasic informationon infantandyoungchild feeding inanHIVcontext.
iii) Health and Water/Sanitation
• Earlyandacceleratedmanagementofsanitation,hygiene,watersources,andhealthprogramsforcommonchildhoodillness(e.g.,diarrhoea,measles)shouldaugmentthemanagementofacutemalnutritionduringanemergency.
• Feedingcentresanddistributionsitesshouldincludeaccesstosafewaterfordrinkingandforhand-washing.
iv) Food Security and Livelihood Programmes
• Wherefoodinsecurityisaresultofanemergencyorexistspriortotheemergency,resourcesshouldbespentonnutritioninterventionsforpreventionofacutemalnutritionortreatmentofMAMonlywhenaGFDorequivalenttransferincashorvoucherisinplace.
8.3 ExitStrategyforEmergencyNutritionResponse(ENR)AnexitstrategyshouldbedevelopedrightatthebeginningoftheENRprogrammethroughstronginvolvementofthedistricthealthteamsand/orstaffoftherelevanthealthfacilities.
Anexitstrategyindicateswhenanemergencyinterventionshouldbephasedoutorcloseddown.Inemergencynutritioninterventionsthisoccurswhenthelevelsofacutemalnutritionhavereduced(<10%withnoaggravatingfactors9)orcrudemortalityrates<1/10,000/day.Itisalsoimportantthatfoodsecurityshouldhaveimprovedandthattherearenootheraggravatingfactorssuchassevere climaticconditionsandinadequateshelter.
Otherfactorstoconsidermayinclude;
• Net reduction in thenumberof childrenattending thecentres (through improvement in thenutritionalstatusorthedisplacementofthepopulationetc.)
• Depletionoffoodstockwithoutbeingrenewed
• Endoforlackoffinancialfunding
• Epidemiologicalcontrolofinfectiousdiseasesiseffective
• Improvedclimaticconditionswhereapplicable.
Programmeclosuremustbedonegraduallyoveraperiodof3-6months.Itisdesirabletostartwithareductionintherations,stoppingnewadmissions,establishinghand-oversolutions,andtrainingofidentifiedfocalperson(s)forthespecificprogrammes
Monitoring and Evaluation
Monitoringandevaluationofanemergencynutritionresponseiscoveredinchapter 10.
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CHAPTER NINEnutrition information, education
and communication
9.0 IntroductionNutrition Information, Education and Communication (IEC) is key to management of acutemalnutrition.
Theactivitiesrelyonavarietyofwell-designedandeffectivematerialswhichmayincludetrainingmaterials thatareusedbyhealthworkers.Healthworkers,VHTsandothercommunityresourcepersonsshouldreceiveappropriatetrainingandfollow-uponuseoftheIECmaterials.
Nutrition education is any combination of education strategies designed to facilitate voluntaryadoption of food choices and other food and nutrition related behaviours to help individualsandcommunitiesmakethebestchoiceoffoodsforadequatenutritionandhealth.Itisdeliveredthroughmultiple channelsand involvesactivitiesat the individual, institutional, communityandpolicylevels.
qualities of effective nutrition education:
• Focusesonspecificbehaviours,actionsandpractices
• Usescommunicationandeducationstrategiestoenhanceawarenessandmotivation
• Employsasystematicbehaviourchangeprocess,includingsocialsupportandempowerment
• Includesenvironmentalinterventions,communityactivationandorganization.
Health Education is any combination of learning experiences designed to help individuals andcommunitiesimprovetheirhealth,byincreasingtheirknowledgeorinfluencingtheirattitudesandpositivebehaviourchange.
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9.1 NutritionEducationProgrammeThe nutrition education programme comprises of goals, objectives, outputs and activities. Thegoalofthenutritioneducationprogrammeistore-enforcespecificnutritionrelatedpracticesorbehaviourstochangehabitsthatcontributetopoorhealth.Thisisdonebycreatingamotivationforchangeamongpeopletoestablishdesirablefoodandbehaviourforpromotionandprotectionofgoodhealth.Effectivenutritioneducationprogrammesmustbeplannedandexecutedinsuchawayastomotivatebeneficiariestodevelopskillsandconfidencefortheadoptionofpositiveandlastingpractices.
Nutritioneducationprogrammesshouldaimat:
1. Increasingthenutritionknowledgeandawarenessofthepublicandofpolicymakers
2. Promotingdesiredfoodbehavioursandnutritionpractices
3. Increasingthediversityandquantityoffamilyfoodsupplies.
Attheonsetoftheprogram,implementersandotherstakeholdersshouldhaveamonthly,quarterlyorannualplanofactivitiesthataretobeconducted.Further,anongoingmonitoringandevaluationplan should be developed. The plan should be specific to the programme and must be wellunderstoodby implementers.Figure15belowshowsaschemeforplanningnutritioneducationprogrammes.
FigUre 15: A scheme For plAnning nUtrition edUcAtion progrAmmes
phAse 1: prepArAtion
• Definingthenutritionalproblem
• Determiningthecausesoftheproblem
• Establishingtheeducationalframe
phAse 2: FormUlAtion
• Settingobjectives
• Designingmessages
• Choosingthemediaandmultimediacombination
phAse 3: implementAtion
• Producingthematerials
• Trainingthechangeagents
• Executingthecommunicationintervention
phAse 4: evAlUAtion
Source: FAO, 1994
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9.2 CommunicatingNutritionInformationKeybenefitsofnutritioninformationandeducationinclude:• CreatesawarenessaboutservicesatHealthfacilitiesandinthecommunity
• Helpstodispelrumours/mythsandmisconceptions
• Helpstolearnaboutcommunityexpectations
• Improvedhealthcareseekingbehaviour
• StrengthenslinkagesbetweencommunityandHealthfacilities.
Principles of effective communication
Clarity:Useconcreteexpressions,simplewords,shortsentencesandavoidambiguity
Completeness- use the 5Ws and H i.e.Who,When,Where,What,Why and How. Answer thequestionsindesigningandrespondingtoanycommunicationmessage
Consideration: Ensuresufficientregard,empathyandrespectfortherecipientanduseappropriatelanguage,mediaandstyle,maintainpleasantandpositiveapproachesandintegrity
Conciseness:Bebrief,exactandtothepointasmuchaspossible
Courtesy: Beandkeeppolite,welcoming,modest,approachable,friendly,attentiveandresponsive
Correctness: Use the correctwords and facts from correct source, through a correctmedia, tocorrectaudienceundercorrectcircumstances
Channelsandmethodsusedtoprovidenutritioneducation
• Individualdiscussions
• Counsellingsessions
• Groupdiscussions
• Communitymeetingsandevents(dramas,healthgameevents)
• Peereducation
• Employeeeducationalseminars
• ElectronicMedia(Television/Radio:Visualandaudiodramas)
• PrintMedia(Brochures,booklets,Posters,Banners,BillBoards,flyers,flipcharts)
• OtherPromotionalmaterials(T.Shirts,calendars,cartyrecovers,pens).
9.3 Proceduresforplanningandfacilitatinganutritioneducationsession• Identifyarelevanttopicfordiscussion
• Identifyaknowledgeablepersontoconductthenutritioneducationsession
• Determinethetargetaudienceandtheapproachyouwillusetohelpthemlearnandparticipateinthesessionforexamplepregnantandlactatingmothers)
• Makeobjectivesforthesession(theyshouldbeSMART:S-Specific,M-Measurable,A-Attainable,R-Realistic,T-Timebound)
• Reviewinformationonthetopicandensureitisuptodate
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• Preparethematerialsyouwillneedtoconductthesession(e.g.handouts,flyers,counsellingcards,flipcharts,posters);preparebriefpromptingnotes
• Communicatethedate,time,venueandtopicofdiscussion
• Documentthenutritionandhealtheducationsession.
9.4 Conductinganutritioneducationsession• Introduction
o Welcomeparticipantsandintroduceyourself
o Reviewtheagenda
o Explorethegroundrules
o Introducethetopicfordiscussion
• Outlinesessionobjectives
• Statewhattheclientwillgainfromthesession
• Reviewanddiscussthetopic
• Reviewthekeypoints
• Conductanevaluationofthetopicdiscussed
Prepare for a Food Demonstration Session• Gatherfooditems,equipmentandmaterials
o Food-ensurethereisvariety-Go,GrowandGlow
o Utensils (plates, cups, chopping boards, sauce pans, knives) and othermaterials - ensuregoodhygiene
o Fuelforcooking-,
o Handwashingfacilities.
Conduct a Food Demonstration:
• Demonstrate tomothers/caregivers how toprepare a simple andnutritiousmeal (for youngchildren,pregnantandlactatingwomen,andothervulnerablegroups)usinglocalingredients.
• Emphasizethefollowing:
o FATVAH(Frequency,Adequacy,Thickness,Variety,Active(responsive)feedingandHygiene
o Feedingasickchild
o Continuedbreastfeedingupto2yearsandbeyond
o Involvingfathersandothercaregiversorfamilymembers.
Mothers/Caregivers Conduct a Return Food Demonstration• Lookatthestepsusedtoperformthereturnfooddemonstration
• Observeareasofomissionthatrequirecorrection
• Thankthemotherorcaregiversforconductingthefooddemonstration.
• Gothroughtheareasthatneedimprovement
• Summarizethekeypoints
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Afterthecookingdemonstration,servethepreparedfoodforthechildrenandmother/caregivers
Summarize the Food Demonstration Session• Checkunderstanding(questionandanswer)
• Re-emphasizekeymessages.
• Thankthemothers/caregiversforcomingandparticipating.
9.5 KeyNutritionRecommendationsThefollowingrecommendations(Table19)willguidethedevelopmentofkeynutritionmessagesthatcanbeemphasizedwhileconductingnutritioneducation.
tAble 19: key nUtrition recommendAtions
topic recommendAtion
OptimalBreastfeeding
• Earlyinitiationofbreastfeedingwithinonehourofbirthforthebabytobenefitfromcolostrum(firstyellowishmilk)
• Exclusivebreastfeedingforthefirst6completedmonths• Breastfeedondemand(aslongastheinfantwants,atleast8–12
timesduringdayandnight)• Appropriatepositioningandattachment• Continuedbreastfeedingupto2yearsorbeyondOR• Continuedbreastfeedingupto12monthsoflifeifthemotherisHIV
positiveandtheinfantisHIVnegative,themotherisonHAARTandtheinfantreceiveARVprophylaxis.
• Continuedbreastfeedingduringillnessandexpressbreastmilkifthebabyisnotabletobreastfeed
OptimalComplementaryfeeding
• At6completedmonthsstartappropriatecomplementaryfoodswhilecontinuingtobreastfeed
• Giveavarietyoffoodstoincludeenergygivingfoods(GO),bodybuildingfoods(Grow)andprotectivefoods(Glow)
• Ensure:
o Properhygieneduringfoodstorage,preparationandservingo Growthmonitoringandpromotionmonthlyo VitaminAsupplementationevery6monthso Immunisation
Feedingofthesickchild(oranadultwhereapplicable)
• Increasefrequencyofbreastfeedingandofferadditionalfood(smallfrequentmeals)
• Asickchildshouldbegivenadiethighinenergy,proteinandmicronutrientespeciallyiron,zincandvitaminsinaformthatiseasytoeatanddigest
Maternal Nutrition
• Increasefoodintakebyeatingoneextramealduringpregnancy,twoextramealsduringlactationinadditiontoeatingtheregularmeals
• Ensureironandfolicacidsupplementation,intermittentpresumptivetreatmentandpreventionofmalaria
• Eatplentyoffruitsandvegetableswitheverymeal
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topic recommendAtion
• Drinkenoughliquidseveryday(8glassesor3NICEcups)• Emphasizetheuseofiodizedsaltandotherfortifiedfoods.• Pregnantmothersshouldbediscouragedfromalcoholconsumption,
smokingandotherun-prescribedmedicationthatmayharmthebaby.• Taketheweight,heightandMUACofallpregnantwomenandrecord
itinthemother/childpassport/ANCregisterandotherrelevantdatacollectingtools.
Control of VitaminAdeficiency(VAD)
Children• VitaminAissafeforchildrenandbooststheirimmunity• PromoteconsumptionofvitaminArichfoodse.g.mangoes,green
leafyvegetables,wildredandorangefruitsandfoodssuchaseggyolk,liver,milkandotherfortifiedfoodssuchasvegetableoil
Vitamin A supplementation• Children6-59monthsshouldbegivenvitaminAevery6monthsasit
protectsthemfromdiseasessuchasnightblindness,diarrhoea,acuterespiratoryinfectionsandreducesdeaths.
• AllnonbreastfedinfantslessthansixmonthsshouldbegivenvitaminA• Childrensickwithmeasles,certaineyeproblems,severemalnutrition.
TheymayneedadditionalvitaminAaccordingtothetreatmentschedule(refertoITC).
Mothers• Encouragepregnantwomenandlactatingmotherstoconsumea
balanceddietandfoodsrichinvitaminAsuchasliver,eggs,orangefleshsweetpotatoes,pumpkindarkgreenleafyvegetables
• LactatingmothersshouldnotbegivenvitaminAroutinely
Control of anaemia
• Emphasizeconsumptionofironrichfoodssuchasliver,redmeat,eggs,fish,wholegrainbread,legumesandironfortifiedfoods.
• PromoteconsumptionofvitaminC-richfoodssuchasoranges,greenvegetablesastheyenhancetheabsorptionofiron.
• Provideadviceonfooditemsandmedicinesthatshouldnotbetakentogetherwithironsupplementssincetheymayinhibitabsorptionsuchasmilk,antacids,teaandcoffee.
• Malaria control
• Dewormingroutinely
Malnourished children with nutritional anemia (commonly due to iron or folic acid deficiency)• Giveonedoseat6mg/kgofirondailyfor14daysforchildrennotinITC
andreceivingRUTF• ChildrenwithSAMandsevereanaemiashouldbemanagedfollowing
ITCprotocols• Avoidironinchildrenknowntosufferfromsicklecellanaemia.• Avoidfolateuntil2weeksafterachildhascompletedthedoseof
sulphurbaseddrugs(Fansidar,Septrinandothers)
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topic recommendAtion
Mothers• Giveallpregnantwomenadoseof200mgofironand5mgoffolate
onceaday(combinedferroussulphateBp200mgandfolicacid0.4mg)• Treatanaemiafor3months• Referseverecasesofanaemiatothenearesthigherlevelofcare• PromoteuseofantimalarialinterventionssuchasLongLasting
InsecticideTreatedmosquitonetstopreventmalariawhichmaycauseanaemia.
Hygieneandsanitation
Personal hygiene, domestic and environmental hygiene• Promotegoodhygienicpracticesinthepreparationandhandlingof
food• Handwashingwithsoapandcleanrunningwater• Protectfoodsfromcontaminationwithinsects,pestsandotheranimals• Keepallfoodpreparationpremises,utensils,andequipmentsclean• Cookfoodthoroughlyorre-heatitthorough• Keepfoodatsafetemperatures
Deworming • Usesafewaterandrawmaterials• Give250mgofmebendazoleor200mgofAlbendaoleforchildren
1-2yearsand500mgsmebendazoleor400mgmsAlbendazoleif>2yearsasasingledose
Note: DO NOT administer if child is less than I year
Growthmonitoringandpromotion(GMP)
• Childrenaged0-2yeasshouldbeweighedeverymonth,theirweightsplottedonthegrowthchartintheChildHealthCardorMotherChildPassport.Explaintothemotherthechild’sprogress
• LengthsforthesechildrenshouldbemeasuredatspecifiedintervalsasperGMPguidelines.Assessandexplaintothemotherthechild’sprogress(basedonlengthforage).
• Children2to5yearsshouldhaveweightsandheightsmeasuredevery6monthstodetermineiftheyaregrowingadequately
• WhenchildrencomeforGMP,checkfortheirimmunization,andvitaminAsupplementationstatus
• Childrenwhosegrowthisfalteringareathighriskandshouldbemonitoredcloselybyhealthfacilitystaff
Immunization
• Encourageallchildren0–5years,adolescentsandpregnantmotherstoreceivetherecommendedvaccinationsasperthenationalimmunizationschedule
• Explaintothemother
o Theimportanceofimmunizationandthenationalscheduleo Barrierstoimmunizationandhowtoovercomethemo Accesstoimmunizationservices
• Makeimmunizationsafe(i.e.checkexpirydate,usesteriledisposableneedles,observecoldchain,usetrainedpersonnel).
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CHAPTER 10monitoring, suPervision,
rePorting and evaLuation, QuaLity imProvement and suPPLy chain
management for imam
10.0 IntroductionTo ensure that the Integrated Management of Acute Malnutrition (IMAM) interventions areachieving their objectives of early case identification and treating acutemalnutrition, activities,inputs,outputsandoutcomesmustbemonitored,supervisedandreportedon.Awelldesignedmonitoringandreportingsystemcanidentifygapsin implementationofrespectivecomponents,provide information for on-going needs assessment, advocacy, planning, and redesigning andaccountability. Monitoring, reporting and overall quality improvement should be an integralcomponentoftheIMAMprogramme.
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10.1KeydefinitionsMonitoringisthesystematicandcontinuouscheckonallaspectsoftheprogrammewhileitisbeingimplemented.Thisisinordertoestablishifinputs,processesandoutputsareproceedingaccordingtoplansothattimelyactioncanbetakentocorrectdeficienciesdetected.ItisimportanttomonitorIMAM activities to ensure quality service delivery, effective use of resources and strengthenaccountability.MonitoringIMAMwillalsopromotecontinuouslearningandimprovement.
Supervision is aprocessofworkingwithand throughothersbyoverseeing theperformanceoroperations in order to achieve organization objectives. There should be regular supervision ofIMAMactivitiesbytrainedandskilledpersonnel.Supervisionaimsatempoweringtheindividualwithtechnicalandadministrativeskillsfordecisionmaking,leadership,communicationandteambuilding.Thiscanbeacquiredthroughonjobcoachingandmentoringamongothers.
Reporting refersto givinganaccountoftheprogramme’sperformanceandinformpolicy..ReportingonIMAMservicesisinlinewiththeHMIS.
Evaluation meansdeterminingthevalue,significance,orworthoftheprogrammethroughcarefulappraisal and study. It looks at programme’s results, changes and impact over time. Evaluationinvolvescarefullyexaminingdataaboutaprojectorprogramme’sresultsdeterminingwhetherandhowwellthesetobjectivesaremetoverasetperiod.
Coverageisameasureoftheextenttowhichtheservicesrenderedcoverthepotentialneedforthoseservicesinthecommunity.CoveragethereforereferstotheextenttowhichIMAMservicesareavailablefortheacutelymalnourishedindividualsincommunity.
Appropriatenessreferstoasuitableintervention,targetedtotherightaudienceandisrightlyandculturallyacceptable.
quality improvementistheuseofquantitativeandqualitativemethodstoimprovetheeffectiveness,efficiency,safetyofservicedeliveryprocessesandsystems,aswellastheperformanceofhumanresourcesindeliveringIMAMservices
Supply Chain Managementisasystemoforganisingpeople,activities,informationandresourcesinvolvedinmovingtheproductsfromthesuppliertothebeneficiary.
10.2MonitoringofIMAMservicesMonitoringcomprisesofthreemajorcomponents:
• Monitoringofindividualtreatmenttoassessclient/patientprogress
• monitoring to assess effectiveness of treatment interventions (i.e. proportion of acutelymalnourishedpatientstreatedeffectively)andcommunity-levelactivitiesformobilisationandcase-finding
• Assessmentofservicecoverage(i.e.proportionofthetargetgroupbeingreachedwithtreatment)andappropriatenessoftheprogrammeforcommunities.
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10.2.1 IMAM data collection tools
Theseincludetoolsusedforindividualandprogrammelevelmonitoring(Table20)
tAble 20: tools Used in monitoring, sUpervision And reporting For imAm service
tools pUrpose
VHT/ICCMregister • TorecorddetailedinformationofclientsscreenedforacutemalnutritionusingMUAC
• Torecorddetailedinformationofclientsreferredtohealthfacilitiesfornutritionandotherhealthservicesaswellasthosefollowedup
Communityreferralforms • UsedbyVHTsandothercommunityhealthandnutritionproviderstoreferpatientswithinIMAMservicesandviceversa
QuarterlyreportformsforVHTs • UsedbyVHTsforquarterlyreportingoncases:assessed,identified;referredandfollowups;healthandnutritioneducationactivitiesandotherhealthrelatedactivitiescarriedoutinthecommunity
Integratednutritionrationcards • ForrecordingtherapeuticorsupplementaryfoodinOTCorSFP
• Totrackapatient’sprogressthroughmonitoringweight,heightandMUAConeveryvisittoOTC/SFP.
Integratednutritionregister • TorecorddetailedinformationofpatientsadmittedtoITC,OTCandSFP
• TotracktheindividualpatientsenrolledintotheIMAMservicesusingIntegratedNutritionregistrationnumber(INRNo.)
• Totrackapatient’sprogressthroughmonitoringweight,heightandMUAConeveryvisittoOTC/SFP
• Torecordpatients’outcomeonexitingthefeedingprogramme
Referralforms • UsedbyhealthcareproviderstoreferpatientswithinIMAMservicesandviceversa
CriticalCarePathwayChart • Torecordthepatient’spresentingsigns,symptomsandinitialmanagementaswellasmonitorprogress(weight,vitalsigns,medicalcomplications,feeding,antibiotics,fluidmanagementetc)
24hourFeedIntakeChart • Isarecordofthepatient’sfeedingplanina24hrperiod(type,frequency,amountandtotalfeeds)
• Monitorsthepatient’sfeedintakeovera24hrperiod
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tools pUrpose
WeightGainTallySheetforWard • TorecordandmonitorrateofweightgainforchildrenreceivingF100(calculatedmonthlyorquarterly)
Tallysheets • Tosummarizeweekly,monthlydatafromINRandcompilereports
HMISmonthlyandquarterlyreports • Toreportoncasespresentedwith/treatedforacutemalnutritioninhealthfacilities
• TracksperformanceofIMAMservicesthroughmonitoringpatientoutcomesvis-a-vissetstandards
*CommunitySupervisionchecklists • Usedatcommunityleveltoassess/monitorqualityofIMAMservices
*HealthfacilityIntegratedsupportsupervisionchecklists
• Usedathealthfacilityleveltoassess/monitorqualityofIMAMservices
NutritionServiceDeliveryAssessment(NSDA)tools
• Toassessqualityofnutritionservicedeliveryatbothhighandlowlevelhealthfacilities
*ChecklistformonitoringENR • MonitorsavailabilityofrequirementsforsettingupandimplementingENRprogramme
*ToolsforconductingFGDsandKIIs • ToassessIMAMcoverageandaccessthroughconductingFGDsandinterviewsistouncoverpotentialbarrierstocomponentsofIMAMinordertoimproveitsdelivery
*Toolsforconducting:1-FGDs(includinginterviewguidesfor:VHTsandothercommunityresourcepersons;beneficiarycaregiversandothercommunitymembers;
2-KIIs(includingindividualinterviewguidesfor:healthandnutritionprogrammemanagersand;forhealthfacilityworkers
• TocaptureinformationfromthosedirectlyandindirectlyinvolvedinIMAM.Thisinformationshouldbecollectedatcommunity,districtandnationallevel
10.2.2 IMAM service performance indicators
ThefollowingaretheindicatorsusedinmonitoringtheeffectivenessofIMAMservices:
indicAtor deFinition
A: otc, sFp
1 Cure rate Numberofpatientssuccessfullycuredasapercentageoftotaldischargesduring thereportingquarter.Dischargesincludecured,defaulters,deathsandnonrespondents)
(Total discharged as cured/Total discharges x100)
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indicAtor deFinition
2 Defaultrate Numberofpatientswhodefaultedasapercentageofalldischarges during the reporting quarter (Default/Total discharges x 100)
3 Non-respondentsrate Number of patients who are non-respondents as apercentageoftotaldischargesduringthereportingquarter(Total non-respondents/Total discharges x 100)
4 Coverage Number of eligible cases who are enrolled in IMAMprogrammedividedby total numberof eligible clients x100
5 Deathrate Thenumberofpatientswhodiedasapercentageoftotaldischargesduringthereportingquarter(Total Died/Total discharges x 100)
b: inpAtient therApeUtic cAre
1 Casefatalitya Numberofpatientswhodiedasapercentageofallnewadmissions for the reportingmonth (s) (Total Died/Total new admissions x 100)
2 Defaulterrate Number of patients who defaulted (ran away) as apercentageofallnewadmissionsforthereportingmonth(s)(Total defaulted/Total new admissions x 100)
3 Failuretorespondb Numberofpatientswhofailedtorespondasapercentageof all newadmissions for the reportingmonth (s) (Total failure to respond/Total new admissions x 100)
4 TransferratestoOTC NumberofpatientstransferredtoOTCasapercentageofnewadmissionsforthereportingmonth(s)(Total transfers to OTC /Total new admissions x 100)
5 Cure rate (if F100 is used for rehabilitation)
Number of patients cured as a percentage of newadmissions for the reporting month (Total cured /Total new admissions x 100)
6 Average rate of weightgainc (only for childrenfeedingfreelyonF100)
Averageweightgain(g)forpatientsonF-100fortheentireweek(7days)dividedbytheiraverageweight(kg)x100.
Good weight gain is >10 g/kg/day-; moderate weight gain 5 up to 10 g/kg/day and poor weight gain is <5 g/kg/day
aCase-fatalityrateof>20%isunacceptable;11-20%poor;5-10%moderateand<5%isacceptable
bseebelowfordetailsonhowtorecognizefailuretorespond
cIftheaveragerateofweightgainispoorfor≥10%ofthechildrenonF-100orthereisadecreaseinaveragerateofweightgainincomparisontopreviousthreemonths,thereisaproblemthatmustbeinvestigated.
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How to recognize failure to respond:
condition ApproXimAte time AFter Admission
Failuretoregainappetite
Failuretostarttoloseoedema
Oedemastillpresent
Failuretogainatleast5g/kg/dayfor3successivedaysafterfeedingfreelyonF-100
Day4
Day4
Day10
AfterfeedingfreelyonF-100
Note: HIV/AIDS patients may not respond as those who are HIV negative
Theindicatorsgivenareprimarilyapplicabletochildren6-59monthsagegroupalthoughothersmaybepartoftheprogram.Morethan90%ofthetargetpopulationiswithinlessthan1daysreturnwalk(includingtimefortreatment).Coverageisgreaterthan50%inruralareas,greaterthan70%inurbanareasand90%incampSituation.
tAble 21 typicAl tArget levels For cUre, mortAlity And deFAUlting rAtes
indicAtors AcceptAble AlArming
sFp otc itc sFp otc
Cure rate >75% >75% >75% <50%
Deathrate <3% <5% <10% >10%
Defaulterrate <15% <15% <15% >30%
Nonrespondentrate <10% <10% <10% >10%
Coverage >70% -
Averagelengthofstayforcuredpatients <90days <60days 7–8days*
Distributionofcentres >90%targetpopulationliveswithin1dayreturnwalkfromcentre
Source:Spherestandards,2011.
• If cure rates are low and death rates are high, it means the programme is not performingeffectively.Thisneedstobeinvestigatedandaddressed.
• If cure rates are low and defaulter rates are high, it means that service is not performingeffectively.Anydefaultercouldrepresentadeath.
*ITClinkedtoOTC
10.2.3 Nutrition Information, Education and Communication
Monitoringanutritioneducationprogrammeisessentialtodetermineitsprogresstowardsachievingthesetobjectives.Qualitativedatacanbecollectedcontinuouslytodeterminetheprogram’s:
o Appropriatenesseffectiveness
o Coverage
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MonitoringindicatorsforNutritionEducationProgrammeinclude:
• Proportionoftopicsconducted;
• ProportionofTrainingsconducted;
• Proportionof“Trainersoftrainers”(TOTs)trained;
• Proportionofprogramsupervisorsandmanagerstrained;
• ProportionofCommunitygroups/individualstrained;
• ProportionofIECmaterialsdeveloped/providedvsthoseplannedfor.
• Proportionofactivecommunitygroupsvsthosetrained.
10.2.4 Emergency Nutrition Response (ENR)
Monitoring helps to ensure that the emergency nutrition response is effective at preventingincreasedand/orexcessivemorbidityandmortalityrelatedtoacutemalnutrition.
The following requirements for setting up and implementation of ENR programme should bemonitored:
• Personnel
o Appropriatestaffandstaffinglevels(managers,logisticssupport,administrationandtechnicalstaff(clinicians,nutritionists,nurses)andsupportstaff.
o Staffspeak/understandthelocallanguageandcultureofthepopulation.
o Stafftrained/orientatedprioronconductingthereliefprogrammes.
o Staffhaveclearjobdescriptionswithclearrolesandresponsibilities.
• Supplies and logistics
o Availabilityofgoodlogisticssystemtoensurethereisnobreakinthepipeline.
o Bufferstocksshouldbeinplaceespeciallywhereinsecurityisanissue.
• Service Linkages for Prevention and Management of Acute Malnutrition o Interventionsto:
- Manageacutemalnutrition
- StrengthenIYCF-E,
- Addresshealth,water,sanitationandhygieneandfoodinsecurity.
• Aggravating factors
o GAMrates(>10%)
o Crudemortalityrates(>1/10,000/day)
o Availabilityoffunding
o Effectiveepidemiologicalcontrolofinfectiousdiseases
o Climaticconditions(severeornot)
o Shelter(whetheradequateornot).
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10.2.5 Monitoring Coverage of IMAM services
Coverage is a critical indicator that should be monitored at programme level. If programmeperformanceisgood(highcure,lowmortalityanddefaultrates)butcoverageispoor,thenthereislowprogrammeimpactatpopulationlevel.Wherecureratesarelower,highercoverageratesareneededtoeffectagivenGAMreductionatpopulationlevel.
Table22showsthecoverageneededinordertoachieveareductioninglobalacutemalnutrition(GAM)atpopulationlevel,at75%curerate.
tAble 22: coverAge needed to eFFect A given redUction in gAm
gAm redUction Aim minimUm coverAge needed
100% Notpossiblewithacurerateof75%
75% 100%
50% 66.7%
25% 33.3%
Note: 75% cure rate is constant
AssessingcoverageidentifiestheproportionofclientsenrolledintheIMAMservicesoutofthetotalnumberofpeoplewhoneedtheinterventioninagivenarea.Coverageisnormallyexpressedasapercentage(i.e.if100peopleareacutelymalnourishedinthecommunityand50areadmittedintheIMAMprogramme,thenthecoverageis50%).
CoverageisoneofthemostimportantindicatorsofhowwelltheIMAMserviceismeetinganeed.A“metneed”istheproductofcoveragerateandcurerate.Aprogrammewithahighcoveragebutlowercurerates(75%coverageX70%curerate=53%ofneedmet)maybebetteratmeetingtheneedthanonewithhighcureratewithalowcoverage(80%cureX25%coverage=20%ofneedmet).
The IMAM coverage is estimated using a population based coverage survey which requiresspecializedassistance(seeValidCommunity-basedTherapeuticCare:AfieldManual-chapter9forinformationonconductingcoveragesurveys.Thereareseveralmethodologiesthatcanbeusedforassessingcoveragee.g.SLEACandSQUEAC.
Monitoring Appropriateness of IMAM programme:
Thefollowingcanbeused:
• Focusgroupdiscussions(FGDs)and
• Interviewswithkeymembersofthecommunity.
ThepurposeofthesediscussionsandinterviewsistouncoverpotentialbarrierstocomponentsofIMAMinordertoimproveitsdelivery.
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10.3 IMAMservicesupervisionAsupervisorshould:
• Givedirectiontotheteam,makedecisions,solveproblems,monitorprogress,providefeedbackandkeeprecords;
• Beendowedwithknowledgeandskillsand;
• Receivesupportandguidancefromtheworkplacetoenablehim/herbeeffectiveasasupervisor
SupervisorsshoulduseintegratedsupportsupervisionchecklisttoassistinmonitoringthequalityoftheIMAMprogramme.
Indicators for Supervision
• Percentageofsupportsupervisionsconductedvsplannedforannuallyatdistrictandnationallevel
• Proportionofsupervisorstrainedonintegratedsupportsupervisionatdistrictandnationallevel
10.4 ReportingFigUre 16: the reporting system oF the imAm progrAmme
At FAcility level:
Health Care Service Providers:• FillinIntegratedNutritionRegistersHMIS Focal Persons:• Compilemonthlyandquarterlyreportsandsubmit
tothefacilityin-chargesFacility In-charges:• Cross-checkthereports• Convenemeetingtoreviewthereports• Submitreportsandrequisitionsfornutrition
supplies/orequipmenttodistrictthroughthehealthsubdistrict(whereapplicable)
ministry oF heAlth
• Summarises,analysesandinterprets,utilizesdatafromdistricts
Providesfeedbacktothedistricts
• Sharesthesummaryreportswithpartners• Consolidatesrequisitionsforsupplies
andequipmentandsubmitstorelevantpartners
• Followsuprequisitionsfornutritionsuppliestoensuretimelydeliverytothedistrict
AT HEALTH SUB-DISTRICT LEVEL:
HMIS Focal Persons:• Crosscheckthereports• Sendreportsandrequisitionsfornutrition
supplies/orequipmenttothedistrict
At district level:
HMIS Focal Persons (Biostaticians):
• Compilethedatafromeachindividualsiteintoasummaryreport
• Analyse,interpret,utilizedataandgivefeedbacktohealthfacilities
• Summariserequisitionsfornutritionsupplies/orequipmentfromeachindividualsite
• SubmitssummaryreportsandrequisitionstoMOHandpartners
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Reporting on stock
a) Amountofstockconsumedinthereportingmonthorquarter(F75,F100,ReSoMal,RUTFandsupplementaryfoods)
b) Stockbalance(athand)isgivenbyamountavailableatbeginningofmonth+stockreceivedduringthemonthminusstockutilized+wastage/leakagesforeachsupply
c) Wastage/leakagesinareportingmonth(s)maybeduetodamagebyrodents,expiryorlossesduringfeedpreparation,etc
d) Supplyprojectionsforthenextquarter–seesectiononsupplychainmanagementfordetails
10.5 EvaluationAnevaluationwilloftenaddresstwomainquestions:
• Aretheresultsthosethatwereintended?
• Andaretheyofvalue?
Evaluationcanbeperformedusing:
• Theexistingdatabasescollectedovertime
• Specificevaluationstudiesconductedatbaseline,midtermandattheendoftheprogramme(seetable22fortools).
10.6Qualityimprovementinintegratedmanagementofacutemalnutritionquality refers to:
• Theabilitytosatisfystatedorimpliedneedsofaperson/population
• Performanceaccordingtostandardsorexpectations
quality improvement in IMAM programming refers to:
• SystematicallyimprovingqualityofIMAMservicesbybridgingthegapsbetweenservicesactuallyprovidedanddesiredstandards.
Attributes of quality:
• Accesstoservices
• Effectivenessofcare
• Interpersonalrelations
• Efficiencyofservicedelivery
• Continuityofservices
• Safety
• Physicalinfrastructureandcomfort(amenities)
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Principles of quality improvement
Qualityimprovementisbasedonfourkeyprinciples:
• Client focus: IMAMservicesshouldbedesignedtomeettheneedsandtheexpectationsoftheclientsorcommunityinordertoimproveserviceuptakeandutilization.
• Focus on systems and processes:
o Byanalysinggapsandidentifyingcausesofpoorperformance
• Testing changes and emphasizing the use of data:
o Changesaretestedtofindoutwhethertheyyieldtherequiredimprovement.
o Dataareusedtoanalyseprocesses,identifyproblemsanddeterminewhetherthechangeshaveresultedinimprovement.
• Team work: Improvement is achieved through the team approach to problem solving andqualityimprovement.
the moh Qi FrAmework And coordinAtion strUctUre:
IMAMQIshouldbefullyembeddedwithintheexistingQIframeworkatalllevels(national,regional,district,sub-districtandhealthfacilitylevels)usingthe5-SmodelandtheiterativePDSA(refertoHSQIFrameworkandHSSP2010/11– 2014/15 for details).
5-S Model
5-Sissequenceofactivitieswhichinclude:sort-set-shine-standardize-sustain.The5-Smodelistheinitialstep/foundationforallqualityimprovementinitiativesbyMoH.
Objectives of 5-S
• Toimprovedhealthcarequalityandproductivity
• Toimprovedinfrastructuremaintenance
• Toimprovedhealthandsafety
Steps in implementing 5-S
a. Sort refers toremovingunnecessaryitemsfromyourworkplace.
b. setreferstoorganizingeverythingneededinproperorderforeasyoperation.
c. Shine refersto maintainingahighstandardofcleanlinessincludingtools,instrumentsandmachinesanddevelopingalongtermmaintenanceplan.
PROCESS OF CAREHow it is done• Quality improvement approaches• Cycle of learning and Improvement
CONTENT OF CAREWhat is done• Norms• Standards• Protocols• Guidelines
OUTPUT/OUTCOMEImproved quality of care and health (e.g standards developed and applied)
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d. Standardize-referstoestablishingtheabovethreeSsasthenormineveryworkplaceandensuringregularmaintenance,cleanlinessandimprovedqualityofcare.
e. Sustain referstocontinuoustrainingandmaintainingthedisciplineofthepersonnel-ensureteamwork, workimprovementteam(WIT)and5-Straining
FIgURE 17: WORk PLACE IMPROVEMENT THROUgH 5-S
The PDSA cycle
• Isawaytotryoutideastoimprovebeforedecidingtoimplement
• Allowsteamstoknowquicklywhetherthechangewillwork
• Gathersdatatoconvincecolleaguesthatthechangeswork
TheQIteamshouldusethePDSAcycletoidentifythegaps,testchangestobridgethegaps,studythetestedchangesandadaptchangesthathavecausedimprovementinIMAMservicedeliveryasbestpractices.
• UsetheappropriateQItools(documentationjournals)todesignQIprojectsonIMAM,monitorperformanceanddocumentbestpractices
• StrengthenexistingQIteamstoaddressIMAMQIactivities
Work EnvironmentImprovement
QI PerformanceImprovement
Higher work efficiency
Better quality assurance• Preparedness• Standardization• Timeliness• Completeness• Communication• Safety
5-S ACTIVITIESSORTSET
SHINESTANDARDISE
SUSTAIN
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FigUre 18: the pdsA cycle
Flow chart is a quality improvement tool that explains the process of doing something frombeginningtoendsuchasanOTCpatientflowchart(asillustratedinFigure19below).
Do: Test the changeFor example start taking and recording weight of all patients attending OTC
Make sure that the change is being implemented according to plan
Collect data about the process being changed
Document any changes which were not in the original plan
Plan: Develop a plan of the changes to addressWhat changes will occur and why? (For example start taking and recording weight of all patients attending OTC to track their progress
Who is responsible for making the changes?
When and how will the changes occur?
• Collect baseline data to measure the effects of change
• Educate and communicate: Inform people about the changes you are testing and include those involved in the changes
act: Summarize and communicate what was learnt from previous stepsIf the change does not give the desired results, then either modify or abandon the plan and repeat the PDSA cycle
If the change was successful, then implement the change as standard procedure or consider implementing the change throughout the system
Study: Verify that the change tested was according to planSee if data is complete and accurate and compare the data with baseline information to see if an improvement has occurred
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FigUre 19: process Flow oF pAtients in otc
CLINICaL aSSESSmENT:• Medical and dietary
history taken• Physical examination• Drugs prescribed
Refer to Inpatient Therapeutic Care (ITC)
RoutIne CounselIng and testIng
foR HIV
appETITE TEST:Appetite test for RUTF conducted
REGISTRaTION IN OTC:• Prescribing RUTF • Recording in
Integrated nutrition register and ration card
• Counselling on use of RUTF
• Given Return dates for follow up
DISpENSING:• Receives prescribed
drugs and RUTF from pharmacy/dispensary
aNTHROpOmETRy aREa:• MUAC, Weight, Height
taken• Classification of nutrition
status
PatIent exIts
PatIent aRRIVal
WaITING aREa:Triage, Nutrition and Health Education
MedICal CoMPlICatIons Passes
aPPetIte test
YES
YES
NO
NO
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Surge Approach
TheIMAMSurgeapproachisaprocessthatinvolvesasetofpracticaltoolstohelphealthsystemstobettermanageservicesforacutemalnutritionovertime.Specifically,theapproachfocusesonimprovingplanningandmanagementoftreatmentservicesduringseasonalspikesorsurgesincaseloadsof acutemalnutrition. It is used toaddressboth severeandmoderateacutemalnutritionwhereappropriate
Components of the Surge Approach include:
• Risk analysis and capacity assessment
Healthfacilitiesshouldanalysethemostlikelycausesofacute malnutritionintheircatchmentareatoestablishwhata‘normal’caseloadlookslikeandwhenandtowhatdegreesurgesoccurthroughouttheyear.
• Thresthshold setting
In this context, thresholdsare thenumberof casesof severeacutemalnutrition seen in thefacility permonth, abovewhich the health facilitywould need tomodify their normal clinicprocedures (usually the ‘alert’ threshold) and/or receive external support from the DistrictHealthOffice(usuallythe‘serious’or‘emergency’threshold).
Basedon thecapacityassessmentandpreviousexperience,a setof caseload thresholdsareagreedonforeachhealthfacility.
• Monitoring against set threstholds
Thresholdsaremonitoredperiodically,byplottingcaseloadsagainsttime.
• Provision of surge support
ThroughtheDHTandotherstakeholders,acomprehensivesurgeappropriateactionandsupportpackagearedeliveredtothehealthunits
• Scaling down surge support
As caseloads reduce, any surge support package is gradually scaled down in line with thethresholds.Ultimately,caseloadsandexternalsupportareexpectedtoreturnto‘normal’pre-surgelevels.
Note: At the end of the ‘surge season’, the health facility and District health staff should review how the scale up of support worked and how the actual caseload trends differed from the trends predicted. This review should also occur whenever major changes in capacity occur at Health Facilities.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA136 JANUARY 2016
TABLE 23: SAMPLE ACTION PLAN FOR IMPLEMENTATION OF qI IN IMAM SERVICES (ALTERNATIVELy ONE CAN USE THE DOCUMENTATION JOURNAL AS IN ANNEx 20)
HealthFacility____________________________
DatePrepared____________________________
Step current status (What we do now)
Changes to be introduced (New things we must do)
Who will organize the changes
New resources needed
Source Who will organize the resources
Who? When? Who? When?
10.7 SupplychainmanagementforimamThis topicoutlines thegoals, typeof supplies, their sourcesand stockmanagementatdifferentlevelsofthehealthsystem.
GoalsofSCMforIMAMsupplies:
i) Topreventstockouts,
ii) Toreducetimeloss,and
iii) Tobuildconfidenceinservicemanagement
tAble 24: types oF imAm sUpplies
type eXAmples when to order
Therapeuticfeeds F75,F100,RUTF,CMVandResomal Quarterly
Supplementaryfoods CornSoyaBlend(CSB),lipidbasednutrientsupplement,Fortifiedblendedfoods(SuperCerealandSuperCerealPlus),BP100,BP5,RUSF,
Quarterly
Anthropometricequipment
MUACtapes,weighingscales,heightboards,
basedonneed
Datacollectiontools HMIS-Integratednutritionregister,integratednutritionrationcard,monthlyandquarterlyreports,registersatdifferentcarepoints
basedonneed
Routinemedicinesandsupplements
RefertochaptersonspecificIMAMcomponents
AsperNMScycle
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 137
Managingstocks involvesthefollowing:
a. quantification of supplies
Projectionsfornutritionsuppliesaredoneregularlyinordertoensureeffectiveprogrammingandminimize on stock outs. Calculations are either based on case loads and target populations orpreviousconsumptionlevelsandshouldinclude10%ofsupplies(bufferstock)estimates.
Consumptionestimatesofthenutritionsuppliesarederivedfromtotalnumberofnewadmittedcasesmultipliedby the recommendedquantitiesof the therapeuticsuppliesused for treatingachild.Forexampleachildin:
ITC (LINkED TO AN OTC) otc sFp
Requiresanestimateof;
o 12sachetsofF75,
o 0.2sachetsofReSoMal.
o MinimalRUTF
o 4sachetsofF100
requiresanestimateof:-
o 136sachetsofRUTF.
Buffer stock
Bufferstockisdefinedasreservesuppliestosafeguardagainstunforeseenshortagesordemands.Itisstockusedoverandabovetheactualstockrequiredorneededtoruntheprogramme.
Itisobtainedbycalculating10%ofthestockneededfortheprogramme.
Transportation,distribution,storageanddispensingofnutritionsuppliesshouldbeintegratedwithothersuppliesatalllevels.Similarly,managementofstockoutsshouldfollowtheexistingprotocols.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA138 JANUARY 2016
references
WHO, 2004; Guidelines for the Inpatient Treatment of Severely Malnourished Children, WorldHealthOrganisation,Geneva.
iAsc, 2008; Transitioning to the WHO Growth Standards: Implications for Emergency Nutrition Programmes,ameetingReportofIASCNutritionClusterInformalConsultation,Geneva,25-27June
Collins, S., Arabella D. and Myatt, M. 2000;Adults:AssessmentofNutritionalStatusinEmergency-AffectedPopulations,July.
Community based therapeutic care (CTC), 2006). CTS research and development programme incollaborationwithValidInternationalandConcernWorldwide.
Valid International, 2006: Community-based Therapeutic Care (CTC), A Field Manual, ValidInternational,FirstEdition.
etAt, 2011,EmergencyTriageandTreatment(ETAT)handbook,Kampala,UgandaUganda2011
FAo, 1994; CorporateResourceDocumentRepository:Agriculture, foodandnutrition forAfricaresource book for teachers, Corporate Resource Document Repository, Food and AgricultureOrganization,1994
golden, M. and grellety, y. , 2006;GuidelinesfortheManagementoftheSeverelyMalnourished,September,2006.
Howard, g. and Snetro, 2004;Howtomobilizecommunitiesforsocialchange
MoH , 2006.ImprovingtheQualityofLifethroughNutrition,AguidelineforfeedingpeoplewithHIV/AIDS,2ndEdition,UgandaMinistryofHealth,KampalaUganda2ndEditionMay2006
MoH , August 2007; Outpatient Care of Children with Acute Malnutrition Training Manual,MinistryofHealthRepublicofUganda,KampalaMinistryofHealth,August2007.
MoH , September 2008; DraftPolicyGuidelinesonInfantandYoungChildFeeding:TheRepublicofUganda,MinistryofHealth,Kampala
MoH , September 25, 2008;Minutes of the IMAM Technical Working Group meeting,MinistryofHealth,RepublicofUgandaKampala.
MoH 2008;DecisionstakenduringameetingtoDiscussKeyTechnicalIssuesonIMAMImplementationin Uganda, presentation of the IMAM TechnicalWorkingGroup,Ministry of Health Republic ofUganda,Kampala.August29.
MoH September 2008; Draft, Integrated Management of Acute Malnutrition,RepublicofKenyaMinistryofHealth,RepublicofKenya.Draft,September.
MoH, 2010, Health Sector quality Improvement Framework and Strategic Plan 2010/11– 2014/15. The Republic of Uganda,MinistryofHealth,Kampala
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 139
MoH, February 2002;NationalAnaemiaPolicy,Uganda,MinistryofHealth,RepublicofUgandaKampala,February.
MoH, 2004,GuidelinesonInpatientManagementofSevereAcuteMalnutrition,MinistryofHealth,Kampala,Uganda.
MoH, February, 2007;DraftInterimGuidelinesfortheManagementofAcuteMalnutritionThroughCommunity-basedTherapeuticCare,GovernmentofMalawi,MinistryofHealth,February.
MoH 2007; Protocol for the Management of Severe Acute Malnutrition,EthiopiaFederalMinistryofHealth,February.
MoH, 2006; Interim Guidelines for the Management of Acute Malnutrition in Adolescents and Adults,MinistryofHealthGovernmentofMalawi,MinistryofHealth,March.
MoH, UNICEF and VALID International, 2006; Draft 2 Integrated Management of Acute Malnutrition Guidelines for Uganda,Valid International,MinistryofHealth,UgandaandUNICEF,Draft2,NovemberKampalaUganda.
MoH, UNICEF and WHO, 2002;Managementofthechildwithsevereillnessorseveremalnutrition:Guidelines for referral facilityqualityof care improvement.Handbook forManagers andHealthworkers,Uganda,MinistryofHealth,Uganda UNICEFandWorldHealthOrganisation,Kampala,Uganda2002
msF, 1995.Nutritionguidelines
Onis, M., et al, September, 2007, 2007;Development of a WHO growth reference for school-age children and adolescents,BulletinoftheWorldHealthOrganisation,September2007.
sphere, 2011;HumanitarianCharterandMinimumStandards inDisasterResponse,TheSphereProject,Secondedition.
UDHS,2011.UgandaDemographicSurvey
UNHCR/WFP (year??) Guidelines on Selective feeding programme, United Nations HighCommissionerforRefuges
UniceF, 2008; Steven-Muyeti,Rianne, CommunityBasedManagementofAcuteMalnutrition inUganda:AProcessReview,UNICEFUganda.
who 1999 Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers, Geneva,WorldHealthOrganisation,1999.
who 2006;Guidelines for the management of common illnesses with limited resources, PocketbookofHospitalcareforchildren,reprintedversion,WorldHealthOrganization,Geneva
who, 2000;ManagementoftheChildwithaSeriousInfectionorSevereMalnutrition:Guidelinesfor care at the first-referral level in developing countries, Department of Child and AdolescentHealthandDevelopment,WorldHealthOrganization,Geneva
WHO, 2003; Guidelines for the Inpatient Treatment of Severely Malnourished Children, World HealthOrganisationGeneva.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA140 JANUARY 2016
who, 2004; Severe Malnutrition: Report of a Consultation to review current literature,NutritionforHealthandDevelopment,WorldHealthOrganization,September6-7.
who, 2007;GuidelinesforanIntegratedApproachtotheNutritionalCareofHIV-infectedChildren(6months-14years)atTreatmentSites/ReferralFacilities,draftHandbook,WorldHealthOrganizationGeneva.
who, 2008;GuidelinesforanIntegratedApproachtotheNutritionalCareofHIV-infectedChildren(6months-14years): Guide forLocalAdaptation,Preliminaryversion forCountry Introduction,WorldHealthOrganization,Geneva.
who, 2008; Transitioning to the WHO Growth Standards: Implications for Emergency Nutrition Programmes,ameetingReportofIASCNutritionClusterInformalConsultation,Geneva,25-27June
who, 2013; Guidelines: Updates onManagement of Severe AcuteMalnutrition in Infants andChildrenWorldHealthOrganization,Geneva.
Woodruff, B. A. and Arabella D; Adolescents: Assessment of Nutritional Status in Emergency-Affected Populations,SecretariatoftheUNACC/Sub-CommitteeonNutrition,July,WorldHealthOrganization,Geneva.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 141
ANNEXES
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA142 JANUARY 2016
Ward Equipment/Supplies• Glucostix/sticksforrandom
bloodsugar
• Runningwater
• Thermometers
• MUACtapes(childrenandadults)
• Weighingscales(mustbefunctioningcorrectly)
o Itemsofknownweightforcheckingscales
• Boardformeasuringlength
o Poleofknownlengthforcheckingaccuracy
• Stadiometer(tomeasurestandingheight)
• Haemoglobinometer
Supplies for IV:• Scalpvein(butterfly)
needles,gaugeforchildren(22,24)foradults(18,20)
• PolesormeansofhangingbottlesofIVfluid
• Givingsets
• IVfluids
• Nasogastrictubes(pediatricsandadults)
• Adhesiveplaster
• Syringes(20and50mlforfeeds)
• Syringes(2mlfordrugs,5mlfordrawingblood,10ml)
• Sterileneedles
• Eyepads
• Bandages
• Gauze
Supplies for blood transfusion:• Unitsofblood
• Syringesandneedles
• Bloodtransfusionsets
• Blanketsorwrapsforwarmingchildren
• Incandescentlamporheater
• Washbasinforbathingpatients
• Safe,homemadetoys
• Clock
• Calculator
For hygiene of mothers and staff• Toiletandhandwashing
facilities
• Cleanwaterandsoapforhandwashing
• Placeforwashingbeddingandclothes
• Facilityforwastedisposal
For reference and record keeping• Relevanttablessuchas:
o Weight-for-Length/HeightReferenceCard
o BMIReferenceCardo F-75ReferenceCardo F-100ReferenceCardo RUTFappetitetest
ReferenceCardo RUTFdosingReference
Cardo AntibioticsReference
Card
o Suitableformsforrecordkeeping,suchastheCCP(CriticalCarePathway)orotherformsrequestingsimilarinformation(weightcharts,monitoringrecords)
o 24-HourFeedIntakeCharts
kitchen Equipment/Supplies• Dietaryscalesabletoweigh
to5g
• Electricblenderormanualwhisks
• Largecontainersandspoonsformixing/cookingfeedfortheward
• Facilitiesforcooking
• Feedingcups,saucers,spoons
• Measuringcylinders(orsuitableutensilsformeasuringingredientsandleftovers)
• Jugs(1-litreand2-litres)
• Refrigeration
• FormakingF-75andF-100:o Driedskimmedmilk,
wholedriedmilk,freshwholemilk,orlong-lifemilk
o Sugaro Cerealflouro Vegetableoilo Safewatersupply
Locallyavailablefoods(forteaching/useintransitiontohomefoods)
ANNEX 1EQUIPMENTANDSUPPLIESNEEDEDFORANUTRITIONWARD/UNIT
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 143
Pharmacy Equipment/Supplies• Pharmaceuticalscales
• WHOORSforuseinmakingReSoMal(orcommercialReSoMal)
• CombinedMineralVitaminMix(CMV)
IfCMVnotavailable:
*Mineralmix(maybepreparedinthepharmacy)or
Electrolytesandminerals:
o Potassiumchloride
o Tripotassiumcitrate
o Magnesiumchloride
o Zincacetate
o Coppersulphate
*Multivitaminwithoutiron
• Ironsyrup(e.g.,ferrousfumarate)
• Folicacid
• VitaminA(highpotencysyrupor50,000/100000/200000IUcapsules)
• Glucose(orsucrose)
• IVfluids–oneofthefollowing:
o Half-strengthDarrow’ssolutionwith5%glucose(dextrose)
o Ringer’slactatesolutionwith5%glucose*
o 0.45%(half-normal)salinewith5%glucose*
*Ifeitheroftheseisused,sterilepotassiumchloride
(20moll/l)shouldbeaddedifpossible.
• Sterilewaterfordiluting
• Waterforinjection(ampoules2,5and10ml)
• Vaccines(BCG,OPV,Pentavalent,RotaVirus,PCVandMeasles)
Drugs(SeeformulationslistedonAntibioticsReferenceCard)
• Amoxicillin
• Ampicillin
• Benzylpenicillin
• Cotrimoxazole
• Gentamicin
• Metronidazole
• Cloxacilllin
• Ceftriaxone
• Mebendazole,albendazoleand/orotherdrugsfortreatmentofworms(asonnoteofdrugkitformanagementofsevereacutemalnutritionwithmedicalcomplications(Seesupportmaterials))
• Gentamycinorchloramphenicoleyedrops
• Atropine1%eyedrops
• Artemether+Lumefantrinetablets
• Artesunate suppository
Forskin
• Gentianviolet
• Zincoxideointment
• Petroleumjellyointment
• Nystatinointmentorcream(forCandidiasis)
• Vaselinegauze(tullegras)
• Silversulphurdiazine
Laboratory resources accessible where applicable• TBtests(x-ray,cultureof
sputum,Mantoux)
• Urinalysis
• Stoolanalysisandculture
• Bloodculture
• Cerebrospinalfluidanalysisandculture
• Genexpert
• HIVtest
o HIVrapidTestingkits
• Bloodsample
o Filterpapers
o RDT
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA144 JANUARY 2016
ANNEX 2TRIAGEOFSICKCHILDREN
• Tiny-Sickinfantaged<2months• Temperatureveryhigh>390• Trauma-majortrauma• Pain-Childinseverepain• Poison-motherreportspoisoning• Pallor-severepalmerpallor• Restless/Irritable/Floppy• Respiratorydistress• Referral-hasanurgentreferralletter• Malnutrition:o visibleseverewastingo Bilateralpittingoedema
• Burns-severeburnsFrontoftheQueue-Clinicalreviewassoonaspossible:• Weigh• Baselineobservations
• Hypoglycaemia(BloodSugar<3mml/dl)• HypothermiaTemp≤35.50C,axillar• Severeinfections• DiarrheaandSeveredehydration• Shock• Verysevereanemia(Hb≤4g/dl)• Cardiacfailure• Severedermatosis• CornealUlceration
priority signs
medicAl complicAtions iF severe AcUte mAlnUtrition
emergency signs:
NON URgENT- CHILDRENWITHNONEOFTHEABOVESIGNS/MEDICALCOMPLICATIONS
Diarrhoeawithsunkeneyes→assessment/treatmentforseveredehydration
Comma/convulsing/confusion:AVPU=‘PorU’orConvulsions
Airway&breathing
Circulation
• Obstructedbreathing• CentralCyanosis• SevereRespiratorydistress• Weak/absentbreathing
Coldhandswithanyof:• Capillaryrefill>3seconds• Weak+fastpulse• Slow(<60bpm)orabsent
pulse
Immediatetransfertoemergencyarea:• Startlifesupport
procedures• Giveoxygen• Weighifpossible
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 145
ANNEX 3 3A:WEIGHT-FOR-LENGTHREFERENCECARDa
(WHO growth Standards)
BOyS' WEIgHT (kg) gIRLS' WEIgHT (kg
-3 sd -2 sd -1 sd median LENgTH (CM) median -1 sd -2 sd -3 sd
1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9
2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0
2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2
2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3
2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4
2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6
2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8
2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9
3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1
3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3
3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5
3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7
4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9
4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1
4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3
4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5
4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7
5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9
5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1
5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3
5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5
5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6
6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8
6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0
6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1
6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3
6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5
7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6
7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8
7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA146 JANUARY 2016
BOyS' WEIgHT (kg) gIRLS' WEIgHT (kg
-3 sd -2 sd -1 sd median LENgTH (CM) median -1 sd -2 sd -3 sd
7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1
7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2
7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4
7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5
8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7
8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8
8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0
8.5 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1
8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3
8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5
9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7
9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9
9.5 10.2 11.1 12.0 87 11.7 10.7 9.9 9.1
9.7 10.5 11.3 12.2 88 12.0 11.0 10.1 9.3
9.9 10.7 11.5 12.5 89 12.2 11.2 10.3 9.5
10.1 10.9 11.8 12.7 90 12.5 11.4 10.5 9.7
10.3 11.1 12.0 13.0 91 12.7 11.7 10.7 9.9
10.5 11.3 12.2 13.2 92 13.0 11.9 10.9 10.1
10.7 11.5 12.4 13.4 93 13.2 12.1 11.1 10.2
10.8 11.7 12.6 13.7 94 13.5 12.3 11.3 10.4
11.0 11.9 12.8 13.9 95 13.7 12.6 11.5 10.6
11.2 12.1 13.1 14.1 96 14.0 12.8 11.7 10.8
11.4 12.3 13.3 14.4 97 14.2 13.0 12.0 11.0
11.6 12.5 13.5 14.6 98 14.5 13.3 12.2 11.2
11.8 12.7 13.7 14.9 99 14.8 13.5 12.4 11.4
12.0 12.9 14.0 15.2 100 15.0 13.7 12.6 11.6
a Amoredetailed tableisavailable onhttp://www.who.int/childgrowth/standards/weight_for_length/en/index.htmlbLengthismeasuredforchildrenbelow2yearsor,ifageisnotknown,below87cm.Forchildren2yearsandabove(or,ifageisnotknown,87cmormore),heightismeasured(seefollowingtable).Recumbentlengthisonaverage0.7cmgreaterthanstandingheight;althoughthedifferenceisofnoimportancetoindividualchildren,acorrectionmaybemadebyadding0.7cmtotheheightifthechildislessthan2years(orbelow87cmifagenotknown)whenrecumbentlengthcannotbemeasured.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 147
3B:WEIGHT-FOR-HEIGHTREFERENCECARDa
(WHO growth Standards)
BOyS' WEIgHT (kg) gIRLS' WEIgHT (kg
-3 sd -2 sd -1 sd median heightb (CM) median -1 sd -2 sd -3 sd
5.9 6.3 6.9 7.4 65 7.2 6.6 6.1 5.6
6.1 6.5 7.1 7.7 66 7.5 6.8 6.3 5.8
6.2 6.7 7.3 7.9 67 7.7 7.0 6.4 5.9
6.4 6.9 7.5 8.1 68 7.9 7.2 6.6 6.1
6.6 7.1 7.7 8.4 69 8.1 7.4 6.8 6.3
6.8 7.3 7.9 8.6 70 8.3 7.6 7.0 6.4
6.9 7.5 8.1 8.8 71 8.5 7.8 7.1 6.6
7.1 7.7 8.3 9.0 72 8.7 8.0 7.3 6.7
7.3 7.9 8.5 9.2 73 8.9 8.1 7.5 6.9
7.4 8.0 8.7 9.4 74 9.1 8.3 7.6 7.0
7.6 8.2 8.9 9.6 75 9.3 8.5 7.8 7.2
7.7 8.4 9.1 9.8 76 9.5 8.7 8.0 7.3
7.9 8.5 9.2 10.0 77 9.6 8.8 8.1 7.5
8.0 8.7 9.4 10.2 78 9.8 9.0 8.3 7.6
8.2 8.8 9.6 10.4 79 10.0 9.2 8.4 7.8
8.3 9.0 9.7 10.6 80 10.2 9.4 8.6 7.9
8.5 9.2 9.9 10.8 81 10.4 9.6 8.8 8.1
8.7 9.3 10.1 11.0 82 10.7 9.8 9.0 8.3
8.8 9.5 10.3 11.2 83 10.9 10.0 9.2 8.5
9.0 9.7 10.5 11.4 84 11.1 10.2 9.4 8.6
9.2 10.0 10.8 11.7 85 11.4 10.4 9.6 8.8
9.4 10.2 11.0 11.9 86 11.6 10.7 9.8 9.0
9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2
9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4
10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6
10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8
10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0
10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2
10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4
11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6
11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA148 JANUARY 2016
BOyS' WEIgHT (kg) gIRLS' WEIgHT (kg
-3 sd -2 sd -1 sd median heightb (CM) median -1 sd -2 sd -3 sd
11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9
11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1
11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3
11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5
12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7
12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0
12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2
12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4
13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6
13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9
13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1
13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4
13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7
14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9
14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2
14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5
14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8
15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1
15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4
15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7
16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0
16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3
16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6
16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9
17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3
a A more detailed table is available on http://www.who.int/childgrowth/standards/weight_for_height/en/index.html.
b For children 2 years and above (or, if age not known, 87 cm or more), height is measured.Recumbentlength isonaverage0.7cmgreater than standingheight;althoughthedifference isofnoimportancetoindividualchildren,acorrectionmaybemadebysubtracting0.7cmfromthelengthsifthechildis2yearsormoreorabove86.9cmwhenstandingheightcannotbemeasured.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 149
3C:BMI-FOR-AGEREFERENCECARDFORCHILDREN5TO19YEARS
Boy’sBMI(kg/m2) Age Girl’sBMI(kg/m2)
-3SD -2SD -1SD Median Year:Months Months Median -1SD -2SD -3SD
12.1 13.0 14.1 15.3 5:1 61 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:2 62 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:3 63 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:4 64 15.2 13.9 12.7 11.812.1 13.0 14.1 15.3 5:5 65 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:6 66 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:7 67 15.2 13.9 12.7 11.712.1 13.0 14.1 15.3 5:8 68 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:9 69 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:10 70 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 5:11 71 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 6:0 72 15.3 13.9 12.7 11.712.1 13.0 14.1 15.3 6:1 73 15.3 13.9 12.7 11.712.2 13.1 14.1 15.3 6:2 74 15.3 13.9 12.7 11.712.2 13.1 14.1 15.3 6:3 75 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:4 76 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:5 77 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:6 78 15.3 13.9 12.7 11.712.2 13.1 14.1 15.4 6:7 79 15.3 13.9 12.7 11.712.2 13.1 14.2 15.4 6:8 80 15.3 13.9 12.7 11.712.2 13.1 14.2 15.4 6:9 81 15.4 13.9 12.7 11.712.2 13.1 14.2 15.4 6:10 82 15.4 13.9 12.7 11.712.2 13.1 14.2 15.5 6:11 83 15.4 13.9 12.7 11.712.3 13.1 14.2 15.5 7:0 84 15.4 13.9 12.7 11.812.3 13.2 14.2 15.5 7:1 85 15.4 13.9 12.7 11.812.3 13.2 14.2 15.5 7:2 86 15.4 14.0 12.8 11.812.3 13.2 14.3 15.5 7:3 87 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:4 88 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:5 89 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:6 90 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:7 91 15.5 14.0 12.8 11.812.3 13.2 14.3 15.6 7:8 92 15.6 14.0 12.8 11.812.4 13.2 14.3 15.7 7:9 93 15.6 14.1 12.8 11.812.4 13.3 14.4 15.7 7:10 94 15.6 14.1 12.9 11.912.4 13.3 14.4 15.7 7:11 95 15.7 14.1 12.9 11.912.4 13.3 14.4 15.7 8:0 96 15.7 14.1 12.9 11.912.4 13.3 14.4 15.8 8:1 97 15.7 14.1 12.9 11.912.4 13.3 14.4 15.8 8:2 98 15.7 14.2 12.9 11.912.4 13.3 14.4 15.8 8:3 99 15.8 14.2 12.9 11.912.4 13.4 14.5 15.8 8:4 100 15.8 14.2 13.0 11.912.5 13.4 14.5 15.9 8:5 101 15.8 14.2 13.0 12.0
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA150 JANUARY 2016
Boy’sBMI(kg/m2) Age Girl’sBMI(kg/m2)
-3SD -2SD -1SD Median Year:Months Months Median -1SD -2SD -3SD
12.5 13.4 14.5 15.9 8:6 102 15.9 14.3 13.0 12.012.5 13.4 14.5 15.9 8:7 103 15.9 14.3 13.0 12.012.5 13.4 14.5 15.9 8:8 104 15.9 14.3 13.0 12.012.5 13.4 14.6 16.0 8:9 105 16.0 14.3 13.1 12.012.5 13.5 14.6 16.0 8:10 106 16.0 14.4 13.1 12.112.5 13.5 14.6 16.0 8:11 107 16.1 14.4 13.1 12.112.6 13.5 14.6 16.0 9:0 108 16.1 14.4 13.1 12.112.6 13.5 14.6 16.1 9:1 109 16.1 14.5 13.2 12.112.6 13.5 14.7 16.1 9:2 110 16.2 14.5 13.2 12.112.6 13.5 14.7 16.1 9:3 111 16.2 14.5 13.2 12.212.6 13.6 14.7 16.2 9:4 112 16.3 14.6 13.2 12.212.6 13.6 14.7 16.2 9:5 113 16.3 14.6 13.3 12.212.7 13.6 14.8 16.2 9:6 114 16.3 14.6 13.3 12.212.7 13.6 14.8 16.3 9:7 115 16.4 14.7 13.3 12.312.7 13.6 14.8 16.3 9:8 116 16.4 14.7 13.4 12.312.7 13.7 14.8 16.3 9:9 117 16.5 14.7 13.4 12.312.7 13.7 14.9 16.4 9:10 118 16.5 14.8 13.4 12.312.8 13.7 14.9 16.4 9:11 119 16.6 14.8 13.4 12.412.8 13.7 14.9 16.4 10:0 120 16.6 14.8 13.5 12.412.8 13.8 15.0 16.5 10:1 121 16.7 14.9 13.5 12.412.8 13.8 15.0 16.5 10:2 122 16.7 14.9 13.5 12.412.8 13.8 15.0 16.6 10:3 123 16.8 15.0 13.6 12.512.9 13.8 15.0 16.6 10:4 124 16.8 15.0 13.6 12.512.9 13.9 15.1 16.6 10:5 125 16.9 15.0 13.6 12.512.9 13.9 15.1 16.7 10:6 126 16.9 15.1 13.7 12.512.9 13.9 15.1 16.7 10:7 127 17.0 15.1 13.7 12.613.0 13.9 15.2 16.8 10:8 128 17.0 15.2 13.7 12.613.0 14.0 15.2 16.8 10:9 129 17.1 15.2 13.8 12.613.0 14.0 15.2 16.9 10:10 130 17.1 15.3 13.8 12.713.0 14.0 15.3 16.9 10:11 131 17.2 15.3 13.8 12.713.1 14.1 15.3 16.9 11:0 132 17.2 15.3 13.9 12.713.1 14.1 15.3 17.0 11:1 133 17.3 15.4 13.9 12.813.1 14.1 15.4 17.0 11:2 134 17.4 15.4 14.0 12.813.1 14.1 15.4 17.1 11:3 135 17.4 15.5 14.0 12.813.2 14.2 15.5 17.1 11:4 136 17.5 15.5 14.0 12.913.2 14.2 15.5 17.2 11:5 137 17.5 15.6 14.1 12.913.2 14.2 15.5 17.2 11:6 138 17.6 15.6 14.1 12.913.2 14.3 15.6 17.3 11:7 139 17.7 15.7 14.2 13.013.3 14.3 15.6 17.3 11:8 140 17.7 15.7 14.2 13.013.3 14.3 15.7 17.4 11:9 141 17.8 15.8 14.3 13.013.3 14.4 15.7 17.4 11:10 142 17.9 15.8 14.3 13.113.4 14.4 15.7 17.5 11:11 143 17.9 15.9 14.3 13.113.4 14.5 15.8 17.5 12:0 144 18.0 16.0 14.4 13.2
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 151
Boy’sBMI(kg/m2) Age Girl’sBMI(kg/m2)
-3SD -2SD -1SD Median Year:Months Months Median -1SD -2SD -3SD
13.4 14.5 15.8 17.6 12:1 145 18.1 16.0 14.4 13.213.5 14.5 15.9 17.6 12:2 146 18.1 16.1 14.5 13.213.5 14.6 15.9 17.7 12:3 147 18.2 16.1 14.5 13.313.5 14.6 16.0 17.8 12:4 148 18.3 16.2 14.6 13.313.6 14.6 16.0 17.8 12:5 149 18.3 16.2 14.6 13.313.6 14.7 16.1 17.9 12:6 150 18.4 16.3 14.7 13.413.6 14.7 16.1 17.9 12:7 151 18.5 16.3 14.7 13.413.7 14.8 16.2 18.0 12:8 152 18.5 16.4 14.8 13.513.7 14.8 16.2 18.0 12:9 153 18.6 16.4 14.8 13.513.7 14.8 16.3 18.1 12:10 154 18.7 16.5 14.8 13.513.8 14.9 16.3 18.2 12:11 155 18.7 16.6 14.9 13.613.8 14.9 16.4 18.2 13:0 156 18.8 16.6 14.9 13.613.8 15.0 16.4 18.3 13:1 157 18.9 16.7 15.0 13.613.9 15.0 16.5 18.4 13:2 158 18.9 16.7 15.0 13.713.9 15.1 16.5 18.4 13:3 159 19.0 16.8 15.1 13.714.0 15.1 16.6 18.5 13:4 160 19.1 16.8 15.1 13.814.0 15.2 16.6 18.6 13:5 161 19.1 16.9 15.2 13.814.0 15.2 16.7 18.6 13:6 162 19.2 16.9 15.2 13.814.1 15.2 16.7 18.7 13:7 163 19.3 17.0 15.2 13.914.1 15.3 16.8 18.7 13:8 164 19.3 17.0 15.3 13.914.1 15.3 16.8 18.8 13:9 165 19.4 17.1 15.3 13.914.2 15.4 16.9 18.9 13:10 166 19.4 17.1 15.4 14.014.2 15.4 17.0 18.9 13:11 167 19.5 17.2 15.4 14.014.3 15.5 17.0 19.0 14:0 168 19.6 17.2 15.4 14.014.3 15.5 17.1 19.1 14:1 169 19.6 17.3 15.5 14.114.3 15.6 17.1 19.1 14:2 170 19.7 17.3 15.5 14.114.4 15.6 17.2 19.2 14:3 171 19.7 17.4 15.6 14.114.4 15.7 17.2 19.3 14:4 172 19.8 17.4 15.6 14.114.5 15.7 17.3 19.3 14:5 173 19.9 17.5 15.6 14.214.5 15.7 17.3 19.4 14:6 174 19.9 17.5 15.7 14.214.5 15.8 17.4 19.5 14:7 175 20.0 17.6 15.7 14.214.6 15.8 17.4 19.5 14:8 176 20.0 17.6 15.7 14.314.6 15.9 17.5 19.6 14:9 177 20.1 17.6 15.8 14.314.6 15.9 17.5 19.6 14:10 178 20.1 17.7 15.8 14.314.7 16.0 17.6 19.7 14:11 179 20.2 17.7 15.8 14.314.7 16.0 17.6 19.8 15:0 180 20.2 17.8 15.9 14.414.7 16.1 17.7 19.8 15:1 181 20.3 17.8 15.9 14.414.8 16.1 17.8 19.9 15:2 182 20.3 17.8 15.9 14.414.8 16.1 17.8 20.0 15:3 183 20.4 17.9 16.0 14.414.8 16.2 17.9 20.0 15:4 184 20.4 17.9 16.0 14.514.9 16.2 17.9 20.1 15:5 185 20.4 17.9 16.0 14.514.9 16.3 18.0 20.1 15:6 186 20.5 18.0 16.0 14.515.0 16.3 18.0 20.2 15:7 187 20.5 18.0 16.1 14.5
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA152 JANUARY 2016
Boy’sBMI(kg/m2) Age Girl’sBMI(kg/m2)
-3SD -2SD -1SD Median Year:Months Months Median -1SD -2SD -3SD
15.0 16.3 18.1 20.3 15:8 188 20.6 18.0 16.1 14.515.0 16.4 18.1 20.3 15:9 189 20.6 18.1 16.1 14.515.0 16.4 18.2 20.4 15:10 190 20.6 18.1 16.1 14.615.1 16.5 18.2 20.4 15:11 191 20.7 18.1 16.2 14.615.1 16.5 18.2 20.5 16:0 192 20.7 18.2 16.2 14.615.1 16.5 18.3 20.6 16:1 193 20.7 18.2 16.2 14.615.2 16.6 18.3 20.6 16:2 194 20.8 18.2 16.2 14.615.2 16.6 18.4 20.7 16:3 195 20.8 18.2 16.2 14.615.2 16.7 18.4 20.7 16:4 196 20.8 18.3 16.2 14.615.3 16.7 18.5 20.8 16:5 197 20.9 18.3 16.3 14.615.3 16.7 18.5 20.8 16:6 198 20.9 18.3 16.3 14.715.3 16.8 18.6 20.9 16:7 199 20.9 18.3 16.3 14.715.3 16.8 18.6 20.9 16:8 200 20.9 18.3 16.3 14.715.4 16.8 18.7 21.0 16:9 201 21.0 18.4 16.3 14.715.4 16.9 18.7 21.0 16:10 202 21.0 18.4 16.3 14.715.4 16.9 18.7 21.1 16:11 203 21.0 18.4 16.3 14.715.4 16.9 18.8 21.1 17:0 204 21.0 18.4 16.4 14.715.5 17.0 18.8 21.2 17:1 205 21.1 18.4 16.4 14.715.5 17.0 18.9 21.2 17:2 206 21.1 18.4 16.4 14.715.5 17.0 18.9 21.3 17:3 207 21.1 18.5 16.4 14.715.5 17.1 18.9 21.3 17:4 208 21.1 18.5 16.4 14.715.6 17.1 19.0 21.4 17:5 209 21.1 18.5 16.4 14.715.6 17.1 19.0 21.4 17:6 210 21.2 18.5 16.4 14.715.6 17.1 19.1 21.5 17:7 211 21.2 18.5 16.4 14.715.6 17.2 19.1 21.5 17:8 212 21.2 18.5 16.4 14.715.6 17.2 19.1 21.6 17:9 213 21.2 18.5 16.4 14.715.7 17.2 19.2 21.6 17:10 214 21.2 18.5 16.4 14.715.7 17.3 19.2 21.7 17:11 215 21.2 18.6 16.4 14.715.7 17.3 19.2 21.7 18:0 216 21.3 18.6 16.4 14.715.7 17.3 19.3 21.8 18:1 217 21.3 18.6 16.5 14.715.7 17.3 19.3 21.8 18:2 218 21.3 18.6 16.5 14.715.7 17.4 19.3 21.8 18:3 219 21.3 18.6 16.5 14.715.8 17.4 19.4 21.9 18:4 220 21.3 18.6 16.5 14.715.8 17.4 19.4 21.9 18:5 221 21.3 18.6 16.5 14.715.8 17.4 19.4 22.0 18:6 222 21.3 18.6 16.5 14.715.8 17.5 19.5 22.0 18:7 223 21.4 18.6 16.5 14.715.8 17.5 19.5 22.0 18:8 224 21.4 18.6 16.5 14.715.8 17.5 19.5 22.1 18:9 225 21.4 18.7 16.5 14.715.8 17.5 19.6 22.1 18:10 226 21.4 18.7 16.5 14.715.8 17.5 19.6 22.2 18:11 227 21.4 18.7 16.5 14.715.9 17.6 19.6 22.2 19:0 228 21.4 18.7 16.5 14.7
ThistablehasbeenconstructedusingtheWHOreferencetablesforBMI-for-agez-scoresfor5to19years.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 153
3D:BODYMASSINDEXREFERENCECARD
Height(cm)
BodyMassIndex
18.5 18 17.5 17 16.5 16
140 36.3 35.3 34.3 33.3 32.3 31.4
141 36.8 35.8 34.8 33.8 32.8 31.8
142 37.3 36.3 35.3 34.3 33.3 32.3
143 37.8 36.8 35.8 34.8 33.7 32.7
144 38.4 37.3 36.3 35.3 34.2 33.2
145 38.9 37.8 36.8 35.7 34.7 33.6
146 39.4 38.4 37.3 36.2 35.2 34.1
147 40.0 38.9 37.8 36.7 35.7 34.6
148 40.5 39.4 38.3 37.2 36.1 35.0
149 41.1 40.0 38.9 37.7 36.6 35.5
150 41.6 40.5 39.4 38.3 37.1 36.0
151 42.2 41.0 39.9 38.8 37.6 36.5
152 42.7 41.6 40.4 39.3 38.1 37.0
153 43.3 42.1 41.0 39.8 38.6 37.5
154 43.9 42.7 41.5 40.3 39.1 37.9
155 44.4 43.2 42.0 40.8 39.6 38.4
156 45.0 43.8 42.6 41.4 40.2 38.9
157 45.6 44.4 43.1 41.9 40.7 39.4
158 46.2 44.9 43.7 42.4 41.2 39.9
159 46.8 45.5 44.2 43.0 41.7 40.4
160 47.4 46.1 44.8 43.5 42.2 41.0
161 48.0 46.7 45.4 44.1 42.8 41.5
162 48.6 47.2 45.9 44.6 43.3 42.0
163 49.2 47.8 46.5 45.2 43.8 42.5
164 49.8 48.4 47.1 45.7 44.4 43.0
Height(cm)
BodyMassIndex
18.5 18 17.5 17 16.5 16
165 50.4 49.0 47.6 46.3 44.9 43.6
166 51.0 49.6 48.2 46.8 45.5 44.1
167 51.6 50.2 48.8 47.4 46.0 44.6
168 52.2 50.8 49.4 48.0 46.6 45.2
169 52.8 51.4 50.0 48.6 47.1 45.7
170 53.5 52.0 50.6 49.1 47.7 46.2
171 54.1 52.6 51.2 49.7 48.2 46.8
172 54.7 53.3 51.8 50.3 48.8 47.3
173 55.4 53.9 52.4 50.9 49.4 47.9
174 55.0 54.5 53.0 51.5 50.0 48.4
175 56.7 55.1 53.6 52.1 50.5 49.0
176 57.3 55.8 54.2 52.7 51.1 49.6
177 58.0 56.4 54.8 53.3 51.7 50.7
178 58.6 57.0 55.4 53.9 52.3 50.7
179 59.3 57.7 56.1 54.5 52.9 51.3
180 59.9 58.3 56.7 55.1 53.5 51.8
181 60.6 59.0 57.3 55.7 54.1 52.4
182 61.3 59.6 58.0 56.3 54.7 53.0
183 62.0 60.3 58.6 56.9 55.3 53.6
184 62.6 60.9 59.2 57.6 55.9 54.2
185 63.3 61.6 59.9 58.2 56.5 54.8
186 64.0 62.3 60.5 58.8 57.1 55.4
187 64.7 62.9 61.2 59.4 57.7 56.0
188 65.4 63.6 61.9 60.1 58.3 56.6
189 66.1 64.3 62.5 60.7 58.9 57.2
190 66.8 65.0 63.2 61.4 59.6 57.8
ANNE
X 4
PROTO
COLFO
RTH
EINPATIEN
TMAN
AGEM
ENTOFTH
ESEVE
RELYM
ALNOURISH
ED
step
prev
enti
on
wA
rnin
g s
ign
sim
med
iAte
Act
ion
1.Treatorp
revent
Hypo
glycem
ia(Low
bloo
dsugar)
Hypo
glycem
iais
abloo
dglucose
<3mmol/L
Fora
llchild
ren:-
1.Fee
dstraightaw
ayand
then
every
2-3ho
urs,dayand
night.
2.Encou
ragem
othe
rsto
watchfo
rany
deterio
ratio
n,helpfeed
and
kee
pchild
1.Low
tempe
rature
(hyp
othe
rmia)n
oted
onrouti
ne
check.
2.Letha
rgy,lim
pnessa
ndlo
ssof
consciou
sness.
3.Childcan
becom
esdrowsy.
PerformDextrostix
testonad
miss
ion,beforegiving
glucoseor
feed
ing.If
hyp
ogly
cem
ia is
susp
ecte
d an
dno
dextrostix
are
availableorifitisnotpossib
leto
geteno
ughbloo
dfortest,
assumethatth
echild
hashyp
oglycemiaand
givetreatm
ent
immed
iatelywith
outlab
oratoryconfi
rmati
on.
Ifconsciou
s:
1.Giveabo
luso
f10%
glucose(5
0ml)orsu
garsoluti
on(1
roun
dedteaspo
onsu
garin3tablespo
onso
fwater).Bo
luso
f10
%glucoseisbest,bu
tgivesugarsoluti
onorF
75fo
rmula
ratherth
anwaitforglucose.
2.Startfe
edingstraightaw
ay:Fee
d2-ho
urly(1
2feed
sin24
ho
urs).U
sefe
edcha
rtto
find
amou
ntto
givean
dfeed
every
2-3ho
ursd
ayand
night.
If un
cons
ciou
s, giveglucoseIV(5
ml/k
gofsterile10%
glucose),
follo
wed
by50
mlo
f10%
glucoseorsucrosebyNGtube
.
2.Treatorp
revent
Hypo
thermia(Low
tempe
rature)
Hypo
thermiaisa
rectalte
mpe
rature
<35.50
C(95.90
F)ora
nun
derarm
tempe
rature
<350
C(950
F).
Fora
llchild
ren:-
1Feed
straightaw
ayand
then
every
2-3ho
urs,dayand
night.
2.Kee
pwarm.
3.Useth
ekang
aroo
techniqu
e,cover
with
ablanket.Letm
othe
rsleep
with
child
tokee
pchild
warm.
Lowte
mpe
rature
NOTE:H
ypothe
rmiain
malno
urish
edchildren
often
indicatesc
oexisting
hypo
glycem
iaand
serio
us
infecti
on.
Takere
ctalte
mpe
ratureonad
miss
ion.(E
nsurethermom
eter
iswellsha
kendo
wn).
Iftherectalte
mpe
ratureisbelow
35.50
C:
1.Fee
dstraightaw
ay(o
rstartre
hydrati
onifnee
ded).
2.Re-warm.P
utth
echild
onthemothe
r’sbarechest(skinto
skincon
tact)a
ndcoverth
em,O
Rclothe
thechild
includ
ing
thehe
ad,coverwith
awarmed
blanketand
placeaheatero
rlampne
arby.
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
155
JAN
UA
RY
201
6
3.Kee
proom
warm,n
odrau
ghts.
4.Kee
pbe
dding/clothe
sdry.D
ry
carefullyafte
rbathing
(dono
tbathe
if
veryill).
5.Avoidexposuredu
ring
exam
inati
ons,bathing
.
6.Useaheatero
rincan
descen
tlam
pwith
cau
tion,d
o no
t use
hotbott
le
waterorfl
uorescen
tlam
p.
3.Fee
d2-ho
urly(1
2feed
sin24
hou
rs).
Mon
itord
uringre-w
arming
•Takere
ctalte
mpe
ratureeverytw
oho
urs:stop
re-
warmingwhe
nitrisesabo
ve36.50
C
•Takeevery30minutesifheaterisu
sedbe
causethechild
maybecom
eoverhe
ated
.
3.Treatorp
revent
dehydrati
on
(Too
littlefluidinth
ebo
dy)
Whe
nachild
haswaterydiarrhoe
a,
giveReSoM
albetwee
nfeed
safte
rea
chlo
osestoo
l.Asaguide
,give50
-10
0mlafte
reachwaterystoo
lifchild
isaged
<2years,or1
00-200
mlifa
ged
2yearso
rolder.
Profusewaterydiarrhoe
a,
thirst,hypo
thermia,sun
ken
eyes,w
eakorabsen
trad
ial
pulse
,coldha
ndsa
ndfe
et,
redu
cedurineou
tput.
DONOTGIVE
IVFLU
IDSEX
CEPT
INSHO
CK(see
sepa
rate
protocolfo
rtreati
ngsh
ock)
Ifde
hydrated
:
1.GiveRe
SoMal5ml/k
gevery30
minutesfo
r2hou
rs(o
rally
orbyna
sogastric
tube
)
2.The
ngive5-10m
l/kginalte
rnateho
ursforupto10ho
urs
(i.e.giveRe
SoMaland
F75
form
ulainalte
rnateho
urs).U
se
InitialM
anagem
entC
hart.
3.StopRe
SoMalwhe
nthereare3orm
orehydrati
onsign
s,or
signsofo
ver-h
ydratio
n.
Mon
itord
uringrehydrati
onfo
rsignsofo
ver-h
ydratio
n:
•increa
singpu
lseand
respira
toryra
te
•increa
singoe
demaan
dpu
ffyeyelid
s
Checkforsignsatlea
sthou
rly.Stopifpu
lsein
crea
sesb
y25
be
ats/minutean
drespira
toryra
teby5
breaths/minute.
4.Correctelectrolyte
imba
lance(Too
litt
lepotassiu
mand
magne
sium,and
too
muchsodium
)
1.UseReSoM
aland
F75
form
ulaas
thesearelowin
sodium
.
2.Dono
tadd
salttofo
odintrod
uced
du
ringthereha
bilitati
onpha
se.
Oed
emade
velopsorw
orsens.
Follo
wfe
edingrecommen
datio
n,asw
ellasrecom
men
datio
norpreventi
onortreatmen
tofd
ehydratio
n:
extrapo
tassium(4
mmol/kgbo
dyweigh
t)and
magne
sium
(0.6mmol/kg)areim
portan
t.
For p
otas
sium
,add
CMVorelectrolyte/m
ineralso
lutio
nor
10%potassiu
mchloridesolutio
ntofe
edsa
ndto
prepa
re
ReSo
Mal.Ifthe
seareuna
vailable,givecrushe
dSlow
K½
tablet/kgbo
dyweigh
tdaily.
For m
agne
sium
,add
CMVorelectrolyte/m
ineralso
lutio
nto
feed
sand
toReSoM
al.
NOTE:P
otassiu
mand
magne
siumarealre
adyad
dedinre
ady
todilu
teF75
and
F10
0pa
ckets.
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
157
JAN
UA
RY
201
6
1.Kee
pmalnu
trition
wardina
sepa
ratero
om
2.Red
uceovercrow
ding
ifpossib
le.
3.W
ashha
ndsb
eforeprep
aringfeed
san
dbe
foreand
afte
rdea
lingwith
any
child
.
4.Givem
easle
svaccine
to
unim
mun
izedchild
renover6m
onths
ofage.
5.Goo
dnu
rsingcare
NOTE:T
heusualsign
sof
infecti
on,suchasfe
ver,are
often
absen
tso
assu
me
all
severelym
alno
urish
edchildren
haveinfecti
onand
treatw
ith
antib
iotic
s.
Hypo
thermiaand
hypo
glycae
miaaresign
sof
severeinfecti
on.
NOTE:e
nsurealld
osesare
given.
Giveth
emontim
e.
Startin
gon
thefirstday,givebroa
d-spectrum
anti
bioti
cs*to
allchildren.
1.Ifth
echild
hasnocomplicati
ons,give:-
Cotrim
oxazole5mlp
aediatric
suspen
sionorallytw
iceada
yfor5
days
OR
2. If
the
child
is se
vere
ly il
l (ap
athe
tic,letha
rgic)o
rhas
complicati
ons(hypo
glycem
ia,h
ypothe
rmia,raw
skin/
fissures,re
spira
torytracto
rurin
arytractinfectio
n)giveIV/IM
ampicillinAN
Dgentam
icin.
Am
picillin:50m
g/kgIM
/IV6-ho
urlyfo
r2days,th
enoral
amoxycillin15m
g/kg8-hou
rlyfo
r5dayso
rifa
moxycillinis
nota
vailableconti
nuewith
ampicillinbu
tgiveorally,50m
g/kg
6-ho
urly
Ge
ntam
icin:7
.5mg/kgIM
/IVon
cedailyfo
r7days.
Inadd
ition
,giveMetronida
zoleaccording
tonati
onalpolicy.
If a
child
fails
to im
prov
e aft
er 4
8 ho
urs A
DDchloram
phen
icol
25mg/kg8hou
rlyIM
/IVfor5
day.
*Sh
ouldbeinline
with
nati
onalpolicy.
For p
aras
itic
wor
ms (
helm
inth
iasi
s, w
hipw
orm
):treatm
ent
shou
ldbede
layedun
tilth
ereha
bilitati
onpha
se.
Forc
hildrenover2yea
rs:G
iveAlbe
ndazole(400
mg,sing
le
dose)a
ndM
eben
dazole100
mgorallytw
iceada
yforthree
da
ys.
Forc
hildrenun
der2
yea
rs:G
ivepyrantel(1
0mg/kg,single
dose)o
rascariasis
with
pyran
telo
rpiperazine.
step
mA
nA
gem
ent
6. C
orre
ct
micronu
trient
deficiencies
1. g
ive
Vita
min
A o
n da
y 1.Ifund
er6m
onthsg
ive50
,000
units;if6
-12mon
thsg
ive10
0,00
0un
its;and
if>12
mon
thsg
ive20
0,00
0un
its.If
thechild
hasanysign
sofv
itaminAdefi
cien
cy,rep
eatthisd
oseon
day2and
day14.
Giveth
efollo
wingda
ily:
2.Folicacid:5
mgon
day1;the
n1mgda
ilyifm
icronu
trientsn
otin
clud
edin
thefeed
s.
3.M
ultiv
itaminsy
rup5mlo
nlyifmicronu
trientsn
otin
clud
edin
thefeed
s.
4.Zinc(2mg/kgbod
yweigh
t)and
cop
per(0.3m
g/kgbod
yweigh
t)ifm
icronu
trientsn
otin
clud
edin
thefeed
s
5.Startiron
(3mg/kg/day)a
fter2
dayso
nF100
catch-upform
ula.(D
ono
tgiveiro
ninth
estab
ilisatio
nph
asean
ddo
notgiveiro
nifchild
receivingRU
TF)
NOTE:V
itaminA,folicacid,m
ultiv
itamins,zincand
cop
pera
realre
adyad
dedinF75
and
F10
0pa
ckets.The
yarealsoin
CMV.
7.Begincau
tious
feed
ingstab
ilizatio
nph
asean
dtran
sition
ph
ase
Stab
ilisatio
nph
ase:
1.GiveF75form
ula(see
feed
cha
rtfo
ramou
nts).The
seprovide
130
ml/k
g/da
y.
2.Give8-12
feed
sover2
4ho
urs
3.Ifth
echild
hasoed
ema++
+,re
duceth
evolumeto100
ml/k
g/da
y(see
feed
cha
rtfo
ramou
nts)
4.Ifth
echild
haspoo
rapp
etite,encou
rageth
emothe
rtocoaxand
supp
ortthe
childfinishingthefeed
.Ife
ating
80%
orlesso
fthe
amou
nt
offered
for2
con
secutiv
efeed
s,useanasog
astrictu
be.Ifindo
ubt,seefeed
cha
rtfo
rintakesbelow
whichtu
befe
edingisne
eded
.
5.Kee
pa24
-hou
rintakechart.Mea
surefe
edsc
arefully.Recordlefto
vers.
6.Ifth
echild
isbreastfe
d,encou
ragecon
tinue
dbrea
stfee
ding
butalso
giveF75.
7.TransfertoF100
form
ulaasso
onasa
ppeti
tehasre
turned
(usuallywith
inone
wee
k)and
oed
emaha
sbee
nlostorisred
uced
8.W
eigh
dailyand
plotw
eigh
t.
Tran
sition
pha
se:
1.Cha
ngetoF10
0:
•for2
days,re
placeF75with
thesameam
ountofF
100on
thene
xtdayin
crea
seeachfeed
by10
mlu
ntilsom
efeed
remainsune
aten
.
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
159
JAN
UA
RY
201
6
8.In
crea
sefe
edingto
recoverw
eigh
tloss:
“Catch-upgrow
th”
reha
bilitati
onpha
se
1.Give6feed
sover2
4ho
urs.The
secan
be3feed
sofF
100an
d3speciallym
odified
familym
eals,highinene
rgyan
dprotein.Rea
dy-to
-use
therap
eutic
food
isanalternati
veto
F10
0,re
commen
dedtobegivenifthechild
isbeing
referred
tooutpa
tientcare.
2.Encou
rageth
echild
toeatasm
uchaspossib
le,sothechild
can
gainweigh
trap
idly.Ifth
echild
isfinishingeverything
,offe
rmorean
dincrea
sesu
bseq
uentfe
eds.M
akesureth
atth
echild
isacti
velyfe
d.
3.W
eigh
dailyand
plotw
eigh
t.
9.Stim
ulateem
otion
al
andsensorial
developm
ent:
Loving
care,playan
dstimulati
on
1.Provide
tend
erlo
ving
care
2.Helpan
den
couragemothe
rsto
com
fort,fee
d,and
playwith
theirc
hildren
3.Givestructured
playwhe
nthechild
iswelleno
ugh.
10.P
repa
refo
rdischa
rge
andfollo
w-up.
1.Obtaininform
ation
onfamilybackgroun
dan
dsocio-econ
omicstatus.
2.In
structm
othe
rshow
tom
odify
familyfo
ods,how
ofte
ntofe
edand
how
muchtogive.
3.Estab
lishalin
kwith
com
mun
ityhea
lthworkersfo
rhom
efollo
w-up.
4.W
ritefullclinicalsu
mmaryinpati
ent-h
eldcard.
5.Sen
dareferrallette
rtotheclinic.
6.Ifoutpa
tientm
anagem
ento
fseveremalnu
trition
exists,inform
themothe
rofthe
closestoutpa
tientcarereferralpointto
herhom
ean
dgiveth
emothe
rawee
klyratio
nofRUTFfo
rhom
eba
sedreha
bilitati
on.
ANNE
X 5
TargetW
eigh
tforReh
ydratio
n
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
2.0
2.04
2.10
2.1
2.14
2.21
2.2
2.24
2.31
2.3
2.35
2.42
2.4
2.45
2.52
2.5
2.55
2.63
2.6
2.65
2.73
2.7
2.75
2.84
2.8
2.86
2.94
2.9
2.96
3.05
3.0
3.06
3.15
3.1
3.16
3.26
3.2
3.26
3.36
3.3
3.37
3.47
3.4
3.47
3.57
3.5
3.57
3.68
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
3.6
3.67
3.78
3.7
3.77
3.89
3.8
3.88
3.99
3.9
3.98
4.10
4.0
4.08
4.20
4.1
4.18
4.31
4.2
4.28
4.41
4.3
4.39
4.52
4.4
4.49
4.62
4.5
4.59
4.73
4.6
4.69
4.83
4.7
4.79
4.94
4.8
4.90
5.04
4.9
5.00
5.15
5.0
5.10
5.25
5.1
5.20
5.36
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
5.2
5.30
5.46
5.3
5.41
5.57
5.4
5.51
5.67
5.5
5.61
5.78
5.6
5.71
5.88
5.7
5.81
5.99
5.8
5.92
6.09
5.9
6.02
6.20
6.0
6.12
6.30
6.1
6.22
6.41
6.2
6.32
6.51
6.3
6.43
6.62
6.4
6.53
6.72
6.5
6.63
6.83
6.6
6.73
6.93
6.7
6.83
7.04
TARg
ET W
EIg
HT
FOR
REH
yDRA
TIO
N (
DO
NO
T Ex
CEED
)
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
161
JAN
UA
RY
201
6
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
6.8
6.94
7.14
6.9
7.04
7.25
7.0
7.14
7.35
7.1
7.24
7.46
7.2
7.34
7.56
7.3
7.45
7.67
7.4
7.55
7.77
7.5
7.65
7.88
7.6
7.75
7.98
7.7
7.85
8.09
7.8
7.96
8.19
7.9
8.06
8.30
8.0
8.16
8.40
8.1
8.26
8.51
8.2
8.36
8.61
8.3
8.47
8.72
8.4
8.57
8.82
8.5
8.67
8.93
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
8.6
8.77
9.03
8.7
8.87
9.14
8.8
8.98
9.24
8.9
9.08
9.35
9.0
9.18
9.45
9.1
9.28
9.56
9.2
9.38
9.66
9.3
9.49
9.77
9.4
9.59
9.87
9.5
9.69
9.98
9.6
9.79
10.0
8
9.7
9.89
10.1
9
9.8
10.0
010
.29
9.9
10.1
010
.40
10.0
10.2
010
.5
10.1
10.3
010
.61
10.2
10.4
010
.71
10.3
10.5
110
.82
Weigh
tbe
fore
rehydrati
on
Targetweigh
t
Lowest
High
est
10.4
10.6
110
.92
10.5
10.7
111
.025
10.6
10.8
111
.13
10.7
10.9
111
.24
10.8
11.0
211
.34
10.9
11.1
211
.45
11.0
11.2
211
.55
11.1
11.3
211
.66
11.2
11.4
211
.76
11.3
11.5
311
.87
11.4
11.6
311
.97
11.5
11.7
312
.08
11.6
11.8
312
.18
11.7
11.9
312
.29
11.8
12.0
412
.39
11.9
12.1
412
.50
12.0
12.2
412
.60
TARg
ET W
EIg
HT
FOR
REH
yDRA
TIO
N (
DO
NO
T Ex
CEED
)
ANNE
X 6
ANTIBIOTICS
REF
EREN
CECAR
D
Sum
mar
y: A
ntibi
otics
for S
ever
ely
Mal
nour
ishe
d Ch
ildre
niF
:g
ive:
NOCOMPLICAT
IONS
Amox
icill
in oral:25
mg/kgevery12ho
ursfor5days
COMPLlCAT
IONS
gen
tam
icin1IVorIM(5
mg/kg),on
cedailyfo
r7days,p
lus:
(sho
ck,h
ypog
lycaem
ia,h
ypothe
rmia,severede
rmatosis,
infecti
ons,IM
CIdan
gersigns,severean
aemia,cardiacfa
ilure,
andcornea
lulcerati
on)
Ampi
cilli
n IVorIM(5
0mg/kg),every6
hoursfor2days
Follo
wed
by:A
mox
icill
in2Oral:2
5mg/kg,
every12
hou
rsfo
r5days
Ifresis
tancetoamoxicillinand
ampicillin,and
presenceof
med
icalcom
plicati
ons:
Seede
tailsofd
rugusebe
lowth
edrug
kit(sup
portm
aterial):
Inth
ecaseofsep
sisorsep
ticsh
ock:IM
ceft
riaxone
orc
efot
axim
e (Forchildren/
infantsb
eyon
don
emon
th:5
0mg/k
gevery8to12ho
urs)+oralc
ipro
floxa
cin (5to
15
mg/k
g2tim
esperday).
Ifsuspectedstap
hylococcalinfecti
ons:Add
:clo
xaci
llin (12,5to
50mg/kg/d
osefour
timesaday,d
epen
ding
ontheseverityofth
einfecti
on).
Ifaspecificinfecti
onre
quire
sanad
ditio
nalanti
bioti
c,ALSO
GIVE
:Sp
ecifi
c an
tibio
tic aredire
cted
onthedrug
kit(see
supp
ortm
aterials).R
eferto
the
drug
kitforsevereacutemalnu
trition
with
med
icalcom
plicati
ons.
1 Ifth
echild
isnotpassin
gurine,gen
tamicinm
ayaccum
ulateinth
ebo
dyand
cau
sedeafness.Dono
tgivethesecond
doseun
tilth
echild
ispassin
gurine.
2 Ifamoxicillinisnotavailable,giveam
picillin,50mg/kgorallyevery6hou
rsfo
r5days.
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
163
JAN
UA
RY
201
6
Dose
s for
Spe
cific
For
mul
ation
sA
nti
bio
tic
ROU
TE /
DO
SE/
FREq
UEN
Cy/
dU
rAti
on
Form
UlA
tio
n
Amoxicillin
Oral:25
mg/kgevery12ho
ursfor5
days
Tablet,2
50m
g
Syrup,125
mg/5m
l
Ampicillin
Oral:50
mg/kgevery6hou
rsfo
r5days
Tablet,2
50m
g
IV/IM:5
0mg/kgevery6hou
rsfo
r2
days
Vialof5
00m
gmixed
with
2.1m
lsterile
waterto
give50
0mg/2.5m
l
Syrup,200
mgSM
X+40
mgTM
Ppe
r5m
l
Metronida
zole
Oral:maxim
um5m
g/kgtw
iceada
yfor
amaxim
umof4
days
Suspen
sion,40mg/m
l
IV/IM
500mg/1
00m
l
Benzylpe
nicillin
IVorIM:5
000
0un
its/kgevery6
hoursfor5days
IV:vialo
f600
mgmixed
with
9.6m
lsterile
waterto
give100
000
0un
its/1
0ml
IM:vialo
f600
mgmixed
with
1.6m
lsterile
waterto
give100
000
0un
its/2
ml
Dose
s for
Sel
ecte
d An
tibio
tics,
for S
peci
fic F
orm
ulati
ons a
nd B
ody
Wei
ghts
Anti
bio
tic
ROU
TE /
DO
SE
FREq
UEN
Cy/
dUrA
tio
n
Form
UlA
tio
nDO
SES
FOR
SPEC
IFIC
BO
Dy W
EIg
HTS
(Use
clo
sest
wei
ght)
Gentam
icin
IVorIM:5
mg/kg
oncedailyfo
r7days
IV/IM:vialcon
taining20
mg
(2m
lat1
0mg/ml),und
iluted
3kg
4kg
5kg
6kg
7kg
8kg
9kg
10kg
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GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA164 JANUARY 2016
ANNEX 7RECIPESFORF-75ANDF-100AlternAtives ingredient AMOUNT FOR F-75Use one of the following recipes for F-75 (Note that cooking facilities are needed):Ifyouhavedriedwholemilk
Driedwholemilk 35g
Sugar 70gCerealflour 35g
Vegetableoil 20g
ComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**
Ifyouhavefreshcow’smilk,orfull-cream(whole)longlifemilk
Milk 300mlSugar 70gCerealflour 35gVegetableoil 20gComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**
Use one of the following recipes for F-100:Ifyouhavefreshcow’smilk,orfull-cream(whole)longlifemilk
Freshcow’smilk,orfull-cream(whole)longlifemilk 880ml
Sugar 75g
Vegetableoil 20g
ComplexMineralandVitaminmix* ½leveledscoop
Watertomake1000ml 1000ml**
Ifyouhavedriedwholemilk
Driedwholemilk 110gSugar 50gVegetableoil 30gComplexMineralandVitaminmix* ½leveledscoopWatertomake1000ml 1000ml**
*WhereCMVisnotavailable,amineralmixshouldbeused(20mlforoneliterofpreparation).Contentsofmineralmixaregiveninannex3ModuleIntroduction*
**Important note about adding water:Addjusttheamountofwaterneededtomake1000mlofformula.(Thisamountwillvaryfromrecipetorecipe,dependingontheotheringredients.)Donotsimplyadd1000mlofwater,asthiswillmaketheformulatoodilute.Amarkfor1000mlshouldbemadeonthemixingcontainerfortheformula,sothatwatercanbeaddedtotheotheringredientsuptothismark.
Directions for making cooked F-75 with cereal flour (top recipes)Youwillneeda1-litreelectricblenderorahandwhisk (rotarywhiskorballoonwhisk),a1-litremeasuringjug,acookingpot,andastoveorhotplate.Amountsof ingredientsarelistedonthepreviouspage.Cerealflourmaybemaizemeal,riceflour,orwhateveristhestaplecerealinthearea.
Itisimportanttousecooled,boiledwaterevenforrecipesthatinvolvecooking.Thecookingisonly4minutesofgentleboiling,andthismaynotbeenoughtokillallpathogensinthewater.Thewatershouldbecooledbecauseaddingboilingwatertothepowderedingredientsmaycreatelumps.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 165
If using an electric blender:1. Putabout200mloftheboiled,cooledwaterintotheblender.(Ifusingliquidmilkinsteadofmilk
powder,omitthisstep.)
2. Addtheflour,milkormilkpowder,sugar,oilandblend.
3. Addboiled,cooledwatertothe1000mlmarkandblendatahighspeed.
4. Transferthemixturetoacookingpotandboilgentlyfor4minuteswhilestirringcontinuously.
5. Somewaterwill evaporatewhile cooking, so transfer themixture back to the blender aftercookingandaddenoughboiled,cooledwatertomake1000ml.AddtheCMVandblendagain.
If using a hand whisk:1. Mixtheflour,milkormilkpowder,sugarandoilina1-litremeasuringjug.(Ifusingmilkpowder,
thiswillbeapaste.)
2. Slowlyaddboiled,cooledwaterupto1000mlmark.
3. Transfertocookingpotandwhiskthemixturevigorously.
4. Boilgentlyfor4minuteswhilestirringcontinuously.
5. Somewaterwillevaporatewhilecooking,sotransferthemixturebacktothemeasuringjugaftercookingandaddenoughboiledcooledwatertomake1000ml.AddtheCMVandwhiskagain
Directions for making non-cooked F-100 recipes If using an electric blender:1. Putabout200mloftheboiled,cooledwaterintotheblender.(Ifusingliquidmilkinsteadofmilk
powder,omitthisstep.)
2. Addtherequiredamountsofmilkormilkpowder,sugar,oil,andCMV.
3. Addboiledcooledwatertothe1000mlmarkandthenblendathighspeed.*
If using a hand whisk:1. Mixtherequiredamountsofmilkpowderandsugarina1-litremeasuringjug;thenaddtheoil
andstirwelltomakeapaste(Ifyouuseliquidmilk,mixthesugarandoil,andthenaddthemilk.)
2. AddCMV,andslowlyaddboiled,cooledwaterupto1000mlmark,whilestirringallthetime1.*
3. Whiskvigorously.
IfCMVisnotavailable,useMineralmix
MineralmixisincludedineachrecipeforF-75andF-100.ItisalsousedinmakingReSoMal.Thecontentsofthemineralmixare listed inAnnexD.Themixcontainspotassium,magnesium,andotheressentialminerals.Itmust beincludedinF-75andF-100tocorrectelectrolyteimbalance.Themineralmixmaybemadeinthepharmacyofthehospital
VitaminsVitaminsarealsoneeded inorwith the feed.Thevitaminmixdescribed inAnnexD cannotbemade in thehospital pharmacybecause amounts are so small. Thus, children areusually givenmultivitamindropsaswell.RecommendedvitaminstobeincludedinthemultivitaminpreparationarelistedinAnnexD.Themultivitaminpreparationshouldnot includeiron.
IfCMV isused,separatemultivitamindropsarenotneeded.
1 Whetherusingablenderorawhisk,itisimportanttomeasureuptothe1000mlmarkbeforeblending/whisking.Otherwise,themixturebecomestoofrothytojudgewheretheliquidlineis.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA166 JANUARY 2016
ANNEX 8 F-75,F100ANDRUTFREFERENCECARDSF-75 Reference Card Volume of F-75 to give for children of different weightsSee reverse for adjusted amounts for children with severe (+++) oedema.
Weight with +++ oedema (kg)
Every 2 hoursb (12 feeds)
Every 3 hoursc
(8 feeds)Every 4 hours
(6 feeds)Daily total
(130 ml/kg)80% of daily total
(minimum)
2.0 20 30 45 260 2102.2 25 35 50 286 2302.4 25 40 55 312 2502.6 30 45 55 338 2652.8 30 45 60 364 2903.0 35 50 65 390 3103.2 35 55 70 416 3353.4 35 55 75 442 3553.6 40 60 80 468 3753.8 40 60 85 494 3954.0 45 65 90 520 4154.2 45 70 90 546 4354.4 50 70 95 572 4604.6 50 75 100 598 4804.8 55 80 105 624 5005.0 55 80 110 650 5205.2 55 85 115 676 5405.4 60 90 120 702 5605.6 60 90 125 728 5805.8 65 95 130 754 6056.0 65 100 130 780 6256.2 70 100 135 806 6456.4 70 105 140 832 6656.6 75 110 145 858 6856.8 75 110 150 884 7057.0 75 115 155 910 7307.2 80 120 160 936 7507.4 80 120 160 962 7707.6 85 125 165 988 7907.8 85 130 170 1014 8108.0 90 130 175 1040 8308.2 90 135 180 1066 8558.4 90 140 185 1092 8758.6 95 140 190 1118 8958.8 95 145 195 1144 9159.0 100 145 200 1170 9359.2 100 150 200 1196 9609.4 105 155 205 1222 9809.6 105 155 210 1248 10009.8 110 160 215 1274 1020
10.0 110 160 220 1300 1040
aVolumesinthesecolumnsareroundedtothenearest5ml.bFeed2-hourlyforat least thefirstday. Then,when littleornovomiting,modestdiarrhoea(<5waterystoolsperday),andfinishingmostfeeds,changeto3-hourlyfeeds.cAfteradayon3-hourlyfeeds:Ifnovomiting,lessdiarrhoea,andfinishingmostfeeds,changeto4-hourlyfeeds.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 167
Volume of F-75 for Children with Severe (+++) Oedema
Weightwith+++oedema(kg)
VolumeofF-75perfeed(ml)a Dailytotal(100ml/kg)
80%ofdailytotala (minimum)
Every2hoursb (12feeds)
Every3hoursc (8feeds)
Every4hours(6feeds)
3.0 25 40 50 300 2403.2 25 40 55 320 2553.4 30 45 60 340 2703.6 30 45 60 360 2903.8 30 50 65 380 3054.0 35 50 65 400 3204.2 35 55 70 420 3354.4 35 55 75 440 3504.6 40 60 75 460 3704.8 40 60 80 480 3855.0 40 65 85 500 4005.2 45 65 85 520 4155.4 45 70 90 540 4305.6 45 70 95 560 4505.8 50 75 95 580 4656.0 50 75 100 600 4806.2 50 80 105 620 4956.4 55 80 105 640 5106.6 55 85 110 660 5306.8 55 85 115 680 5457.0 60 90 115 700 5607.2 60 90 120 720 5757.4 60 95 125 740 5907.6 65 95 125 760 6107.8 65 100 130 780 6258.0 65 100 135 800 6408.2 70 105 135 820 6558.4 70 105 140 840 6708.6 70 110 145 860 6908.8 75 110 145 880 7059.0 75 115 150 900 7209.2 75 115 155 920 7359.4 80 120 155 940 7509.6 80 120 160 960 7709.8 80 125 165 980 785
10.0 85 125 165 1000 80010.2 85 130 170 1020 81510.4 85 130 175 1040 83010.6 90 135 175 1060 85010.8 90 135 180 1080 86511.0 90 140 185 1100 88011.2 95 140 185 1120 89511.4 95 145 190 1140 91011.6 95 145 195 1160 93011.8 100 150 195 1180 94512.0 100 150 200 1200 960
aVolumesinthesecolumnsareroundedtothenearest5ml.bFeed2-hourlyforat least thefirstday. Then,when littleornovomiting,modestdiarrhoea(<5
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA168 JANUARY 2016
waterystoolsperday),andfinishingmostfeeds,changeto3-hourlyfeeds.cAfteradayon3-hourlyfeeds:Ifnovomiting,lessdiarrhoea,andfinishingmostfeeds,changeto4-hourlyfeeds.
RUTF reference card. quantities of RUTF in Transition.
Child’sweight
DailyweightofRUTF(g)
NumberofRUTFsachetsperday(ifonesachet=92g).
3 83 1
3.2 88 1
3.4 94 1
3.6 99 1.2
3.8 105 1.2
4.0 110 1.5
4.2 116 1.5
4.4 121 1.5
4.6 127 1.5
4.8 132 1.5
5 138 1.5
5.2 144 1.5
5.4 149 1.75
5.6 155 1.75
5.8 160 1.75
6 166 1.75
6.2 171 2
6.4 177 2
Child’sweight
DailyweightofRUTF(g)
NumberofRUTFsachetsperday(ifonesachet=92g).
6.6 182 2
6.8 188 2
7 193 2.2
7.2 199 2.2
7.4 204 2.2
7.6 210 2.5
7.8 215 2.5
8 221 2.5
8.2 226 2.5
8.4 232 2.5
8.6 237 2.75
8.8 243 2.75
9 248 2.75
9.2 254 2.75
9.4 259 3
9.6 265 3
9.8 270 3
10 276 3
quantities of RUTF in Rehabilitation (OTC)
WEIgHT OF PATIENT (kg) SACHETS/DAy SACHETS/WEEk3.0-3.4 1.25 9
3.5-3.9 1.5 11
4.0-5.4 2 14
5.5-6.92 2.5 18
7.0-8.4 3 218.5-9.4 3.5 25
9.5-10.4 4 28
10.5-11.9 4.5 32> 12.0 5 35
Adolescents10-14yrs 5 35Adolescents>14yrsandadults 6 42
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 169
F-100 Reference Card - Range of Volumes for Free-Feeding with F-100
WeightofChild(kg)
Rangeofvolumesper4-hourlyfeedofF-100(6feedsdaily) RangeofdailyvolumesofF-100Minimum(ml) Maximum(ml)a Minimum
(150ml/kg/day)Maximum
(220ml/kg/day)2.0 50 75 300 4402.2 55 80 330 4842.4 60 90 360 5282.6 65 95 390 5722.8 70 105 420 6163.0 75 110 450 6603.2 80 115 480 7043.4 85 125 510 7483.6 90 130 540 7923.8 95 140 570 8364.0 100 145 600 8804.2 105 155 630 9244.4 110 160 660 9684.6 115 170 690 10124.8 120 175 720 10565.0 125 185 750 11005.2 130 190 780 11445.4 135 200 810 11885.6 140 205 840 12325.8 145 215 870 12766.0 150 220 900 13206.2 155 230 930 13646.4 160 235 960 14086.6 165 240 990 14526.8 170 250 1020 14967.0 175 255 1050 15407.2 180 265 1080 15887.4 185 270 1110 16287.6 190 280 1140 16727.8 195 285 1170 17168.0 200 295 1200 17608.2 205 300 1230 18048.4 210 310 1260 18488.6 215 315 1290 18928.8 220 325 1320 19369.0 225 330 1350 19809.2 230 335 1380 20249.4 235 345 1410 20689.6 240 350 1440 21129.8 245 360 1470 2156
10.0 250 365 1500 2200
ªVolumesperfeedareroundedtothenearest5ml.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA170 JANUARY 2016
Danger Signs Related to Pulse, Respirations, and Temperature
Alert a physician if these occur.
Danger sign: Suggests:
PulseandRespirations Confirmedincreaseinpulserateof25ormorebeatsperminute,alongwithConfirmedincreaseinrespiratoryrateof5ormorebreathsperminute
InfectionorHeartfailure(possiblyfromoverhydrationduetofeedingorrehydratingtoofast)
Respirationsonly Fastbreathing:• 50breaths/minuteormoreinchild2
monthsupto12monthsold*• 40breaths/minuteormoreinchild12
monthsupto5years
Pneumonia
Temperature AnysuddenincreaseordecreaseRectaltemperaturebelow35.5oC(95.9oF)
• Infection• Hypothermia(possiblydueto
infection,amissedfeed,orchildbeinguncovered)
Inadditiontowatchingforincreasingpulseorrespirationsandchangesintemperature,watchforotherdangersignssuchas:• anorexia(lossofappetite)
• changeinmentalstate(e.g.,becomeslethargic)
• jaundice(yellowishskinoreyes)
• cyanosis(tongue/lipsturningbluefromlackofoxygen)
• difficultbreathing
• difficultyfeedingorwaking(drowsy)
• abdominaldistention
• newoedema
• largeweightchanges
• increasedvomiting
• petechiae(bruising)Normal ranges of pulse and respiratory rates:
AgeNORMAL RANgES (PER MINUTE)
pUlse respirAtions
2monthsupto12months 80upto160 20upto60*
12monthsupto60months(5years) 80upto140 20upto40
*Some children age 2 months up to 12 months will normally breathe fast (i.e. 50 – 60 breaths per minute) without having pneumonia. However, unless the child’s normal respiratory rate is known to be high, he should be assumed to have either overhydration or pneumonia. Careful evaluation, taking into account prior fluid administration, will help differentiate the two conditions and plan appropriate treatment.
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 171
ANNEX 9: THERAPEUTIC MIlk REFERENCE CARdS FOR INFANTS lESS THAN 6 MONTHS WITH SAM9A:THERAPEUTICMILKREFERENCECARDSFORINFANTSLESSTHAN6MONTHSWITHSAM(STABILIZATIONPHASE)Checktheweightofthechildandseethevolumeofmilkneededfor24hoursandfrequencyoffeedsexpected.
•Donotmakeadjustmentsforoedema
•Tryatallcoststofeedverysmallbabiesatleast8timesaday.
Togiveallthenecessaryvolumein24hours,whentheidealfrequencyisimpossibletofollow,itisbettertoreducethenumberoffeedwithoutreducingthetotaldailyamountthantoskipmeals.
Weight of infant (kg)
Total feed volume in 24
hours (ml)
Volume of feed according to feed frequency (per 24 hours)12 feeds
(ml)10 feeds
(ml)8 feeds
(ml)7 feeds
(ml)6 feeds
(ml)5 feeds
(ml)1.2 240 20 20 25 30 35 451.3 240 20 25 30 30 35 451.4 240 20 25 30 35 40 451.5 240 20 25 30 35 40 451.6 300 25 30 35 40 45 551.7 300 25 30 35 40 45 551.8 300 25 30 40 40 45 601.9 300 25 30 40 45 50 602.0 300 25 35 40 45 50 652.1 300 25 35 40 45 50 652.2 360 30 35 45 50 60 702.3 360 30 35 45 50 60 702.4 360 30 35 45 50 60 702.5 420 35 40 50 55 65 752.6 420 35 40 50 55 65 752.7 420 35 40 50 55 65 752.8 420 35 40 55 60 70 802.9 420 35 40 55 60 70 803.0 480 40 45 60 65 75 853.1 480 40 45 60 65 75 853.2 480 40 45 60 65 75 853.3 480 40 45 60 65 75 853.4 480 40 45 60 65 75 853.5 480 40 50 65 70 80 953.6 480 40 50 65 70 80 953.7 480 40 50 65 70 80 95
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA172 JANUARY 2016
Weight of infant (kg)
Total feed volume in 24
hours (ml)
Volume of feed according to feed frequency (per 24 hours)12 feeds
(ml)10 feeds
(ml)8 feeds
(ml)7 feeds
(ml)6 feeds
(ml)5 feeds
(ml)3.8 480 40 50 65 70 80 953.9 480 40 50 65 70 80 954.0 540 45 55 70 75 85 1104.4 540 45 55 70 75 85 1104.5 600 50 60 80 90 95 1204.9 600 50 60 80 90 95 1205.0 720 60 70 90 100 110 1304.4 720 60 70 90 100 110 1304.5 720 60 80 100 110 120 1504.9 720 60 80 100 110 120 1506.0 840 70 85 110 120 140 175
How total feed volumes are calculated for initial feeding
Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaguide,theaveragevolumeoffeed/kg,accordingtoweightinthestabilizationphaseis:
weight Feed ML/kg/ 24 hoUrs*
1.2-1.5kg 180 ml/kg
1.6-1.9kg 170 ml/kg
2.0-3.0kg 155 ml/kg
3.1-3.5kg 145 ml/kg
3.6 -6.0 kg 130 ml/kg
*averageroundedto nearest5mltherefore absolutevolumesper kgbodyweight mayvaryalittle,these are guidancevolumes.
9B:THERAPEUTICMILKREFERENCECARDFORINFANTSLESSTHAN6MONTHSWITHSAMWHOARENOTBREASTFED(TRANSITIONPHASE).
Weight of infant
kg
Total feed volume in 24
hours (ml)
Volume of feed according to feed frequency (per 24 hours)
12 feeds(ml)
10 feeds(ml)
8 feeds(ml)
7 feeds(ml)
6 feeds(ml)
5 feeds(ml)
1.2 300 25 25 35 40 45 601.3 300 25 30 40 40 45 601.4 300 25 30 40 45 50 601.5 300 25 30 40 45 50 601.6 360 30 40 45 50 60 701.7 360 30 40 45 50 60 701.8 360 30 40 50 50 60 801.9 360 30 40 50 60 65 802.0 360 30 45 50 60 65 852.1 360 30 45 50 60 65
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 173
Weight of infant
kg
Total feed volume in 24
hours (ml)
Volume of feed according to feed frequency (per 24 hours)
12 feeds(ml)
10 feeds(ml)
8 feeds(ml)
7 feeds(ml)
6 feeds(ml)
5 feeds(ml)
2.2 480 40 45 60 65 80 902.3 480 40 45 60 65 80 902.4 480 40 45 60 65 80 902.5 540 45 50 65 70 85 1002.6 540 45 50 65 70 85 1002.7 540 45 50 65 70 85 1002.8 540 45 50 70 80 90 1052.9 540 45 50 70 80 90 1053.0 600 50 60 80 85 100 1103.1 600 50 60 80 85 100 1103.2 600 50 60 80 85 100 1103.3 600 50 60 80 85 100 1103.4 600 50 60 80 85 100 1103.5 600 50 65 85 90 105 1253.6 600 50 65 85 90 105 1253.7 600 50 65 85 90 105 1253.8 600 50 65 85 90 105 1253.9 600 50 65 85 90 105 1254.0 720 60 70 90 100 110 1454.4 720 60 70 90 100 110 1454.5 780 65 80 105 125 125 1554.9 780 65 80 105 125 125 1555.0 960 80 90 115 130 145 1704.4 960 80 90 115 130 145 1704.5 960 80 105 130 145 155 1954.9 960 80 105 130 145 155 195
6.0 1080 90 110 145 155 180 225
How total feed volumes are calculated for the transition phase (non-breastfed infants)
Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaroughguide,theaveragevolumeoffeed/kg,accordingtoweightinthetransitionphaseis:
weight Feed ML/kg/ 24 hoUrs*
1.2 -1.5 kg 225 ml/kg
1.6 -1.9 kg 205 ml/kg
2.0 -3.0 kg 200 ml/kg
3.1 -3.5 kg 180 ml/kg
3.6-6.0kg 170 ml/kg
*averageroundedtonearest5mlRefer to the large table to manage individual infants
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA174 JANUARY 2016
9C: THERAPEUTICMILK FEEDS IN THE RECOVERY PHASE FOR INFANTSLESSTHAN6MONTHSWHOARENOTBEINGBREASTFED.
Weightof infant
Totalfeedvolumein24hours
Volumeoffeedaccordingtofeedfrequency(per24hours)
12feeds 10feeds 8feeds 7feeds 6feeds 5feeds
1.2 360 30 30 40 50 55 70
1.3 360 30 40 50 50 55 70
1.4 360 30 40 50 55 65 70
1.5 420 35 40 50 60 70 80
1.6 480 40 50 55 65 70 90
1.7 480 40 50 55 65 70 90
1.8 480 40 50 65 65 70 95
1.9 480 40 50 65 70 80 95
2.0 480 40 55 65 70 80 105
2.1 480 40 55 65 70 80 105
2.2 600 50 55 70 80 95 110
2.3 600 50 55 70 80 95 110
2.4 600 50 55 70 80 95 110
2.5 660 55 65 80 90 105 120
2.6 660 55 65 80 90 105 120
2.7 660 55 65 80 90 105 120
2.8 660 55 65 90 95 110 130
2.9 660 55 65 90 95 110 130
3.0 780 65 70 95 105 120 135
3.1 780 65 70 95 105 120 135
3.2 780 65 70 95 105 120 135
3.4 780 65 70 95 105 120 135
3.5 780 65 80 105 110 130 150
3.6 780 65 80 105 110 130 150
3.7 780 65 80 105 110 130 150
3.8 780 65 80 105 110 130 150
3.9 780 65 80 105 110 130 150
4.0 840 70 90 110 120 135 175
4.4 840 70 90 110 120 135 175
4.5 960 80 95 130 145 150 190
4.9 960 80 95 130 145 150 190
5.0 1140 95 110 145 160 175 210
5.4 1140 95 110 145 160 175 210
5.5 1140 95 130 160 175 190 240
5.9 1140 95 130 160 175 190 240
6.0 1320 110 135 175 190 225 280
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 175
How total feed volumes are calculated for catch-up/rehabilitation (non-breastfed infants)
Thelowertheweightoftheinfant,thehigherthevolumeoffeedperkgrequired.Asaroughguide,theaveragevolumeoffeed/kg,accordingtoweightinthecatchupphaseis:
weight Feed ML/kg/ 24 hoUrs*
1.2 -1.9 kg 270 ml/kg
2.0 - 3.0 kg 270 ml/kg
3.1 -3.5 kg 240 ml/kg
3.6 -6.0 kg 230 ml/kg
*average roundedtonearest5ml
Refer to the large table to manage individual infants
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA176 JANUARY 2016
ANNEX 1024-HOURFEEDINTAKECHART
Completeonechartforevery24-hourperiod.
Name:____________________________________________________
HospitalIDnumber______Admissionweight(kg)_____Today’sweight(kg)_____
DATE: TYPEOFFEED: GIVE: feedsof ml
Time a.Amountoffered(ml)
b.Amountleftincup(ml)
c.Amounttakenorally(a–b)(ml)
d.AmounttakenbyNG,ifneeded(ml)
e. Estimatedamountvomited(ml)
f.Waterydiarrhoea(ifpresent,yes)
Columntotals c. d. e. Totalyes:
Total volume taken over 24 hours =amounttakenorally(c)+amounttakenbyNG(d) –totalamountvomited(e) =___ml
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 177
ANNEX 11DAILYWARDFEEDCHART
DATE:
WARD:
NameofChild
F-75 F100/F-100Diluted(SDTM)*
Numberfeeds
Amount/feed(ml)
Total(ml) Numberfeeds
Amount/feed(ml)
Total(ml)
F-75(totalml)neededfor24hours F-100/F100Diluted(totalml)neededfor24hrs
Amountneededfor hours* Amountneededfor hours**
Amounttoprepare(rounduptowholelitre)
Amounttoprepare(roundupto wholelitre)
*F100Diluted(SDTM)isforinfantslessthansixmonths
**Dividedailyamountbythenumberoftimesfeedsarepreparedeachday. Forexample,iffeedsarepreparedevery12hours,dividedailyamountby2.
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA178 JANUARY 2016
ANNEX 12WEIGHTGAINTALLYSHEETFORWARD
week oF:dd/mm/yr
good weight gAin:10 g/kg/day
moderAte weight gAin: 5 up to 10 g/
kg/day
poor weight gAin: < 5 g/kg/
day
NumberofchildrenonF-100forentire
week:.............
Totals
%ofchildrenonF-100inward
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 179
ANNEX 13 MONITORINGCHECKLISTS
checklist For monitoring Feed prepArAtion
observe: yes no comments
Areingredientsfortherecipesavailable?
Areingredients’expirydateswithinacceptableranges?
Isthecorrectrecipeusedfortheingredientsthatareavailable?
Areingredientsstoredappropriatelyanddiscardedatappropriatetimes?
Arecontainersandutensilskeptclean?
Dokitchenstaff(orthosepreparingfeeds)washhandswithsoapbeforepreparingfood?
AretherecipesforF-75andF-100followedexactly? (Ifchangesaremadeduetolackofingredients,arethesechangesappropriate?)
Aremeasurementsmadeexactlywithpropermeasuringutensils(e.g.,correctscoops)?
Areingredientsthoroughlymixed(andcooked,ifnecessary)?
Istheappropriateamountofoilmixedin(i.e.,notleftstuckinthemeasuringcontainer)?
IsmineralmixorCMVaddedcorrectly?
Iscorrectamountofwateraddedtomakeupalitreofformula?(Staffshouldnotaddalitreofwater,butjustenoughtomakealitreofformula.)
Arefeedsservedatappropriatetemperatures?
Arethefeedsconsistentlymixedwhenserved(i.e.oilismixedin,notseparated)?
Arecorrectamountsputinthecupforeachchild?
Isleftoverpreparedfooddiscardedpromptly?
Other:
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA180 JANUARY 2016
checklist For monitoring wArd procedUres
observe: yes no commentsFeedingArecorrectfeedsservedincorrectamounts?Arefeedsgivenattheprescribedtimes,evenonnightsandweekends?Arechildrenheldandencouragedtoeat(neverleftalonetofeed)?Arechildrenfedwithacup(neverabottle)?Isfoodintake(andanyvomiting/diarrhoea)recordedcorrectlyaftereachfeed?Areleftoversrecordedaccurately?AreamountsofF-75keptthesamethroughouttheinitialphase,evenifweightislost?Aftertransition,areamountsofF-100givenfreelyandincreasedasthechildgainsweight?wArmingIstheroomkeptbetween25oC-30oC(totheextentpossible)?Areblanketsprovidedandchildrenkeptcoveredatnight?Aresafemeasuresusedforre-warmingchildren?Aretemperaturesofpatientstakenandrecordedcorrectly?weighingArescalesfunctioningcorrectly?Arescalesstandardizedmonthly?Arechildrenweighedataboutthesametimeeachday?Aretheyweighedaboutonehourbeforeafeed(totheextentpossible)?Dostaffadjustthescaletozerobeforeweighing?Arechildrenconsistentlyweighedwithoutclothes?Dostaffcorrectlyreadweighttothenearestdivisionofthescale?Dostaffimmediatelyrecordweightsonthechild’sCCP?AreweightscorrectlyplottedontheWeightChart?giving Antibiotics, medicAtions, sUpplementsAreantibioticsgivenasprescribed(correctdoseatcorrecttime)?Whenantibioticsaregiven,dostaffimmediatelyrecordontheCCP?IsfolicacidgivendailyandrecordedontheCCP?IsvitaminAgivenaccordingtoschedule?IsamultivitamingivendailyandrecordedontheCCP?AfterchildrenareonF-100for2days,isthecorrectdoseofirongiventwicedailyandrecordedontheCCP?wArd environmentAresurroundingswelcomingandcheerful?Aremothersofferedaplacetositandsleep?Aremotherstaught/encouragedtobeinvolvedincare?Arestaffconsistentlycourteous?Aschildrenrecover,aretheystimulatedandencouragedtomoveandplay?
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 181
checklist For monitoring hygiene
observe: yes no commentshAnd wAshingAretherefunctionalhandwashingfacilitiesintheward?Dostaffconsistentlywashhandsthoroughlywithsoap?Aretheirnailsclean?Dotheywashhandsbeforehandlingfood?Dotheywashhandsbetweeneachpatient?MOTHERS’ CLEANLINESSDomothershaveaplacetobathe,anddotheyuseit?Domotherswashhandswithsoapafterusingthetoiletorchangingdiapers?Domotherswashhandsbeforefeedingchildren?bedding And lAUndryIsbeddingchangedeverydayorwhensoiled/wet?Arediapers,soiledtowelsandrags,etc.storedinbag,thenwashedordisposedofproperly?Isthereaplaceformotherstodolaundry?Islaundrydoneinhotwater?generAl mAintenAnceArefloorsmopped?Istrashdisposedofproperly?Isthewardkeptasfreeaspossibleofinsectsandrodents?
Aresurfacesandwallsdusted?Food storAgeAreingredientsandfoodkeptcoveredandstoredatthepropertemperature?Areleftoversdiscarded?Feeding Utensils wAshingArefeedingUtensilswashedaftereachfeed?Aretheywashedinhotwaterwithsoap?toysAretoyswashable?Aretoyswashedregularly,andaftereachchildusesthem?
ANNE
X 14
SA
MPL
EDISCH
ARGECA
RDTh
issampledischa
rgecardisin
tend
edto
befolded
.Thistype
ofc
ardwou
ldnee
dtobead
aptedforlocaluse.A
growthcha
rtcou
ldbefolded
insid
ethis
cardora
ttached
toit
.di
schA
rge
cArd
For C
hild
Rec
over
ing
from
Sev
ere
Mal
nutr
ition
Hosp
ital N
ame
Child
’s na
me:
___
____
____
____
___
M
F
Dat
e of
birt
h: _
____
__
date
Wei
ght (
kg)
Ht_/
Leng
th (c
m)
% w
eigh
t-for
-hei
ght
Adm
issi
onDi
scha
rge
Inst
ructi
ons f
or fe
edin
g at
Hom
e
Wha
ttofeed
?(In
clud
erecipe
ifnee
ded)___
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Howm
uchan
dho
wofte
n?___
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Med
icati
ons a
nd S
uppl
emen
ts
Give__
____
____
__drops
____
____
____
(mul
tivita
min
pre
para
tion)
with
food
onc
e da
ily.
Give1ta
bletfo
licacidon
cedailyfo
r___
____
____
_days.
Give__
____
____
____
____
____
Iron
twiceda
ilyfo
r1m
onth.
Other:_
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Dang
er S
igns
– B
ring
Child
for I
mm
edia
te C
are
i
Com
e fo
r Sch
edul
ed F
ollo
w-U
p Vi
sits
Nex
t Pla
nned
Fol
low
-Up
Reco
rd o
f Vis
itsda
tepl
ace
date
Ht/L
engt
hW
eigh
t%
wt-f
or-h
t
Vita
min
A –
Brin
g Ch
ild fo
r a D
ose
Ever
y Si
x M
onth
sN
ext D
ose
Vita
min
A:
Reco
rd o
f Dos
es R
ecei
ved:
date
plac
eda
teDo
se
Imm
uniza
tions
giv
en
Nex
t Im
mun
izatio
nda
teDo
se(s
) nee
ded
Tickorrecordda
tegiven
:
BCG
Notabletodrin
kor
Stop
sfee
ding
Diarrhoe
athan
1day
orblood
instoo
lSw
ellin
ginfe
et,
hand
s,legsora
rms
Fastord
ifficultbreathing
Convulsio
n(fits)
Fever(feelsh
ot)
OPV
0
DPT1
OPV
2
DPT2
OPV
2
DPT3
OPV
3
Mea
sles
ANNE
X 15
SPEC
IALIZE
DNUTR
ITIO
USFO
ODSSH
EET
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
185
JAN
UA
RY
201
6
Abbreviatio
ns:B
=Belgium
,Ban
=Ban
galade
sh,C
h=Sw
itzerland
,D=German
y,DR
=Dom
inianRe
public,Fr=
France,I=India,IL=Italy,Mad
=
Mad
agacar,M
al=M
alaw
i,N=Norway,SA=So
uthAfric
a,US=UnitedStatesofA
merica
Note:Referto
thede
cisio
ntooland
guida
nceno
tein
usin
gprod
uctshe
etand
follo
wingthede
cisio
nsm
adeon
wha
ttyp
eofprodu
ctstouse
*Qua
ntityisre
ferringtookcalsinmostcases
GNCMAM
TaskforcePRO
DUCT
SHE
ET,V
ERSIONApril20
14
ANNE
X 16
CR
ITICAL
CAR
EPA
THWAY
CHAR
T(-5
PAG
ES)
sig
ns
oF
sho
ckN
oneLetha
rgic/uncon
sciousCo
ldperiphe
riesSlow
cap
illaryrefill(>3
second
s)
Wea
k/fastpulse
If le
thar
gic
or u
ncon
scio
us, p
lus e
ither
slow
capi
llary
refil
l or w
eak/
fast
pul
se, g
ive
oxyg
en.
Give
IV g
luco
se a
s des
crib
ed u
nder
Blo
od G
luco
se (l
eft).
Then
giv
e IV
flui
ds:
Amou
nt IV
flui
ds p
er h
our:
15m
lx__
___k
g (c
hild
’s w
t)=_
____
____
ml
Start:
Mon
itore
very10minutes
*2nd
hr.
Mon
itore
very10minutes
Time
*
Resp.rate
*
Pulse
rate
*
*If r
espi
rato
ry &
pul
se a
re sl
ower
afte
r 1ho
ur, r
epea
t sam
e am
ount
IV fl
uids
for 2
nd h
our:
then
alte
rnat
e Re
SoM
al a
nd F
-75
for u
p to
10
hour
s as i
n rig
ht p
art o
f cha
rt b
elow
. If n
o im
prov
emen
t on
IV fl
uids
, tra
nsfu
se
who
le fr
esh
bloo
d. (S
ee le
ft. H
aem
oglo
bin.
)
sig
ns
oF
seve
re m
Aln
Utr
itio
nSeverewastin
g?YesNo
Oed
ema?0+++++
+De
rmatosis?
0+++++
+(ra
wsk
in,fi
ssures)
Weigh
t(kg):Heigh
t/leng
th(cm):
SDsc
ore:orM
UAC:
tem
perA
tUre
____
___0 C
rectalaxillary
If re
ctal
<35.
50C
(95.
90F)
, or a
xilla
ry <
350C
(950
F),
activ
ely
war
m p
atien
t . C
heck
tem
pera
ture
eve
ry 3
0 m
inut
es
blo
od
glU
cose(m
mol/l):
If <3
mm
oVI a
nd a
lert
. Giv
e 50
ml b
olus
of 1
0% g
luco
se
or su
cros
e (o
ral o
r NG)
If <
3mm
oVI a
nd le
thar
gic,
un
cons
ciou
s, o
r con
vulsi
on, g
ive
ster
ile 1
0% g
luco
se IV
: 5m
lx__
kg(child’swt)=_
__ml,then
give50
mlb
olus
NG.
Tim
eglucosegiven:OralNGIV
hAem
og
lobi
n(H
b)(g/I):o
rPackedcellvol(PC
V):
Bloo
dtype
:
diAr
rho
eAWatery
diarrhoe
a?Yes
No
Ifdiarrhoe
a,circ
leSkinpinchgo
esbackslo
wly
Blood
instoo
l?Yes
No
signspresent:R
estle
ss/irritab
leLethargic
Thirsty
Vomiting
?Yes
No
Sunken
eyes
Drymou
th/ton
gueNotears
CRIT
ICAL
CAR
E PA
THW
Ay (C
CP) -
-- N
UTR
ITIO
N W
ARD/
UN
ITN
AME _
____
____
____
____
____
M F
DAT
E O
F BI
RTH
OR
AgE_
____
____
__DA
TE O
F AD
MIS
SIO
N__
____
__ T
IME_
____
___H
OSP
.ID N
o....
......
..
Com
men
ts o
n pr
e-re
ferr
al a
nd/o
r em
erge
ncy
trea
tmen
t alre
ady
give
n:
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
init
iAl
mAn
Agem
ent
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
187
JAN
UA
RY
201
6
Time
Start:
Resp.R
ate
Pulse
rate
Weigh
t
Passed
urin
e?YN
Num
berstools
Num
berv
omits
Hydrati
onsign
s
Amou
ntta
ken(m
l)F-75
F-75
F-75
F-75
*Sto
p Re
SoM
al if
: Inc
reas
e in
pul
se r
esp.
rate
s
Jugu
lar v
eins
eng
orge
d
Inc
reas
ing
oede
ma
e.g.
puff
y ey
elid
s Weigh
tgainexceed
sthe
weigh
tbeforediarrhoe
aorisabo
ve5%ofw
eigh
tbeforerehydrati
on
If di
arrh
oea
and/
or v
omiti
ng, g
ive
ReSo
Mal
. Ev
ery
30 m
inut
es fo
r firs
t 2 h
ours
, mon
itor a
nd
give
:*
5mlx___
__kg(child’swt)=__
__mlR
eSoM
al
For u
p to
10
hour
s, g
ive
ReSo
Mal
and
F-7
5 in
alte
rnat
e ho
urs.
Mon
itor e
very
hou
r. Am
ount
of R
eSoM
al to
offe
r:*
5to10mlx___
_kg(child’swt)=__
__to__
__mlR
eSoM
al
AN
TIB
IOT
ICS
(All
rece
ive)
D
rug/
Rou
teD
ose/
Freq
uenc
y/D
urat
ion
Tim
e of
1st d
ose
If Hb
<4g/
dI o
r PCV
<12%
tran
sfus
e 10
mVk
g w
hole
fres
h bl
ood
(or 5
-7)m
l/kg
pack
ed c
ells
slow
ly o
ver 3
hou
rs
Amou
nt:Tim
estarted:
eye
sig
nsNon
eLeftRight
meA
slesYesN
oBitot’ssp
otsPus/in
flammati
onCorne
al-cloud
ing
Cornea
lulcerati
onIf
ulce
ratio
n, g
ive
vita
min
A &
atr
opin
e im
med
iate
ly.
Reco
rd o
n Da
ily C
are
page
.Orald
osesvita
minA:
<6m
onths
50000
IU
6-12
mon
ths
10000
0IU
≥12
mon
ths
20000
0IU
Feed
ing
Beginfe
edingwith
F-75asso
onasp
ossib
le.
(Ifchildisre
hydrated
,rew
eigh
beforede
term
ining
amou
ntto
feed
.New
weigh
t:___
___kg)
Amou
nt fo
r 2-h
ourly
feed
ings
:___
__mlF-75*
Timefirstfe
d:__
____
____
____
_*I
f hyp
ogly
caem
ic, f
eed
1/4
of th
is am
ount
eve
ry h
alf
hour
for fi
rst 2
hou
rs: c
ontin
ue u
ntil b
lood
glu
cose
re
ache
s 3m
mol
/l.Re
cord
all
feed
s on
24-h
ours
Fee
d in
take
cha
rt
dAily
cAr
e
W
eek1
W
eek2
Wee
k3
dAys
in h
osp
itAl
12
34
56
78
910
1112
1314
1516
1718
1920
21
Date
Dailyweigh
t(kg)
Weigh
tgain(g/kg)
Calculateda
ilyafte
ron
F-100
Oed
ema0+++
+++
Diarrhoe
a/vomit0
DV
FEED
PLA
N:Typ
efeed
Nofeed
sdaily
Totalvolum
etaken
(ml)
ANTIBIOTICS
Listprescrib
edanti
bioti
csin
leftcolumn.Allo
wone
rowfo
reachda
ilydose.Drawaboxaroun
dtheda
ys/ti
mesth
ateachdrug
shou
ldbegiven.Recordinitialsw
hengiven
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
189
JAN
UA
RY
201
6
FOLICAC
ID5m
g1m
g
VITA
MINA*
*GiveDa
y1routi
nelyifnotin
feed
sunlesse
vide
nceofdoseinpastm
onthorn
oeyesig
n.GiveDa
y2&Day15if
patie
ntadm
itted
with
eyess
ignsorrecen
tmea
sles
Multiv
itamin(ifn
otin
feed
)
Drug
forw
orms(Note
type
ofw
orm)
Beginiro
naft
er2dayso
nF-10
0Iro
n2xda
ily
FOREYEPR
OBLEM
S:Ch
loramph
enicolor
gentam
ycin
1drop
4xdaily
After10da
ys,w
heneyedrop
sarenolong
ernee
ded,sh
ade
boxesforeyedrops
Atropine
1drop
3xda
ily
Derm
atosis0+++
++
+
Bathing,1%
perm
angana
te
OTH
ER
mo
nit
ori
ng
rec
ord
Mon
itorrespiratoryra
te,p
ulsera
te,a
ndte
mpe
rature4-hou
rlyunti
lafte
rtransition
toF-100
and
pati
entisstab
le.T
henmon
itorin
gmaybelessfreq
uent
(e.g.twiceda
ily
Respira
toryra
te
BREA
THS/
MIN
UTE
Pulsera
te
BEAT
S/ M
INU
TE
Tempe
rature
39.0
38.5
38.0
37.5
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
191
JAN
UA
RY
201
6
37.0
36.5
36.0
35.5
35.0
34.5
Date/T
ime:
Dang
ersign
s:W
atchfo
rincreasingpu
lseand
respira
tions,fasto
rdiffi
cultbreathing,su
dden
increa
seord
ecreaseinte
mpe
rature,rectaltem
peraturebelow
35
.5o C,and
otherch
angesincond
ition
.See
Dan
gerS
ignslisted
onba
ckofF-100
Referen
ceCard.Normalra
ngesofp
ulseand
respira
toryra
tesa
realso
listed
on
backofF-100
Referen
ceCard.
wei
ght
chA
rt
Nam
e:
Weigh
tonad
miss
ion
Kg
Heigh
t/leng
th:
cmOed
emaon
adm
ission:0+++
+++
Weigh
tatD
ischa
rge
Kg
Enterlikelyrang
eofw
eigh
tsontheverticalaxisinanap
prop
riatescale(e
.g.e
achrowre
presen
ting0.1kg).A
llowro
wsbe
lowth
estartin
gweigh
tincase
weigh
tdecreases;w
eigh
tmaydecreasebyasm
uchas30%
ifth
echild
hasse
vereoed
ema
Weight (use appropriate scale)
1
2 3
4 5
6 7
8 9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28D
ays
GU
IDE
LIN
ES
FO
R N
TEGR
ATED
MAN
AGEM
ENT
OF A
CUTE
MAL
NUTR
ITIO
N IN
UG
AN
DA
193
JAN
UA
RY
201
6
CO
MM
ENTS
/OU
TCO
ME
com
men
ts:
TEAC
HIN
g g
IVEN
TO
PAR
ENTS
/ CA
REg
IVER
S
imm
Un
iZAt
ion
sIm
mun
izatio
ncard?YesN
oCircleim
mun
izatio
ns
alread
ygiven.Recordinitialand
datewhe
nan
yisgiveninhospital
Immun
izatio
nFirst
Second
Third
Booster
BCG
Atbirth
Polio
Atbirth
6wee
ks14
wee
ks
DPT
Atbirth
6wee
ks14
wee
ks
Mea
sles
9mon
ths
--
-
spec
iAl
disc
hArg
e An
d Fo
llo
w U
p in
strU
ctio
ns:
pAti
ent
oU
tco
me
Circleoutcome:
DATE
CIRC
UMSTAN
CES/CO
MMEN
TS
Tran
sferto
OTC
Early
dep
arture
(againstadv
ice)
Early
disc
harge
Referral
Death
Num
bero
fdaysa
ftera
dmiss
ion(circ
le):<2
4hrs1-3d
ays4-7da
ys>7d
ays
Approxim
atetim
eofdeath:D
ayNight
Appa
rentcau
se(s):
Hasc
hildre
ceived
IVfluids?YesN
o
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA194 JANUARY 2016
ANNEX 17: REFERRAl FORMS17A:COMMUNITYREFERRALFORM
ministry oF heAlthcommUnity reFerrAl Form
ClientRef.No:________________ Date:________________________
ClientName:_________________ Sex: Male Female
SubCounty:__________________ Parish:________________________
Village:__________________________________________________________
Healthyfacilityclientisreferredto:____________________________________
MUAC:(Tick correct colour of MUAC) Green Yellow Red
Oedema(Swellingofbothfeet: Yes No
(Tick“Yes”ifclienthasswellingofbothfeetand“No”ifthereisnoswellingofbothfeet
Volunteer’sName:_________________________________
Feedback from Health Worker to Community Volunteer(Fill and give to the client)
Date:_____________________
Clientadmittedto:(Tick as appropriate)
OutpatientTherapeuticCare(OTC)(followuponRUTFadherence)
InpatientTherapeuticCare(ITC)
SupplementaryFeedingProgramme
Doesnotqualifyforadmission(counseloneatingwellandhygiene)
HealthWorker’sNameandSignature:_________________________________
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 195
17B:HMIS032:REFERRALNOTE
DateofReferal________________
TO______________________________
FROM
HealthUnit_________________________________ Referralnumber________________
REFERENCE
PatientName:_________________________________________________________________
Age:________________Sex: Male Female
Pleaseattendtheabovepersonwhowearereferringtoyourhealthunitforfurtheraction.
HistoryandSymtoms:
Investigationsdone:
Diagnosis:
Treatmentgiven:
Reasonforreferral:
Please complete thiss note on discharge and send it back to our unit.
Nameofclinician:________________________________ Signature:__________________
To be completed at the referral site
Dateofarrival:__________________Dateofdischarge:___________________
Furtherinvestigationsdone:_________________________________________________________
Diagnosis:
Treatmentgiven:__________________________________________________________________
Treamentorsurveillancetobecontinues:______________________________________________
Remarks:________________________________________________________________________
Nameofclinician:________________________________ Signature:__________________
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA196 JANUARY 2016
ANNEX 18 INTEGRATEDNUTRITIONRATIONCARD
#of visits Comment/treatment received
Adm
1
2
3
4
5
6
7
8
9
10
11
#of visits
date Weight (kg)
MUAC (colour code)
grade of oedema
Adm
1
2
3
4
5
6
7
8
9
10
11
#of units per day
#of units given
Date of next visit
Ministry of HealthIntegrated Nutrition Ration Centre
Nutritionprogram:SFP[]OTC[]
Otherspecify...................................................
Site:________________________________
District:_____________________________
Client’sName:_________________________
AgeofClient:_________________________
Sex:______________
Client’sNo.:_________________________
Caregiver/Nextofkin:___________________
Village:_________________________
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 197
ANNEX 19 HEALTHANDNUTRITIONEDUCATIONRECORDFORM
date Topic venue Conducted by Participants Areas Needing Emphasis
Remarks Sign
Males Females
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA198 JANUARY 2016
ANNEX 20 DOCUMENTATIONJOURNALFORQIACTIVITIESDocumentation journal for qI activities
Thedocumentationjournal isastandardtoolusedfortrackingandreflectingonqualityof IMAMservices in the health facility and community continuously. The journal helps teams to suggestchanges and continuouslymonitor performance, share lessons learnt that contribute to change(improvement/decline).Thisfacilitatesfollow-upandroutinesupportsupervisionofIMAMservices.Thejournalhasthree(3)parts:
part 1: DocumentswhattheIMAMteam/facilityistryingtoaccomplishandwhy.
part 2:AworksheetwhereeachofthechangesimplementedattheIMAMfacility/communityarelisted,includingnotationoftheireffectivenessandthedateswhentheywerestartedorended(if applicable).
part3: A provision for graphing the IMAM dataor results,and annotating run charts with yourchangestoascertaintheimpactofthechangessuggestedandtried.
Dependingon thechanges suggested, levelof serviceprovisionand indicators tobeaddressed,teamscandecideonthefrequencyofdataaggregationandreporting/feedback.Refer to examples below:
Sample documentation journal for qI activities
Nameofthefacility:____________________District:______________Region:______________
Teamleader:__________________________Teammembers:_____________________________
Startdateforimprovementproject:_____________________Enddate:_____________________
Part 1: Descriptionof situation
Improvement objective(Improve nutrition assessment at OPD)
Indicator for the objectivePercentage of clients/patients assessed for nutrition status at OPD
Descriptionof problem
BrieflydescribetheIMAMproblembeingaddressedandgapsbetweenthecurrentsituationandyourimprovementobjectives.StatethedifferencesbetweentheMOHstandardofcareandthecurrentpractices.Alsodescribesomeofthechallengeswiththecurrentsituation.(E.g.,Only 10% of OPD clients are assessed for nutrition status)
JANUARY 2016 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 199
Part 2: Changes Worksheet - qI Team Activities
Pleaselistbelowthechangesthattheteamhastriedinordertoachievetheimprovementobjective.Writeallchanges,whethereffectiveornot.Alsonotewheneachchangewasstartedandwhenitended(whereapplicable)toenableyoutoannotatetheresults.
Planned and tested changes
Inthespacebelow,listallofthechangesthatyouareimplementingtoaddresstheimprovementobjective.Writeonetotwosentencestobrieflydescribethetestedchange.
start dateDD/MM/yy
end date(if applicable)DD/MM/yy
Was any Improvement registered? (yes/No)
CommentsNoteanypotentialreasonswhythechangedidordidnotyieldimprovement;alsonoteanychangeinindicatorvalueobservedrelatedtothischange.
E.g., On-job training for all OPD staff
5th /Jan/2016 7th /June/2016 No Few staff at OPD
E.g., Allocate more staff to OPD
8th/June/2016 13th/Dec/2016 Yes Monthlyaggregateddataindicatedimprovement
3.
4.
5.
6.
7.
Part 3: graph Template – Annotated Results
Use the graph below to document your progress. Indicate the value of the numerator anddenominator.
TITLEIndicatorValue
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA200 JANUARY 2016
Time 0 1 2 3 4 5 6 7 8 9 10 11 12
Numerator
Denominator
%
Notes on the indicators. Writedownanyadditionalcommentsyoumayhaveontheperformanceofindicators.Writeanythingderivedfromthechangesworksheetandthegraphtemplatethatmightexplaintheperformancetrendsoftheimprovementobjective.
_________________________________________________________________________
_________________________________________________________________________
Notes on other observed effects(lessons learnt). Pleasewritehereanyeffects(positiveornegative)youarecurrentlyobservingasaresultofthequalityimprovementeffort,suchascommentsfrompatients,changes inyourperformanceormotivation,improvedefficiency,orthesurvivalstoryofasickpatient.Youmayuseyournotestotellthecompletestoryatthenextlearningsession(s).
(Footnotes)
1 ReportoftheWHOInformalConsultationontheuseofPraziquantelduringPregnancy/LactationandAlbendazole/MobendazoleinChildrenunder24months
2 ManagementofsevereMalnutrition:Amanualforphysiciansandotherhealthworkers,WHO1998
GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA204 JANUARY 2016